Teaching new interns and students – stress the basics
I have had the “pleasure” of an interesting attending stretch – June 10 – July 9. The new interns started Sunday June 24th. New 3rd year students started the next day.
The attending job changed dramatically in one day. The June interns were ready for residency. All the conversations occurred at a very high level. We worked on some fine points of internal medicine to help them grow.
With new interns and students, it is back to basics. We must assume very little, but we do have their attention.
So for the past 2 weeks we have stressed the basics.
How do we manage pancreatitis?
What is th...
Source: DB's Medical Rants - July 5, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
How can attending physicians promote wellness?
As a ward attending physician, I have some influence over learners’ lives. During my time with them, I can impact their daily activities, but I can also serve as a role model of wellness.
Step #1 – run efficient rounds. The time we spend on rounds can have a negative impact on a resident’s ability to leave on time. Develop time constraints for rounds. Recognize when a consult, or order has a high priority – and give the intern or resident time during rounds to get that work done.
Step #2 – maximize their control. Total lack of control negatively impacts wellness. Do not micromanage...
Source: DB's Medical Rants - July 3, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Making efficient rounds
This article suggests not – What Happens When the Attending Comes to Work Rounds?
Efficiency occurs when the attending physician allows the resident to handle the care details. The attending physician should (in my opinion) focus on the big picture. The resident team should suggest care, and use the attending physician as a sounding board. The attending physician should teach through a discussion of the differential diagnosis, or the appropriate test ordering strategy, and role modeling patient interactions (occasionally repeating the history, demonstrating physical exam findings, and even delivering news ...
Source: DB's Medical Rants - July 1, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Another guideline problem – inaccurate CV risk estimation
This article – Recent Update to the US Cholesterol Treatment Guidelines summarizes the guideline. The guideline uses a risk calculator to guide lipid lowering (mostly statin) prescribing.
Many critics (including me) felt that the calculator greatly overestimated CV risk. Since the guideline depends on accurate estimation of that risk, testing and potentially improving the calculator has a high priority.
A recent Annals of Internal Medicine article – Clinical Implications of Revised Pooled Cohort Equations for Estimating Atherosclerotic Cardiovascular Disease Risk – tests the original calculator again...
Source: DB's Medical Rants - June 25, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Sore throats – #thefineprint
Saying that sore throats are simple has become a trope, as thus many physicians do not seem to have a thoughtful approach to adolescent/young adult pharyngitis. As the author of the Centor Score, I would like you to consider these points when seeing sore throat patients.
The most important use of the score involves identifying those who need neither diagnostic tests nor antibiotics. Too many urgent cares run a group A rapid strep test on everyone with a sore throat.
The score is meant for acute (3 day or less) sore throat symptoms.
The score stratifies adolescent/young adults with bacterial pharyngitis – group A...
Source: DB's Medical Rants - June 18, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The danger of pronouncements in medicine
“Experts” mean to improve health. They have great intentions, but we all know what is paved with good intentions.
This week I twice checked my blood pressure on a machine at our grocery store. The first time my blood pressure with 134/82 and the machine told me I had an elevated blood pressure. The second time it was 124/78 and it told me that my blood pressure was elevated. I was very pleased with my blood pressure, and astonished. The machine justifies these interpretations because a group of “experts” wrote and published a guideline pronouncement that redefined almost everyone as either b...
Source: DB's Medical Rants - June 10, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
New drugs for hyperkalemia
FDA Approves Lokelma for Hyperkalemia
The US Food and Drug Administration (FDA) has approved sodium zirconium cyclosilicate (Lokelma, AstraZeneca) — a medication that rapidly restores normal potassium levels — for adults with hyperkalemia.
Formerly known as ZS-9, the drug is a “highly-selective, oral potassium-removing agent,” the company explains in a company news release.
Hyperkalemia has become a significant problem. With more type 2 Diabetes Mellitus, we are seeing an explosion of chronic kidney disease. In patients with CKD 3b and 4, patients often develop hyporenin, hypoaldosterone and thus type I...
Source: DB's Medical Rants - May 21, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Syncope week – Day 2 – high-risk features
Our first task is to decide whether the patient needs admission. The list is not exhaustive, but very suggestive. These features require admission and careful cardiac evaluation:
Major
New onset chest pain, headache, abdominal pain or breathlessness
Syncope during exertion or when supine!
