Robert Centor MD MACP ๐ฎ๐ฑ @rmcentor.bsky.social
@medrants
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Academic internist focusing on teaching. Annals On Call podcast Unremarkable Labs @unremarkablelab
Joined April 2009
DIURETIC RESISTANCE (an #UncleBob #5goodminutes tweetorial). 1/ 54 yo man w/ LVEF 30%. D/C from hospital 6 weeks - optivolemic.On Lisinopril 20 mg daily, Carvedilol 25 mg bid, Furosemide 80 mg bid. He now has dyspnea & peripheral edema &15 lb gain.h/t @dhekidney & @kidney_boy.
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#UncleBob is considering doing a tweetorial on eGFR as many learners do not seem to understand the strengths and limitations. If this post gets 10 likes - I will work on a careful exposition later today.@CPSolvers @UnremarkableLab @CuriousClinPod.
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1/ #UncleBob presents #5goodminutes for #newinterns #meded.Here is a rather arbitrary list of podcast episodes for 1st month interns. We have samples from @COREIMpodcast @thecurbsiders @CPSolvers and Annals on Call. This is a short list, which we hope whets the appetite.
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1/ #UncleBob has thoughts on planning your career for young clinician-educators. Read for #5goodminutes, then consider for longer. Do not plan your career, rather strive to be the best you. Excellence gets recognized. Opportunities will appear.
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Urine electrolytes - several different uses. 1. FeNa - for oliguric patients.2. Urine anion gap - for cause of normal gap acidosis.3. Urine chloride - to categorize metabolic alkalosis.4. Urine Na and K - to assess for inappropriate mineralocortoids.
#medtwitter can somebody explain urine electrolytes to me because I am looooooooooost?!!!! #NephrologyConsult please!.
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1/ #UncleBob has Pet Peeves - I explain them in ward orientation.1. Chills - rigors or not.2. Night sweats - drenching or not.3. DM - what type, for how long.4. CKD - what stage, what etiology - and stage 3a is very different than 3b.5. HFrEF - what EF, possibly NYHA class.
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Please stop calling me a provider. I consider that a huge insult. Iโm an internist.
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Absolutely the wrong question - i.e., resilience. What are we doing to make practicing medicine less stressful? How can we allow physicians to spend the appropriate amount of time with each patient and reduce the onerous administrative burdens?.Solve that one first!.
Did you know that 44% of female clinicians feel burnout at least once a week compared to 36% of male clinicians?. What are leaders in academic medicine doing to create environments that foster physician resilience? #GenderinClinicianBurnout
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The first 2 years of medical school are extremely poorly designed. Anatomy, physiology, basic biochemistry, etc are important, but students are so overwhelmed that they do not absorb the basics. We should teach to insure a level of understanding rather than to Step 1.
What are other things do we do in #MedEd for no reason / follows dogma of way itโs been?!.
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#UncleBob - to become an excellent diagnostician, you must develop a skeptical attitude. This allows you to avoid premature closure. Donโt accept any new or old diagnoses unless they make sense and you can verify the diagnosis. @CPSolvers @UnremarkableLab @ImproveDX.
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@anonmed15 1/ You are not stupid.2/ You are learning every day.3/ You won't really understand how much you've learned until day 1 of R2.4/ Your feeling is NORMAL.
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A question for #MedEd - as a clinician educator, do you ever model history taking? As a learner have you ever watched a seasoned clinician take the initial history. I posit that role modeling does not receive enough importance for clinical teaching. @DxRxEdu @rabihmgeha.
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1/.Hypokalemic quadriparesis (or severe hypokalemia).39 yo Egyptian admitted with quadriparesis &K = 1.3.Spend #5goodminutes reading how #KashlakChief conceptualizes &teaches this electrolyte disorder. hope @thecurbsiders and @CPSolvers enjoy & @kidney_boy appropriately critiques.
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The big trick is learning to โthink out loudโ with learners. When discussing a patientโs problems, make explicit WHY you are asking particular questions, doing exams, evaluating laboratory tests. That is what learners want and need to learn. #TeachDx.
