Sunday, December 16, 2018

Morning Report

I don't know if they still call it that or not - but back in the day when I was an intern Morning Report was a meeting of all of the admitting residents with the attendings or Chief of Internal Medicine.  The goal was to review the admissions from the previous night, the initial management, and the scientific and clinical basis for that management. Depending on where you trained, the relationship between house staff and attendings could be affiliative or antagonistic. In affiliative settings, the attendings would guide the residents in terms of management and the most current research that applied to the condition. In the antagonistic settings, the attendings would ask an endless series of questions until the resident presenting the case either fell silent or excelled.  It was extremely difficult to excel because the questions were often of the "guess what I am thinking" nature. The residents who I worked with were all hell bent on excelling.  After admitting 10 or 20 patients they would head to the library and try to pull the latest relevant research.  They may have only slept 30 minutes the night before but they were ready to match wits with the attendings in the morning.

Part of that process was discussing the relevant literature and references.  In those days there were often copies of the relevant research and beyond that seminar and research projects that focused on patient care. I still remember having to give seminars on gram negative bacterial meningitis and anaphylaxis.  One of my first patients had adenocarcinoma of unknown origin in his humerus and the attending wanted to know what I had read about it two days later.  I had a list of 20 references. All of that reading and research required going to a library and pulling the articles in those days.  There was no online access.  But even when there was - the process among attendings, residents, and medical students has not substantially changed.

I was more than a little shocked to hear that process referred to as "intuition based medicine" in a recent opinion piece in the New England Journal of Medicine (1).  In this article the authors seem to suggest that there was no evidence based medicine at all.  We were all just randomly moving about and hoping to accumulate enough relevant clinical experience over the years so that we could make intuitive decisions about patient care.  I have been critical of these weekly opinion pieces in the NEJM for some time, but this one seems to strike an all time low. Not only were the decisions 35 years ago based on the available research, but there were often clinical trials being conducted on active hospital services - something that rarely happens today now that most medicine is under corporate control.

Part of the author's premise here is that evidence-based medicine (EBM) was some kind of an advance over intuition-based medicine and now it is clear that it is not all that it is cracked up to be. That premise is clearly wrong because there was never any intuition based medicine before what they demarcate as the EBM period. Secondly, anyone trained in medicine in the last 40 years knew what the problems with EBM were from the outset - there would never be enough clinical trials of adequate size to include the real patients that people were seeing.  I didn't have to wait to read all of the negative Cochrane Collaboration studies saying this in their conclusions.  I knew this because of my training, especially training in how to research problems relevant to my patients. EBM was always a buzzword that seemed to indicate some hallowed process that the average physician was ignorant of.  That is only true if you completely devalue the training of physicians before the glory days of EBM.

The authors suggest that interpersonal medicine is what is now needed. In other words the relationship between the physician and patient (and caregivers) and their social context is relevant.  Specifically the influence the physician has on these folks.  Interpersonal medicine "requires recognition and codification of the skills that enable clinicians to effect change in their patients, and tools for realizing those skills systematically." They see it as the next phase in "expanding the knowledge base in patient care" extending EBM rather than rejecting it.  The focus  will be on social and behavioral aspects of care rather than just the biophysical. The obvious connection to biopsychosocial models will not be lost on psychiatrists.  That is straight out of both interpersonal psychotherapy (Sullivan, Klerman, Weissman, Rounsaville, Chevron) and the model itself by Engel.  Are the authors really suggesting that this was also not a focus in the past?

Every history and physical form or dictation that I ever had to complete contained a family history section and a social history section.  That was true if the patient was a medical-surgical patient or a psychiatric patient.  Suggesting that the interpersonal, social, and behavioral aspects of patient care have been omitted is revisionism that is as serious as the idea of intuition based medicine existing before EMB.

