Adam Cifu
@adamcifu
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Internist, professor, patient. Author: Ending Medical Reversal; Symptom to Diagnosis; Sensible Medicine. Podcasts: S2D & Clinical Excellence. Loves Baseball.
Chicago, Illinois
Joined October 2011
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It's a little hard to listen to the parade of experts telling us of the milder disease caused by omicron as my hospital overflows with cases.
It's the denominator, stupid.
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A fact that should not have taken years in practice to realize: most people in poor health did nothing to deserve it and pretty much anyone that enjoys good health should consider themselves fortunate rather than deserving.
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After eavesdropping on residents talking about days off this weekend.
Me: When I was a resident we never had days off. If they tried to give me a day off I came in anyway.
Resident: Sounds like you needed therapy.
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UpToDate should have a function that the 3rd time you look something up a pop appears saying, "You have reviewed this topic multiple times. You will never learn it. Please give up."
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I'm no rock star lecturer. But I sit through a lot of lectures by people who should not be making the amateur mistakes they do. Here are some suggestions regarding the things that bug me most. What would you add?
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Saw a patient in their 10th decade this week. They declined 3 of my 4 recommendations. Not much I could say...
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I'm considering randomizing my patients, with consent of course, to virtual visits with one of these two doctors to see who has better outcomes.
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Dinner conversation after teaching my 15-year-old daughter about Pap smears.
Me: Do you know which medical school George Papanicolaou went to?
Her: No🙄
Me: The same one as Anthony Fauci and your dad.
Her: Seems like one of those people hasn’t quite measured up.😘
Me: Ouch
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Anybody have a good name for the hydroxychloroquine/azithro/ivermectin combo capsule I am getting ready to market?
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About half my class failed our first organic chemistry class freshman year of college. Our professor, Claude Wintner, responded with an hour long lecture on time management and study skills. The most important lecture I ever attended. Not sure where I’d be without it.
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Me, joking, "I feel bad. My flu shot made me sick." 12 y/o daughter, "That's correlation not causation."
#proudparent
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I think it might be time to fight misinformation fire with misinformation fire.
Since I got the COVID shot I have lost 10 pounds, decreased my 5K time, been twice as productive at work, and become a better parent.
What has the vaccine done for you?
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A patient to me today:
"I wanted to let you know that your diagnosis was wrong.
You seem like the kind of doctor who would want to know."
A curse and a complement in 2 sentences.
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Being able to quickly recognize when someone knows more than you and then stop talking and start listening is a skill that needs to be continuously honed.
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OK, here is a shocking piece of advice. You know what is the best way to learn medicine, at any stage of your career? Continue to see patients and read about what they have. Shocking, right?
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Even though I am a medical educator, I hate workshops, role plays, and breakout sessions. There, I've said it.
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Saw a doctor as a patient yesterday. The experience (a good one) reminded me of this slide. I think we would benefit from occasional visits by an undercover standardized patients who would give us feedback.
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Shocking result. Truly shocking!!!
😉
Vitamin D Supplements for Prevention of Covid-19 or other Acute Respiratory Infections: a Phase 3 Randomized Controlled Trial (CORONAVIT)
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Patient today reminiscing about her partner of > 60 years. He used to fix things in their old Chicago home.
"Now every time something stops working I curse the house and then realize how much I miss him. I then thank the house for reminding me."
It was hard not to cry.
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If someone were to ever publish a book of photographs of old hospital entrances, I would buy it.
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Journalists need to stop with the:
"Important person X has tested positive for COVID even after being vaccinated."
In the next 20 years we are going to have innumerable positive tests in asymptomatic people or people with colds. This is not news and does harm.
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Went totally "out of my lane" with some career/personal advice for our 4th years. What would you add?
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Finally got to read this. Thoughtful and powerful.
"I believe we should stop trying to prevent all symptomatic infections in healthy, young people by boosting them with vaccines containing mRNA from strains that might disappear a few months later."
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I've decided that you're only a true internist if your reaction to an elderly patient's A1C improving (7.7-7.0-6.3) is worry.
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Felt the need to update my 10 commandments. Fortunately, on twitter, commandments are not written in stone.
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When I start my own medical center a few awards I'd like to see given.
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1/2
With all due respect to POTUS's docs at Walter Reed, the current situation reminds me of this paragraph from a book written by the amazing Ben Kean, my parasitology teacher in med school.
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Returned to the office today to an incredibly nice message from a long term patient on mine. Reminded me of this.