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Dinner with 2 random guys I found in SF. Weird names: the mathematician and the magician. โฆ@rabihmgehaโฉ โฆ@DxRxEduโฉ Incredible sushi dinner and even better conversation
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#UncleBob is a proud clinician-educator. Clinician-educators are highly valued by learners, but often not by administrators. Fewer awards, less fame, but great daily rewards from seeing learners grow and patients benefit. @gradydoctor @DxRxEdu @rabihmgeha @UABGIM @SocietyGIM.
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Pro tip:.When the Xray reading does not fit the patient presentation, find the radiologist and discuss the image with him/her. Radiologists are valuable colleagues. #5goodminutes #KashlakChief @thecurbsiders.
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#UncleBob wonders if you know tdefinition of paroxysmal nocturnal dyspnea (PND). (1) awaking from sleep with dyspnea (2) having to be upright for around 30 minutes or more. patients with COPD &/or OSA satisfy (1) but they can lie down immediately. You need both to report PND.
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Please accept that family gatherings are not safe. Not safe for Hanukkah, Christmas, Kwanza or any other reason. Please do not gather this month. Let the surge slow down. Wait for you turn at the vaccine. Please do not gather - family is not safe. No gatherings are safe.
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#UncleBob #5goodminutes Day 13/31.I listened to an intern call a consult. Afterwards I taught him something everyone should learn, but often donโt. Lead w/ the question - then tell the story. Consultants should immediately understand what you want. @thecurbsiders @uabimres.
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1/ #UncleBob presents a #5goodminutes tweetorial on the FeNa. The idea is simple, with normal kidneys and volume contraction, the kidney should avidly reabsorb sodium. With acute tubular injury, the problem is that the tubules cannot reabsorb Na.
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1/ #UncleBob recently presented a patient who had a hyperkalemia, normal gap acidosis (type 4 RTA) to @DxRxEdu & @rabihmgeha . But why does hyperkalemia cause a normal gap acidosis?. @tony_breu.
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A medical hero of #UncleBob often said: โIn medicine, never get cocky.โ We took that to me that we should always keep our minds open. Remain skeptical and regularly reassess what is going on. Ask for help when you feel the patient needs a second look. Wise words for my career.
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Basic principles:. eGFR only works with a stable creatinine and normal muscle mass. By definition AKI does not havea stable creatinine -therefore eGFR is meaningless. This does make drug dosing extremely difficult.
Should doses of all renally excreted drugs patient is taking need to be adjusted based on patient eGFR in AKI, or just some of them (e.g antibiotics) during hospitalization? #medtwitter #internalmedicine @kidney_boy @medrants @Nephro_Sparks @NephroMD #nephrology.
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1/ #KashlakChief spends more than #5goodminutes exploring normal anion gap metabolic acidosis (NAGMA) due to CKD. We see many CKD patients on sodium bicarbonate tablets or sodium citrate. This tweetorial will start with why we treat NAGMA. @thecurbsiders.
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The Birmingham VA is doing a wonderful job delivering the COVID-19 vaccine. I feel very fortunate to have received my first dose today. โฆ@ACPinternistsโฉ โฆ@SocietyGIMโฉ โฆ@uabimresโฉ โฆ@UABGIMโฉ
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50 years ago this week I fell in love with Internal Medicine (started my IM student rotation). I'm a day late for #InternalMedicineDay . Our specialty requires clear thought processes, knowledge & an ability to connect with patients. I love being an internal medicine physician.
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1/ #UncleBob has many thoughts about this tragic tale of diagnostic errors!.@UAB_ID @uabimres @acp @sgim @BradSpellberg @PaulSaxMD @AnaerobeSociety .Hard to Swallow | NEJM
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1/ Anion gap acidosis.#UncleBob loved Episode 30 - Anion gap metabolic acidosis via @CPSolvers Definitely worth #5goodminutes I have a slightly different schema and will use this tweetorial to present a complementary approach and provide some key refs.
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#UncleBob clapped on rounds 4 an intern today. Pt admitted & found to have a patchy infiltrate in the right lung. He had received rx for CAP 4 weeks ago. Intern told me that we stopped antibiotics because pt had no fever, productive cough or other CAP symptoms. So I clapped.
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1/ #UncleBob has these suggestions for interns and rising interns:. Pt. malnourished (especially living on EtOH) - assume thiamine deficiency and treat aggessively - check PO4 now and for the next two days (refeeding syndrome).
