Adam Rodman
@AdamRodmanMD
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Physician, educator, historian, author, co-director @iMEDEducation @BIDMC_IM , host of #histmed podcast @BedsideRounds , studies 🤖+🧠. He/him/his. 🖖🚲
Boston, MA
Joined March 2010
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What happens when a patient in the remotest parts of the world develops a surgical abdomen?
New
@BedsideRounds
on dramatic appendectomies in the Antarctic and on a submarine at wartime -- and how this influenced the first effective medical AI.
Ep link:
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Everyone is the hospital is working really hard right now, but I especially wanted to thank our residents.
You all are being tested like very few generations of trainees have been historically.
I really appreciate all that you're doing for your patients.
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Why do we use godawful blue-background-with-bright-yellow-text for medical school lectures?
A 🧵on magic lanterns, darkrooms, path dependence, and “things we do for no reason”
👇
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I love that in this painting of an attending physician's rounds, you can see how much has changed (and how much hasn't), including the medical student who appears to be using his phone during the encounter (sorry time travelers, it's a notebook)
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The entire idea of a "physical exam" is a 20th century invention. Seriously, in Rene Laennec could see us auscultating patients' lungs in whom we had just obtained a chest CT, he would lose it.
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It's time for me to channel my inner
@tony_breu
-- which means it's Tweetorial time!
So let's talk about azotemia (elevated blood urea nitrogen) after an upper gastrointestinal bleed!
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So many arguments about what's wrong with medicine today are predicated on imagined (and inaccurate) histories. Let's take some examples from my colleagues who imagine a "golden" age of the exam:
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American progress notes are > 4 times longer than our colleagues' in other countries (source: )
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They're called discharge summaries for a reason, not "discharge copy-pasted-crappy-progress-note-that-lists-every-little-thing-that-happened-during-a-hospitalization."
🙋♂️ What’s your unpopular opinion in medicine that will get you in this position?
#MedTwitter
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Why are medical podcasts like
@thecurbsiders
,
@BehindTheKnife
,
@emcrit
, and
@AFPpodcast
so popular for learning? And who is making them? And can they be trusted?
We listened to (and coded) the top 100 podcasts on the Apple podcasts US medicine chart to find out!
A 🧵⬇️
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Of all the awards I've won, I think this is most meaningful. No matter my other endeavors, my top goal is to be the best doctor I can to my patients. Thanks so much to all my nursing, therapy, social work, and medical colleagues. You don't know how much this means to me!
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The quality improvement movement hasn't improved healthcare quality, especially when taking into account the massive amount of money and manpower we spent collecting and analyzing quality metrics. A new paradigm is necessary.
What’s your unpopular medical opinion that would land you in this position?
Drop it in this thread
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It’s time for another
#histmed
Tweetorial -- this time I'm going to talk about the pesky definition of a fever, and where the 98.6 F average body temp came from!
Full disclosure: will use C AND F for temp, but no K or R.
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Supposition: there are so many notes in the medical record of a hospitalized patient that if a physician ACTUALLY read each one in its entirety, there'd be no time for anything else.
I think much of our note writing is performative -- not driven towards actual patient care.
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Can I still complain about that stupid article in JAMA that chastised physicians for using the phrase "chest x-ray" instead of radiograph? (because, of course, x-rays are actually invisible waves of energy we cannot see).
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The other day, I walked in to one of my severely demented patients with her hair beautifully done in a complex braid. One of our aides had washed and braided it for her. Such simple, little acts show so much humanity.
One of the greatest honors in our profession is witnessing the beautiful acts of kindness nurses do for patients every day:
- sweet conversations about children and families
- relieving shame of the body and its functions
- respect for and relief of pain
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Almost exactly a year ago, I had a modestly controversial tweet about routine daily physical exams -- and about how we should probably spend more time actually talking to our patients daily rather than pretending to examine then.
The reason to do a physical exam (or pieces of a physical exam) is because it helps you make decisions about caring for the patient.
If you want to connect with them, maybe spend that time talking to them, instead of pretending to listen to their heart and lungs?
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This is officially my favorite Netter plate: "hormonal pathways in the rage reaction"
Anyone have a better Netter for a Netter-off?
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Would anyone be up for publishing a controversial piece on "physical exam kabuki"?
Maybe"Things We Do For No Reason: the daily physical exam"?
The argument, "it builds connection with our patients" is the ultimate post hoc fallacy that I would love to push back against.
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I have just finished the first draft of (what I think is) literally the best grand rounds I have ever prepared -- an overview of the links between our understanding of clinical reasoning and artificial intelligence, stretching back over a century but contextualizing today.