I don't understand why the authors just can't face the facts and acknowledge the serious problems with EBM and the reasons why it has not lived up to the hype.  There needs to be a physician there to figure out what it means and be an active intermediary to protect the patient against the shortfalls of both the treatment and the data. As far as interpersonal medicine goes that has been around as long as I have been practicing as well.  Patients do better with a primary care physician and seeing a physician who knows them and cares for them over time. They are more likely to take that physician's advice.  Contrary to managed care propaganda (from about the same era as EBM) current health care systems fragment care, make it unaffordable, and waste a huge amount of physician time taking them away from relationships with patients.

Their solution is that physicians can be taught to communicate with patients and then measured on patient outcomes.  This is basically a managed care process applied to less tangible outcomes than whether a particular medication is started. In other words, it is soft data that it is easier to blame physicians for.  In this section they mention that one of the author's works for Press Ganey - a company that markets communication modules to health care providers. I was actually the recipient of such a module that was intended to teach me how to introduce myself to patients. The last time I took that course was in an introductory course to patient interviewing in 1978.  I would not have passed the oral boards in psychiatry in 1988 if I did not know how to introduce myself to a patient.  And yet here I was in the 21st century taking a mandatory course on how to introduce myself after I have done it tens of thousands of times.  I guess I have passed the first step toward the new world of interpersonal medicine.  I have boldly stepped beyond evidence based medicine.   

I hope there is a lot of eye rolling and gasping going on as physicians read this opinion piece.  But I am also concerned that there is not. Do younger generations of physicians just accept this fiction as fact?  Do they really think that senior physicians are that clueless?  Are they all accepting a corporate model where what you learn in medical school is meaningless compared to a watered down corporate approach that contains a tiny fraction of what you know about the subject?

It is probably easier to accept all of this revisionist history if you never had to sit across from a dead serious attending at 7AM, present ten cases and the associated literature and then get quizzed on all of that during the next three hours of rounding on patients.

George Dawson, MD, DFAPA


1: Chang S, Lee TH. Beyond Evidence-Based Medicine. N Engl J Med. 2018 Nov 22;379(21):
1983-1985. doi: 10.1056/NEJMp1806984. PubMed PMID: 30462934.

Graphic Credit:

That is the ghost of Milwaukee County General Hospital one of the teaching affiliates of the Medical College of Wisconsin.  It was apparently renamed Doyne Hospital long after I attended  medical school there.  It was demolished in 2001.  I shot this with 35mm Ektachrome walking to medical school one day. The medical school was on the other side of this massive hospital.


  1. As a psychiatry resident I've noticed the following:
    1. some older attendings are still practicing according to the standard of care from their training bc they have not kept up. When discussing treatment rationale with them they say things like "this is how I've always done this", "this is how I was trained etc". Admittedly this might be true for younger attendings as well but they are less out of date by nature of completing training more recently.

    2. "Interpersonal medicine" is a catchphrase bc managed care has obliterated the doctor-patient relationship with hospitalists, mid levels, shift work and constantly changing insurance networks that discourage long term relationships between physicians and patients. Sure, the SH/FH is part of the chart for billing but it is not a meaningful part of the medical record in most systems. The information contained in FH/SH is trivial at best and cannot replace actually knowing the patient, their problems, values etc and building trust with them over time. Patients are hesitant to trust us bc they think we don't know them and don't understand them and *gasp* sometimes they are right. A checkbox or line in their chart doesn't fix this.

  2. Thanks for your reply - can you give a couple of examples of attendings not practicing according to modern standards of care.

    I wonder why they are in teaching programs.

    Agree with you about the hospitalist model. And also about the fragmentation of care everywhere including outpatient settings. Medical records these days are much less meaningful because of billing and coding bullet points and templates. They are designed for the business rather than clinical side.

    Do EHR notes differ for people being followed by the same person on a long term basis?

    It might be an interesting study.


  3. This is a corpmed Madison Ave. rhetorical trick, basically relabelling something that's been around into a new marketable catchphrase. Kind of like "mindfulness".