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My grandfather’s med school transcript. Trying to decide if I would have ranked him to match. 😉
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Family member just spent 36 hours in the hospital. Reminded that nurses are God’s gift to humanity.
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Ok, inspired by another week on the inpatient medicine service.
A. Get vaccinated.
B. If you are over 60, obese, and have not yet been vaccinated you are making a huge mistake (possibly the last mistake you will make). DM me if you want to talk. Seriously.
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PSA
Not every patient seen in an ER or urgent care "needs to his/her primary care physician in the next 2-3 days."
(Feeling especially overburdened today.)
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Can I bill at a higher level if a visit made me really sad? How about if I was so sad I needed to consult with another physician?
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Rough clinic yesterday. Recognized I was not doing a great job with the last patient. Called him today to review his labs. Started our conversation, "Sorry if I was not at my best yesterday."
Wow, did that stimulate quite a conversation!
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This is, as usual, excellent — whether you agree or not.
@VPrasadMDMPH
What we are doing to college kids is total madness
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Something I never thought I would write when I was training: All the patients in my practice with HIV are over 70.
(Back in the early 1990's I also never thought I would "tweet" that, but that is a different story).
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Just gave a patient of mine a list of all the Colorado ski areas that have free lift tickets for people over 80. I am not sure this was a good medical intervention.
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One last question for twitter today.
What "medical myths" do you find particularly pernicious, persistent and irritating? What are your medical myth pet peeves?
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Two pieces of news today: vaccines shockingly effective; CDC director feels impending doom. Which do you think will get more press coverage?
@VPrasadMDMPH
@MonicaGandhi9
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A reflection on privilege. Walked from the hospital to my office to get my lunch. Dressed like this: no white coat, no stethoscope, no ID. Six strangers referred to me as doctor (hello doctor, morning doctor...). Certainly realize that’s far from everyone’s experience.
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I find it sort of amusing all the people who are expressing shock (shock I tell you) that there are healthcare disparities in this country.
Where exactly have you been?
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I’ve come to realize that I value in leaders what I value in a good doctor: The ability to admit when you don’t know, to acknowledge complexity, and to admit that the impact of certain decisions you made keep you up at night.
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One of the best pieces of advice I ever received about practice. Identify a patient concern that makes you miserable (dizziness, fatigue, headache...). Learn everything you can about it. You will then actually look forward to tackling it.
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Saw a patient today whose symptoms had been attributed to anxiety. On my assessment there was a clear organic cause -- a diagnosis with which the previous doc was just unfamiliar. A good reminder to get help before you ascribe atypical symptoms to anxiety.
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A funny Friday phone call.
Me: Hi, this is Dr. Cifu, I am covering for your doctor, can I help you.
Pt: What is your name?
Me: Dr. Cifu, Adam Cifu
Pt: I follow you on twitter!
(We agreed that I would tweet about this anonymously.)
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Slide made for my medical student who claimed he did not smell the scrotal wound because he had to keep his mask on. Sheesh, kids these days...
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I am not proud to admit that it has taken a pandemic to make me stop, greet, and thank every environmental services employee I see in the hospital.
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OK, I just pulled out the, "Would you rather have a sore arm or would you rather die of COVID!?!"
I was not proud of myself. It was the end of a long morning.
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Since my exam pet peeve tweet seemed to irritate a lot of people, presentations pet peeves. I like the article better than the slide!
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Gave two 4th shots to people who will likely not benefit from them while I failed to get two others to get a 1st shot that they would very likely have benefited from. Ahhh, the work of a PCP.
🙄
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Given some recent experiences, I felt the urgent need to update and republish this slide.
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There’s a saying that anyone driving faster than you is crazy and anyone driving slower doesn’t know how to drive. Similar with COVID-19: anyone taking more precautions than you has an anxiety issue and anyone taking fewer is an idiot.
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Just for the record, being a doctor is exponentially easier than being a patient (or the child of a patient).
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This is an occasional post for me, always after a talk given by someone who should know better.
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Born of 25 years of practice, my 10 commandments for avoiding clinical errors. What would you add?
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Pointed out to me by a student today. The two COVID-19 papers we read had an author:patient ratio of 1.25.
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This tweet will date me.
Two reasons I will never use a scribe:
I do most of my best thinking when I write my notes.
I think the exam room is for the doctor and the patient; I will not open it up for my convenience.