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Our new study in
@JAMAInternalMed
looking at the reasoning abilities of GPT-4 compared with human physicians just came out.
Big picture: AI displays (much) better reasoning than humans, makes diagnoses similarly, but hallucinates considerably more.
A 🧵to put in context ⬇️
How good is
#AI
at clinical reasoning? An early, simulated assessment
“An LLM was better than physicians in processing
medical data and clinical reasoning using recognizable frameworks as measured by R-IDEA”
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For anyone bemoaning the "good old days", an experiment in which 10 healthy medical students were made to drink blood to figure out the volume necessary to produce melena. TL;DR 50-80 mL
@mondhiry
( -- 1939!)
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Can GPT-4 solve really hard medical cases and come up with a good list of differential diagnoses?
@zahirkanjee
@byrondcrowe
and my study is out in
@JAMA_current
, and the short answer is, “Yes.”
But what does this all mean? 🧵⬇️
In this study, a generative artificial intelligence (AI) model provided the correct diagnosis in its differential in 64% of challenging cases and as its top diagnosis in 39%.
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Thirty years that changed medicine -- all the infectious disease identified from 1877 (anthrax) to 1906 (pertussis).
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Useless medical word of the day: upper and lower extremity. Are the words arm and leg too much? Or are we just allowing that we might eventually take care of patients with tentacles?
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For all those who wanted a recording of my grand rounds on diagnosis, here it is!
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Hey everybody. I'm putting
@BedsideRounds
on hiatus for the time being.
As a hospitalist (an inpatient internal medicine doctor) in Massachusetts, I expect the next several weeks will be some of the busiest of my life.
Good luck to everyone. We're all in this together.
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During the 1889 flu ("Asiatic flu"), a panicked public turned to quinine and antipyrine (an early anti-pyretic) to save them, leading to reported shortages among druggists.
The historical parallel to chloroquine and its analogues in COVID-19 is striking.
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This is fantastic. In this study, nurses' concern about a patient has a positive LR of 18 for ICU transfer, and *40* for the highest level of concern ("worry factor" as they term it in the paper). Area under the curve 0.92!
TL;DR -- when your nursing colleagues worry, LISTEN.
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Okay, I think it's time to be a party pooper here. It's very hard to prove a negative -- but unless someone has a primary source that proves otherwise, I'm pretty sure this is a myth (that lasix is named because it "lasts six hours") A brief 🧵
Resident blew my mind today
Lasix is named Lasix because it LAsts SIX hours !!!!!!!!
🤯🤯🤯
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I hereby propose Rodman's Law:
If there are two medical interventions without clear evidence supporting one over the other, the default should be the one that makes the patient less miserable.
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Incredibly honored to be recognized as
@bidhospitalists
teacher of the year by my amazing residents
@BIDMC_IM
! I'm glad you guys appreciated my pressured ranting and late night deep dive emails (instead of just thinking I'm a crazy person) 😀
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Honest question -- we call a troponin a "cardiac enzyme" because creatine kinase is an enzyme, and the troponin has replaced that test, right? And we just kept calling them enzymes despite the fact that a troponin is not an enzyme?
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The fingernails are the windows to the soul
(Actually, I suspect the clinical utility of most nail findings is nil, but most of my House MD exam moments have been through the nails)
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The reason to do a physical exam (or pieces of a physical exam) is because it helps you make decisions about caring for the patient.
If you want to connect with them, maybe spend that time talking to them, instead of pretending to listen to their heart and lungs?
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19th century physicians often had personal mottos.
Laennec's was "the whole medical art lies in observation"
Osler's was "equanimity"
Kind of sad that we've dropped this tradition. What would yours be?
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Why you should always Google yourself: because otherwise, I wouldn't have found this gem of a review (in a list of the author's favorite podcasts):
"Bedside Rounds
A doctor with an annoying voice talks about the history of medicine. Not much more to it than that."
Um, thanks?
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Adam's daily 🔥take:
A SOAP note does not have discrete sections of subjectivity and objectivity but rather a continuous spectrum throughout.
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My (preaching to the choir) 🔥 take: digital educational skills -- whether teaching on
#MedTwitter
, podcasting, or making videos -- are essential
#meded
skills for the 21st century. And we can teach these to future educators.
A Tweetorial🧵:
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When I was a medical student at Tulane, I took an advanced internal medicine course taught by Chad Miller (and Ben Rothwell).
We read Rouche and Holmes. We went to the art museum to look at paintings and sat in the French quarter and made careful observations of people passing.