    What really needs to be embraced is not interpersonal but programmatic treatment, especially for most depression and anxiety disorders. Bredesen writes about this for Alzheimer's prevention and I think it has broader application. I've come to the conclusion that giving someone an SSRI that has a 10 percent advantage over placebo isn't going to do much if their diet is 80 percent carbs and they are 12 hour a day dopamine fiends on social media. It's really not that interpersonal, there are certain basic rules of life and wisdom that work for everyone. (All happy families are the same as the saying goes). You can get some markers to personalize and tweak it but most of the basic management is the same. I recall all the hype about cytochrome markers 15 years ago and how we were supposed to choose antidepressants based on that. Mayo went all in on that and it was a blind alley in the end.

    As far as intuition is concerned, 17th century physicians intuited that bloodletting and leeches helped the balance of body humours and late 20th century mothers intuited that self-esteem and helicopter parenting would create non-neurotic mature humans and the list of epic fails is large. I almost forgot that 1990s pain management physicians intuited that opioids were underprescribed. You could call the opioid epidemic a triumph of interpersonal medicine because it put subjective feelings front and center. Intuition cannot stand on its own divorced from the empirical.

  4. There are definite rules of life and rules that work that originate from outside of medicine. Temperance/moderation is a pretty basic one that many Americans rebel against at their peril.

    At many levels I see this like Wittgenstein may have - semantics. Harvey Cushing come up with his own quality improvement program for neurosurgery in the early 20th century when he dropped the mortality rate for craniotomies by 80%. The historical list of improvements in medicine is long. It is basically an advertising trick to say we have now invented quality improvement or evidence based medicine or interpersonal medicine and everybody before us was a chump.

    I think intuition and basic quackery were factors before medicine became scientific and medicine was scientific long before the proclaimed EBM era. In fact my biochemistry and pharmacology seminars (as applied to medicine) were some of the most rigorous scientific exercises I have on on the field.

    To me and people who think like me - medicine is technical expertise. Some people cringe at the word because they think it implies cold and impersonal. I don't think that anyone I have seen has that experience. There is technical expertise in science, medicine, and how you communicate with patients.

    And the average physician has a lot more of it than can be learned in a 4 hour communications module.

  5. The term interpersonal is ironic because it's just a rhetorical trick to appeal to demoralized people offended by assembly line care into thinking they are getting something different or special. The seminars on this are basically going to be a Monty Python call and response sketch..."repeat after me, minions, we all get interpersonal care now. Crowd: Yes, we all get interpersonal care, we are all individuals."

    1. There will undoubtedly be an interpersonal template and a corporate webinar that all MDs will be mandated to take. And you are right - after you get your 80% score on the quiz at the end you will be able to say that we are all certified in interpersonal medicine. And I would predictably be able to quiz any of those people on the interpersonal dimension of care and they would think I was from another planet.

      Reminds me of the original managed care promise that primary care was going to be emphasized and specialty care minimized. I think I have posted the APA seminar I attended back in the early days of managed care when one of their consultants told a large crowd of psychiatrists that he was going to buy out all of our practices and convert them to primary care. He was going to do the same for orthopedic surgeons, etc.

      That lasted until the business world found they could replace physicians by non-MDs, own most the specialists, and own most of the procedural care done by specialists. Now if I use the physicians search in my health plan and look for primary care internal medicine in my area - I pull up 50 names less than 10% of them are MDs. Pretty incredible how the corporate world has decimated the field at an ever increasing cost.

  6. It's incredible how the cardiologists just walked away from something precious based on the BS they were told and believed hospital cardiology was a trend they couldn't fight. The BS became reality simply because it was repeated forcefully and often, Soviet style. It's like a stranger walked up to them and asked them for the keys to their house and they just said yes out of fear without really assessing the risk of saying no. If physicians could muster 1/10th of the animosity they have toward junior colleagues toward corpmed, at lot of problems would get solved. I actually think corpmed are master psychologists in sensing human weakness and exploiting it. Doctors are really dupes in this regard. The old DSM self-defeating personality disorder description comes to mind.