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Rigors = SHAKING chills - often teeth rattling.Chills = feeling chilly - almost everyone in the ED feels chilly.And rigors (not vanilla chills) have a strong OR for bacteremia.
@cantab_biker @TheCribsiders @medrants My (basic) understanding is that #rigors is a more severe, uncontrollable shaking than just your garden variety shivering when febrile. Any other #medtwitter folks want to weigh in? @medrants.
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Pro tip for students and residents. Just give the age of the patient, do not add an adjective like young, middle aged or elderly. You can add looks younger or older than age. #5goodminutes #KashlakChief @thecurbsiders .(I am 69, do not call me elderly).
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Sitting with my great friend David OโDell from โฆ@NebraskaMedโฉ We both won teaching awards from โฆ@ACPinternistsโฉ We both felt grateful and honored
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1/ #UncleBob has observations from 42 years of ward attending:. 1. Learning is hard. Inducing learning is also hard. 2. Repetition does work. Teach something and then a week later ask questions. When the learners did not learn, let them know that this is NORMAL.
I spend a long time trying to learn and understanding how to learn. My view:.1) There are no shortcuts - a building requires one brick at a time. 2) Simplify - make the info simple. Twitter helps here!.3) Be humble! Normalize reading the same over and over and over. .
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1/ .Treating metabolic acidosis, brief tweetorial #UncleBob . Todayโs @CPSolvers Virtual Morning Report: complicated patient w/ an AKI. Labs: normal gap acidosis w/ inadequate compensation. Whether to treat the acidosis created some controversy.@tony_breu @kidney_boy.
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#UncleBob has used this terminology for years. "Great caseโ implies complexity of thought processes and the patient benefits. โFascinating but sad caseโ - the patient does not benefit, but we learn much. Please do not use the term Great case unless it is great for the patient.
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99% of those hospitalized with the Delta variant have not had vaccination. 99%. Explain anyone who does not want to get vaccinated. Please. Somebody. Of course you cannot explain a rationale. Please go and get vaccinated.
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#UncleBob was on a golf trip many years ago. A CV surgeon had this wisdom:.Learning to do the CABG operation was very easy, but he needed to do 100-200 to understand what to do when it wasn't easy or something started going wrong. I think this is true for many of our dxs.
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#UncleBob has the following question:.Should I produce a tweetorial on diuretic resistance? Based on the podcast I did with @kidney_boy.
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Inadequate physical examination is the 2nd most important cause of diagnostic error in the ED. #DEM2019 .#UncleBob loves this talk on the value of the exam. Avoid โtech trustโ #5goodminutes.
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1/ #UncleBob started medical school 50 years ago. Medicine is always progressing. Here are some things we did not have:. Diseases: HIV, Lyme, Takasabu, MRSA. infectious disease Medications: Only 1st generation cephalosporins, no fluoroquinolones, a variety of MRSA drugs, etc.
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#UncleBob has some thoughts about liver test interpretation. During today's @CPSolvers Virtual Morning Report, we had a robust discussion of the meaning of the liver tests. I hope this thread will be worth #5goodminutes.@MohitHarshMD @rabihmgeha @DxRxEdu.
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#UncleBob volunteers to do a tweetorial on lessons learned from our 2012 study. If I get 10 likes - will proceed sometime this week.
@medrants @DrRayMD @OhioStateMed @OSUMedPedsRes @NCHPedsRes @Broy3445 I love, love, love that study. I've gushed about it here before. It was transformative for me as a teacher and overhauled my approach. I recommend it to everyone. P.S. I also loved realizing that you were the senior author looong after I'd already fell in love with the paper.๐.
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1/ #UncleBob.12 years ago @LisaWillett13 and I wrote this piece: Becoming a better ward attending Each time I reread the piece, I feel that it has aged very well. Nonetheless, here are a few extra thoughts for you to consider.
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Podcasts clearly belong on CVs (I also have a podcast section. When you do a podcast you impact many more learners than giving Grand Rounds!.You clearly deserve Assoc Prof!.
Finally got around to adding a new heading in the old CV. PODCASTS. Better watch out Associate Professor, I have my eyes on you!
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Today I will spend much more than #5goodminutes enjoying my 70th birthday. I love internal medicine, teaching and learning, yet will not spend time for several days. #KashlakChief will stress the life part of work life! @thecurbsiders and @CPSolvers understand!.