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#spoileralert
: a lot of things. And if you’re interested in that, I produce an entire podcast of medical history and how modern medicine came to be called
@BedsideRounds
. You can even get CME credit if you're a member of
@ACPinternists
!
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Well, this was not expected!
@BedsideRounds
is now written up in the
@bmj_latest
as one of "five podcasts every medical student should listen to!" Thanks to Anna-Lucia Koerling (the author, who I'm not sure is on Twitter) -- I'm glad you enjoy, and incredibly honored!
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"When there is no reason to believe there is any difference in outcomes between two interventions, choose the one that sucks less for the patient" - Rodman's Law
The pain experienced by your patient as the phlebotomist searches for a vein should be the strongest deterrent of unnecessary daily labs.
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If the justification for a medical practice is, "that's what we've always done," it's probably a good idea to take a long, skeptical look.
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Since my thread on the historicity of the exam can gained some traction, here's a reading list if you're interested in gaining perspective on the nature of clinical reasoning -- rather than "just so" stories about imagined halcyon pasts (the era of "the Giants")
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This past Tuesday, I was honored to help plan and participate in what I think is the first ever clinicopathologic conference (CPC) with an artificial intelligence (Dr. GPT-4) discussant
@BIDMC_IM
.
It was… eerie... to say the least.
These were my experiences: 🧵⬇️
📢Who do you think reigns supreme for today's Clinicopathology Conference (
#CPC
) ?
Dr.
@stephcabral_
vs Dr. Kevin He vs Dr.
@AdamRodmanMD
vs ChatGPT
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TL;DR - 35mm 🎞️used🔵for visibility; early 🖥️used 🔵/🟡 (among others) for visibility, and PPT and other slide presenters adopted these standards by default. Great example of path dependence!
I just saved you 20+ Tweets 😄
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This is that happens when you ask me to lecture about anything I want 😂
Coming Tuesday
@BIDMC_IM
! Putting all the reading I've done over the past two years to explore the McKeown thesis into some clinical context. Hope to see all my residents there!
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What other things do we commonly do to patients today that have a similar evidence basis to “blue powerpoints with yellow text?
Why do we have a medical culture that largely accepts tradition?
What else do we only do because of path dependence?
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Another wonderful piece by
@VPrasadMDMPH
. For those applicants who had high school or college jobs bagging groceries, working as a waiter, &c, PUT IT ON ERAS!
I know you don't believe me now, but food service has far more relevance to practicing medicine than pipetting in a lab
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Have you ever wondered where SOAP notes come from?
Do you wonder why we spend SO MUCH time at the computer, instead of with our patients?
Do you worry that we way we document warps our diagnostic thinking?
Then see you at BIDMC Gen Med Grand Rounds tomorrow!
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One of my favorite books on the history of diagnostic reasoning (fortunately it's still in print!) is Medical Thinking by Leslie King Snow. I haven't read it in its entirety in years, but the opening is a vivid reminder of medicine just a few generations ago.
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@GavinPrestonMD
"Hi, my name is Adam Rodman and I'll be your doctor. You can call me Adam if you'd like. How would you like me to call you?" - every patient I meet for the first time
Asking someone how they'd like to be referred to is a mark of respect, not the other way around.
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If you couldn't make it. I'll be live tweeting the
@BIDMC_Education
conference on AI, clinical reasoning, and the future of medical education!
@iMedEducation
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The reason that we do ANYTHING in medicine needs to be based on reasoning based on the medical conditions and realities of today -- and not imagined histories of the past.
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About a month ago, I commissioned
@sukritibanthiya
to draw this AMAZING image to celebrate six years of
@BedsideRounds
(and to finally provide some swag) -- and it turned out better than I could have ever imagined!
And now I've set up a
@TeePublic
store:
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I am planning on creating a "mini-curriculum" (probably five talks) on medical history and epistemology targeted towards medical students.
Any ideas for topics? I already have:
➡️Hx of nosology (what is a disease?
➡️Hx of the physical exam
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This rotation, for a day I made my entire team drink only thickened liquids for a day (myself included). I ended up using six packets of Thickit, including for the Coke I drank in the AM (wasn't going to thicken my coffee ...)
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Early chest x-rays were very poor at showing the lung parenchyma. These images are from Francis Williams' radiography department at Boston City Hospital. The patient would have to lie in this position for almost 45 minutes, producing the image seen below.
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So excited to speak on what I think is one of the most exciting innovations in medical education in the last decade
@BIDMC_Academy
with
@tony_breu
and
@ShreyaTrivediMD
!