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Should everyone (patients, HCWs, visitors…) mask in healthcare settings from now on, forever?
Yes
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No
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For years, the last handout I give the students in my fourth year course has been (totally shameless, unsought) life advice. This AM, seeing patients, reflecting on things I really love about my job, I decided to update them. Felt the need to share before next February.
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87 year old (who did not go to medical school) with edema.
"I don't know what it is, doc. Is it my heart, my kidneys, my liver, or just my veins?"
Quite a differential!
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Going on the inpatient service next week. Printing out my diagnostic reasoning penalty cards...
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I am so often amazed (and, to be honest, frightened) at the connections and diagnoses that I only make while writing the note after the patient has left.
Glad I'm an internist and not and ER doc.
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Quite a vaccine hesitant clinic today. A new line I have been employing, "I can understand having been worried about the safety of shot when I got it back in December but certainly not now after 100 million people have gotten it."
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A quotation that I heard on a podcast that I can't get out of my head:
Disease only treats humans equally when our social orders treat humans equally.
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Something odd about this company joining the likes of Rolex, Lavazza, and AMEX sponsoring the US Open.
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My graduation day tweet. Good luck to all the new minted MDs!
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As our students head into their residencies, my yearly advice (which seems to be always evolving).
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You can tell how far along a trainee is by listening to whether they are presenting the information that they collected or the information that you need.
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"I'll get it because you have cared for me for the last 20 years and clearly are only interested in my health. I have ignored the 14 relatives who have been hassling me." Music to the ears of a PCP.
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When I order a lab, and Epic alerts me to the fact that I just ordered the same lab 2 days ago, I want to scream, "I'm an internist, that's what I do!"
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Just getting to this. So interesting.
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What is the most Sisyphean activity in your 21st century life?
Mine, unsubscribing from email lists.
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From a wise colleague.
The most dangerous doctor is a kind, empathic, humanist who is incompetent and lazy.
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Here is something I see as an early career mistake: insisting that you will not fill a prescription for a patient who hasn't been in for a while until they show up for a visit.
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My heart goes out to the tired looking, disheveled, sad looking people wearing visitors IDs at 7:00 in the morning on a Sunday in the hospital. Makes my whining about having to round seem pretty pathetic.
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My last clinic with Dr. Brukner who interviewed me for this job in 1997 and became my boss, mentor, dean, colleague, friend, and academic fairy godmother.
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100% reliable anecdotal data.
It has been a year since I have had a cold.
Masking works.
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Prepare yourself for this truly profound realization:
The best way to stay current with medicine is to continue to see patients, read up on what you care for, and discuss cases with colleagues.
Thank you. Have a nice weekend.
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A tweetorial.
One of my favorite points to making when teaching diagnostic reasoning it to stress that positive findings are immensely more important than negative ones. I believe this so strongly that it is point 4 on my diagnostic reasoning yellow card.
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I do not care for it when anybody - patient, colleague, consultant - feels the need to inform me of their academic pedigree.
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My holiday tradition for the past few years has been to repost my twitter slides when I go on the inpatient service at the start of December since I have generally run out of time and things to say. So here we go, slide a day until I run out. Day
#1
, 10 doodles.
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Spectacular images that you might not want to look at...
Migrating Dirofilaria repens | NEJM
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I really like this. My favorite line:"Changing the USMLE to a pass-fail format would require residency programs to find other, potentially more meaningful, ways of evaluating applicants." That would be a very good thing.
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Patient of mine declined a flu shot because his wife wasn't there to get one as well. Sort of like not wanting to get ahead of your partner on a Netflix series.
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The career in medicine humility effect. On rounds.
1st patient: "You are the most polite and kind doctor I have ever met."
Family member of 2nd patient (literally right across the hall). "The communication has been poor and we have lost our trust in you."
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Allergic rhinitis presenting as "I think I have a CSF leak" is diagnostic of googling symptoms.
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I’m beginning to think this is the career trajectory of a physician: As you age and experience more personal health issues you develop greater empathy. For a time this makes you a better doctor but eventually your empathy is so great that it paralyzes you and you have to retire.
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I would not be surprised if, on the average inpatient medical service, more time is spent discussing the results of tests that should not have been ordered than discussing which tests should be ordered.
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As our
@UChiPritzker
students, along with thousands of other medical students, head toward graduation, ten pieces of advice, offered humbly..
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On the day we send another class out into the word - or at least to residency - a few words of advice.
What would you add?
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