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Making โhandoff roundsโ with my great colleague Gustavo Heudebert. He made rounds with us today insuring a smooth transition for the patients and learners
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Working on my clinical reasoning
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#UncleBob restating @VPrasadMDMPH meaning of 95% effective. Many do not understand this. If your chance of infection is 2% (per month) w/o the vaccine, then with the vaccine it is .05*2 = 0.1% (1/1000). And these infections will be less severe. @UAB_ID @UABGIM @CPSolvers.
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1/ I asked Chat GPT why clinician educators are undervalued in academic medicine. While the answer is not elegant, I think it is spot on:.
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1/ The classic presentation at morning report for hypercalcemia starts with polyuria, constipation and confusion. #UncleBob wanted to understand why - stimulated by @CuriousClinPod ? @HannahRAbrams @tony_breu @AvrahamCooperMD.
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#UncleBob making rounds today. Expand the picture to see the button our division provided to all physicians. Our patients can see what we look like without the mask!. @EstradaElJefe @UABGIM @uabimres
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Wonderful meeting of general internal medicine specialists. โฆ@Gurpreet2015โฉ โฆ@AdamRodmanMDโฉ and Geordie Schiff
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#UncleBob just received a wonderful text. A wonderful family medicine hospitalist finally got his green card after a long struggle. I wrote an impassioned email for him. This is a victory of the physician, his family and the United States! IMGs are extremely important for us.
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Iโm having a bossy fit at #sgim23. Too many presenters use the term provider. This contradicts @ACPIMPhysicians policy. We are internal medicine physicians. Not providers.
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1/ Thoughts on presenting on rounds #UncleBob - #5goodminutes. This is how I do rounds - would love questions and critiques. I explain my expectations the first day on the service. @WrayCharles @LisaWillett13 @iMedEducation #MedEd @ShreyaTrivediMD @AdamRodmanMD.
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1/ .Reciprocal creatinine plots (AKA 1/creatinine vs time) - why internists should understand this concept. #5goodminutes #KashlakChief @thecurbsiders I hope @kidney_boy will comment and correct any errors.
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@ebtapper You do not have to know the dose. Check a urine Na and K. Try a dose. Recheck. If you don't have a high enough dose, the urine K will be higher than the urine Na. Works for spironalactone, eplerenone and amiloride.
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18/. I hope this tweetorial makes sense. @kidney_boy and I have a useful podcast on the topic: Diuretic Resistance @AnnalsofIM @ACPinternists I welcome critiques and amplifications.
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#UncleBob and @DoctorRachael proudly unveil: Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the @ACPinternists @AnnalsofIM Inspired by @BradSpellberg .@ABsteward will like this.@UAB_ID @DrJeanneM @TMcCarty2010.
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Patient admitted w/ syncope. Orthostatic BP w/ pulse 50 lying & standing (on beta blocker). Sodium 123, serum osms 255, urine osms 133. Your job is to explain the findings. Tweetorial to follow after your guesses. @CPSolvers @kidney_boy @hswapnil @COREIMpodcast @thecurbsiders.
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#UncleBob & team have been discussing Torsemide vs Furosemide - important article: Meta-Analysis Comparing Torsemide Versus Furosemide in Patients W/ Heart Failure T > F 4 functional status & hospitalizations.@dhekidney @kidney_boy.@uabimres @RossFarris1.
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1/ How to decipher today's abnormal FBP:. 82 yo woman admitted 4 GI bleed (esophageal ulcer) Transfused & volume repleted. 4 days later BMP 142/3.4/112/17/5/0.8.Admission.142/4.2/101/25/45/1.3.#KashlakChief asks.Why is the bicarb 17? .@CPSolvers & @thecurbsiders.
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Today is an important holiday for Hindus - Ganesha birthday. " Ganesha is widely revered as the remover of obstacles,[9] the patron of arts and sciences and the deva of intellect and wisdom.โ . We can all join our many colleagues and friends with best wishes. #UncleBob
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1/ On Chalk Talks - #UncleBob opines for #5goodminutes.I consider the development of chalk talks a very useful (perhaps even essential) activity for successful clinician-educators. @Sharminzi @AnnKumfer @IgG4thewin @CPSolvers @DxRxEdu @rabihmgeha @tony_breu #MedEd.