One of the things I find so wonderful is how much the format has evolved over the past year.
A brief 🧵👇
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Another editorial cartoon from the Boston Daily Globe in 1889 showing quinine defeating "La Grippe" (a common name for influenza) while the standard of care (uh, whiskey) looks sullenly on.
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Many of us already listen to amazing medical podcasts like
@TheCurbsiders
,
@CPSolvers
,
@NephJC_Podcast
,
@medrants
#AnnalsonCall
in our own time
-- but will medical podcasting be integral to medical education?
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Do large language models have a probabilistic understanding of disease states? And what does this mean for the future of diagnosis and clinical reasoning?
I explore this with Thomas Buckley,
@arjunmanrai
, and
@dr_dmorgan
in our new paper in
@JAMANetworkOpen
.
A brief 🧵⬇️
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If you couldn't attend my grand rounds at
@WUDeptMedicine
, it has been uploaded to YouTube! ()
Again -- thank you so much for having me (and to
@MohitHarshMD
for a way-too-gracious introduction).
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Are there better colors to use in a modern powerpoint?
@JenniferSpicer4
pointed me to this modern research on PPT presentations -- it's actually remarkably similar to research in the 1970s showing black on white is the most readable! (and blue among the least)
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Sometimes I get overly cynical and think that profiteering off the backs of medical students will never end. And sometimes, I'm very happy to be reminded that advocacy and optimism actually works.
USMLE STEP 2 CS IS CANCELLED FOREVER!!!!!
No more USMLE Step 2 CS!!!
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Putting the finishing touches on a new grand rounds! (I'm trying to put together a new one each year which I refine throughout the year). A big picture explanation on the cognitive nature of diagnosis that I've been working on for the past two years.
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I might be driving myself down a crazy rabbit hole. I keep reading descriptions of the Russian Flu of 1889 -- the description is SO similar to COVID-19.
We've previously assumed that the flu epidemics prior to the 20th century have been influenza -- but how can we be sure?
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@jbcarmody
@drwangmd
So I don't know the actual answer (the idea of "panels" that are reimbursed at certain rates seems to be a post-WW2 phenomenon), but the tests (or their precursors) on the Chem7/BMP/&c were developed by Otto Folin c1909; phos and mag levels were developed until the 1920s
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The "ancient" and "sacred" exam that we imagine Hippocrates, Avicenna, Vesalius, Laennec, and Osler all performed lovingly on their patients before us moderns got distracted by alienating technology NEVER EXISTED. It's a 20th century nostalgia, not based on historiography
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If you ever doubt how much path-dependence there is in medicine, the appropriate doses for quinine were based on cinchona decoctions in the Schedula Romana published in *1651*, and weren't changed until the 1970s.
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Do you make Tweetorials, infographics, medical podcasts, or streaming videos for medical education?
Or have you ever wanted to try?
You're a digital educator -- and we have exciting news! This year's
@iMedEducation
#DigitalEducation2022
conference has a teaching competition!
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All of our bacterial identification in 2019 is based on the application of textile dyes from the 1860s, in a method developed in the 1880s. That's kinda crazy, right?
This is wool dyed by crystal violet, the dye used in the gram stain.
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@MElashwal97
@CNemehMD
@samsfeelinggood
Oh man -- I'm probably going to make a lot of people mad :)
But I think the folk belief exists because there's some truth to it (see, eg, this fascinating RCT: )
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We don't let long haul truckers do it.
We don't let pilots do it.
Remind me how we work for an "evidence-based" field again?
I worked an unexpected overnight last night
This 🧵 is an exhausted, muddy-headed takedown of the historic but continued saddling of medical trainees with ridiculous work hours
There will be no data and I will appeal to emotion a lot
Here we go!
#MedTwitter
1/
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I'm giving grand rounds again! This time I'm going to give a talk that's a long-time coming (almost four years in the making!) -- a historical framework for how we know things it medicine! It'll be interesting, I promise.
Please come, and please come say hi!
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I am SO excited to give
@BIDMC_IM
Gen Med grand rounds tomorrow!
➡️What does it mean to make a diagnosis?
➡️Why do collect data from our patients the way that we do?
➡️Why do we call it "data"?
➡️Why are we so miserable with the EMR?
➡️Will computers replace us?
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The idea that APSO notes -- that is, SOAP notes with the assessment and plan at the top -- are unironically suggested as a way to "fix" medical documentation shows how devoid of real ideas we really are.
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Very exciting news!