  7. Ran into a coworker who read this post just a few minutes ago. He suggested the theme was:

    "There was evidence-based before there was Evidence-Based" (my caps added)

    I thought that summed it up pretty well

  8. To clarify, I don't think evidence based is close to a Holy Grail. "Evidence-Based in caps" really means a bureaucracy's opinion on the weight of evidence. Which is often wrong and not a substitute for physician critical thinking. Evidence-Based Guidelines have been spectacularly wrong on opioids and statins and nutrition. The fifth vital sign and Wessonality to replace butter and sugar in everything wasn't the idea of a rogue physician. The thinking rogues fought all this nonsense. Also what is often considered evidence based often isn't. There's not a shred of evidence supporting the Food Pyramid and 6-7 servings of grain a day, it's not bad data, they just made it up with the assistance of Big Ag.

  9. I figure it's only a matter of time before CMS declares the PHQ9 to be the new fifth vital sign...

  10. I will just keep it simple, who in their right mind wants to be a physician since it became obvious that politics was going to rule Health Care choices and decisions? I would be very skeptical of anyone finishing med school since 2010, knowing full well that Obamacare was going to cripple and gut true health care that was based on caring and concern interventions.

    It's that simple to me, so, why do we put up with colleagues who are just there in medicine for the sake of either outwardly making money as able, or just willingly be pawns in political behaviors?

    Health care as we who have been providing it prior to the early 90s know it is dead as a profession per Hippocratic principles. Who else has the guts to say it?!...

  11. I still think there is hope.

    Medical school positions are still very competitive - although there is the question of why not more medical school positions. The cost argument of replacing physicians with non-physicians does not seem like a reasonable argument to me since in many settings the billing is the same. Just another political decision.

    The people I run in to each day still want to do the right thing. I am working with many young, energetic and bright colleagues who provide excellent care and read the necessary research regularly.

    Sure we would be able to provide better service if the EHR was intelligent rather than a a millstone around the neck. We would be able to provide better service if medicine was squarely focused on clinical care rather than business models and politics.

    Many years ago someone told me that you can find your niche in a hierarchy and survive there even if you disagree with everything else going on in that organization. I think there are plenty of us out there. Raising money for legal action in the MOC debacle was a good sign. Most of this activity initiated by Cardiologists from prestigious institutions is another good sign.

    At least some of our colleagues are starting to realize that no progress can be made unless we fight the power.

  12. I am of two minds on the issue of younger physicians. I think they realize EHR is complete garbage but on the other hand they are quite indoctrinated into the routine and they view medicine as shift work. I keep hearing that they will make it better because they are tech savvy, but once you hit thirty your fluid intelligence drops and the chance of innovation drops. I think it would have happened by now. Of course, the regulatory capture of EHR makes it next to impossible to bring a better mousetrap into widespread use. The templates I copyrighted for medical-legal exams simply using WP developer are much better than Epic. Almost any medical software developed in the eighties is too, so I'm not bragging.

    I am appalled by the Aspergerization of the clinical exam. It's all about tests and images and not touching people and picking up the subtle signs on exam, the beautiful art of medicine. I haven't taken my shirt off in ages. I think they've forgotten DeGowan and DeGowan. I prefer a physician over 50.

  13. Agree - not impressed with the tech savvy argument. First of all its not really tech. EHRs are the IBM Selectrics of the 21st century. Second, is really that hard to learn dumbed down tech? The most sophisticated EHR today is the equivalent to desktop database software and less than the equivalent of ddx generators of the 1990s.

    EHR templates are the equivalent of the old paper notation "WNL" as in "We Never Look".

    I still have my copy of DeGowan and DeGowan.

    You hardly ever see any of those techniques anymore. I wonder if physical diagnosis means anything anymore or it is just a rite of passage?

  14. I still have mine too, the little brown book. I think the CN2-12 exam is a lost art. They go straight to imaging.