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#UncleBob @UnremarkableLab fans - I have several requests to develop a podcast based on the Zoom sessions. Please let me know if you think this is a good idea and if you would be willing to join a team to pick topics and help with production.
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#UncleBob #5goodminutes you invest in this article will never be recovered. This is absolutely brilliant. Unfortunately, hospital administrators never read NEJM. @uabimres @uabgim @ACPinternists @SocietyGIM @SocietyHospMed @thecurbsiders @CPSolvers @COREIMpodcast.
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Happy Thanksgiving to all my twtter colleagues! I am very thankful for all I learn here and especially for the extremely positive attitude of young physicians with respect to learning using this wonderful social media tool. @UABGIM @uabimres @ACPinternists @SocietyGIM.
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This is absolutely brilliant @PaulSaxMD How to Figure Out the Length of Antibioticย Therapy Spend #5goodminutes per orders of #KashlakChief .Do you hear me @thecurbsiders .@TMcCarty2010 @DrJeanneM @DoctorRachael @elleneaton17.
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#UncleBob proudly presents. Annals On Call - The Right Antibiotic, for the Right Infection, and for the Right Duration @AnnalsofIM . featuring @DoctorRachael and @BradSpellberg . This is a must for both outpatient and inpatient internists.
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#UncleBob - rule number 1 for clinician educators - help your learners grow. Give immediate constructive feedback - including positive feedback for a job well done. When learners grow you are a success. #MedEd @LisaWillett13 @bhamjamo_md @uabimres @DxRxEdu @rabihmgeha.
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#UncleBob rejects the civil liberty argument for choosing to not get vaccinated. The harm they cause others obviates that reasoning. Please reconsider your responsibility to society. Please get vaccinated - and if you are vaccinated, please get a booster. @ACPinternists.
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#TeachDx .Over the past several years, we have started focusing on making the HPI a focus of teaching and learning. We give immediate feedback on the HPI, prior to hearing about the physical exam, labs or imaging. We focus on what is extraneous and what is left out, and say why.
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All Hospitalists and clinician educators and internal medicine residents should read this. Increasing creatinine during diuresis for systolic dysfunction aNd volume overload is actually a good sign. Great blog post!.
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He Had Trouble Breathing, and Inhalers Didnโt Help. What Was Going On? Now this is a brilliant story - and something I have never heard of - thanks @LisaSandersmd .@CPSolvers @rabihmgeha @DxRxEdu @martinr43087111 @starrgazed @anandiyermd.
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I think that is why many of us are so committed to podcasting, tweetorials, and zoom conferences. The more options one has to learn medicine, the better one can individualize the learning process. What we cannot duplicate are great outpatient and inpatient clinician/educators.
@iMedEducation Many things that we dont have the evidence. However we waste a lot of time re-inventing the wheel. IE- why can't a student at school A listen to a murmur lecture from school B (since they are good) rather than school A having someone give it just because they are from school A.
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1/ #UncleBob continues his tips for newer IM ward attendings. Many physicians and most learners have suboptimal understanding of laboratory testing interpretation. Yet, we order tests almost willy-nilly. #MedEd @uabimres @uabgim @CPSolvers.
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1/ #UncleBob - 5 podcasts for interns #5-4-interns.Hypertension in the Hospital . Beware the Oxygen Fairy . @AnnalsofIM On Call.
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@Dr_Oubre My first month of ward attending was January 1980 - yes 42 years. I run problems by colleagues constantly. I research questions regularly. Looking things up, discussing with colleagues are characteristics of excellent physicians. @DxRxEdu @rabihmgeha.
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#UncleBob challenges you to #5goodminutes.Pt comes to ED for confusion. Labs return & pt has a Na of 118. What 2 situations should you exclude before giving IV fluids? (or when is 2 l NS a serious mistake).Answer in ~12 hrs.@thecurbsiders @CPSolvers @kidney_boy @uabimres.
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#UncleBob just finished an 18 day stretch on the teaching service. I was off service for 6 months due to my age. Once again, I am so impressed with the quality of the learners and their desire to grow as physicians. Kudos 2 @uabimres & their leaders @LisaWillett13 @bhamjamo_md.
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