@ShreyaTrivediMD
and I co-founded
@iMedEducation
@BIDMC_Medicine
earlier this year, dedicated to the advocacy and study of all types of digital education, and we are hosting a (virtual) national conference on January 22nd.
We want you to come!
A brief 🧵⬇️
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Where did the godawful yellow-text-on-blue-background default powerpoint template that was all the rage in Med Ed for the past decade come from? I remember as a med student at Tulane being specifically told to do my powerpoints like that...
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@reverendofdoubt
When I'm working on a solo service, I tell my discharging patients that they have to ask me three questions before I'll leave their room.
Always get some interesting questions 😀
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I am going to force my poor residents to play a Dungeons and Dragons roleplaying session to learn about myths in hospital medicine (maybe I can call it Wards and Wizards??)
Any ideas for classes for the game for their characters?
@cjchiu
@BrighamSK
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Hey guys!
@tony_breu
and I are looking professorly for our live podcast on the history of syphilis! Room 114 -- come and join us!
#IM2019
#Curb19
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The "ee" to "ah" change of egophony in lung consolidation was described by Shibley in his Chinese patients. He would have then count 1-2-3 (yi, er, san) to test for pectoriliquy, and noted that yi (ee) changed to "ah" over the pneumonia.
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Money quote from the Oath of Maimonides:
"May I never see in the patient anything but a fellow creature in pain"
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Well, now that angry tweet is a point-counterpoint-rebuttal series in
@JHospMedicine
!
The first piece is by me and
@ShaneWarnockMD
, and I cut right to the point: Routine daily physical exams in hospitalized patients are a waste of time.
🧵⬇️
or
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Should we mourn CMS ditching the review of systems documentation requirements? Or celebrate? Or something else?
@Gurpreet2015
and I I think is a HUGE opportunity for medical educators to better teach history taking -- and clinical reasoning. A 🧵⬇️
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So thankful to
@BIDMC_Medicine
for inviting me for super esoteric topics for gen med grand rounds! (and to
@_JosephLi
for an over-gracious introduction!)
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And if you're "a certain age" (as I am) you'll remember this was everywhere! My first programming language was QBASIC when I was 7 years old -- with a blue background and yellow/white/grey text!
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Hey
#medtwitter
-verse! Did you know I host a podcast about medical history and its influence on cultural and society? You probably did since you follow me on Twitter, and there's not really any other good reason to .. but just in case: Bedside Rounds!
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While neck deep in stats papers from the 1940s, I just realized that receiver operator characteristic curves are thus named because they were developed for radar receiver operators looking for aircraft in WW2. How did I not realize that until now?!
@adamcifu
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And that is how you end up with this guide to a national scientific conference in 2006 and the advice that
@jbcarmody
references to only use this at national meetings
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Today
@AvrahamCooperMD
and my essay on AI/LLMs and medical education comes out in
@NEJM
, about the challenges our field faces and what we should do about it.
I wanted to give some context for this essay, and talk about some of the things we can be doing NOW.
A brief 🧵⬇️
Medical educators have a crucial role in shaping the inevitable integration of AI into the healthcare.
@AdamRodmanMD
and I wrote about it in NEJM ⬇️
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How can we medically tell whether someone is alive or dead? It's a trickier question than you might think --
@tony_breu
and I dig deep in this live
@BedsideRounds
which we gave last month for
@ACPMAChapter
-- The Last Breath!
link:
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One of the most remarkable documents -- and achievements -- of our species: a piece of parchment signed by the members of the Global Commission for Smallpox Eradication Certification, signed on December 7, 1979 in Geneva.
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And they are in print!
@tony_breu
and I wrote a duo of articles about historical and ethical controversies in cardiovascular death determination for
@accpchest
that are now in print!
The Last Breath:
The Last Beat:
Short 🧵⬇️
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The diagnosis toxic-metabolic encephalopathy (which my residents now document with TME) is slowly driving me CRAZY. It's not a useful diagnosis! There are actual toxic encephalopathies (like dig toxicity) and actual metabolic encephalopathies (like myxedema coma)
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Question for
#IDtwitter
-- incidence of serotonin syndrome in retrospective studies in patients on antidepressants and linezolid appears to be quite low (and maybe not even increased; eg )
Am I missing something? Why do we routinely hold linezolid?
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If you want to dig through the data yourself, you can access our study at
@MedTeachJournal
:
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My residents still make fun of me about my obsession with Frank's sign
Frank’s sign: having this diagonal crease on the earlobe is associated with a 45% increased risk of cardiovascular disease.
#MedTwitter
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