Sudden palpitation followed by syncope
Minor
No warning symptoms or short (<10 sec) prodrome
Family history of sudden cardiac death at young age
Syncope in sitting position
Past Medical History
Known heart disease – decreased LVEF, or known coronary artery disease
Physical Exam
Unexplained BP < 90 in emergency departm...
Source: DB's Medical Rants - May 8, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Syncope guidelines published Day 1
The Europeans have published a thorough guideline for syncope. I have not had time to absorb the entire guideline – it is dense but seems very well done. There is enough material here for 5 days of short posts rather than one long post. Today, I have copied their key messages.
2018 ESC Guidelines for the diagnosis and management of syncope, European Heart Journal
10. Key messages
The ESC Task Force has selected 19 simple rules to guide the diagnosis and management of syncope patients with TLOC (total loss of consciousness) according to the 2018 ESC Guidelines on syncope:
Diagnosis: initial evaluation
At the initi...
Source: DB's Medical Rants - May 7, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The value of controversy in medicine – sepsis
Conclusion:
No high- or moderate-level evidence shows that SEP-1 or its hemodynamic interventions improve survival in adults with sepsis.
We must hope that this controversy will lead to gathering more information to resolve the controversies and improve care. Science demands controversy. Medicine demands that we view everything critically. My opinions on the controversy are not as important as exposing the controversy. (Source: DB's Medical Rants)
Source: DB's Medical Rants - May 4, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The tyranny of metrics – a book review
From the Amazon web site:
How the obsession with quantifying human performance threatens our schools, medical care, businesses, and government
Today, organizations of all kinds are ruled by the belief that the path to success is quantifying human performance, publicizing the results, and dividing up the rewards based on the numbers. But in our zeal to instill the evaluation process with scientific rigor, we’ve gone from measuring performance to fixating on measuring itself. The result is a tyranny of metrics that threatens the quality of our lives and most important institutions. In this timely and powerful book, Jer...
Source: DB's Medical Rants - April 27, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM attendings – my favorite question – Chapter 22
“What do you do for fun?”
That is my favorite question. And I use it with patients and learners.
With patients, it opens a window to the possibility of anhedonia. It also helps you understand who the patient is. Just asking the question often creates a sense that we care about the person who has the disease.
In the outpatient setting you can use the answer on each visit to gauge the patient’s quality of life. If you have someone who regularly fishes, and then one day no longer goes fishing, you probably have a clue that something serious is wrong. If they have been fishing, the fact that you ask...
Source: DB's Medical Rants - April 16, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Tips for IM Attendings – Chapter 22 – take a mental break
We present sitting, and it usually takes 2 full hours to hear 8 patients (and that means going quite fast at times). Those 15 minutes are gold. Almost all residents and interns are very grateful. But I am also grateful. I take that time to walk downstairs to get a drink. I chat with the students or house staff, depending on the day. When we start back we are refreshed and (I believe) more productive.
Breaks are healthy. Talking about non-medical issues is healthy.
So think about how you can take a mental break (and perhaps even a physical break) during rounds. You and your learners will benefit, and therefo...
Source: DB's Medical Rants - April 11, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The cirrhosis chalk talk
Some days on ward rounds we have time for relatively short chalk talks. Over the years I have developed many. Learners seem to like this one in particular.
We start with this question – name complications that cirrhotic patients develop for which we have secondary prevention. Knowing this list and the associated drugs allows us to peruse the drug list to add to the PMH when it is not readily available.
Here is my list:
Esophageal varices – most patients with significant varices are taking a non-specific beta blocker. More recently evidence suggests that carvedilol might be better than propranolol or nad...
Source: DB's Medical Rants - April 2, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Using 1/creatinine to assess the possibility of AKI
Many patients with CKD have a slowly progressive decline in function. Often these patients get admitted with a higher creatinine than their previous documented creatinine. We then often quickly label them as having AKI. But we should also consider the possibility that the patient’s new creatinine represents continued deterioration of their CKD.
While not perfect (few if any formulas used for renal disease or fluid and electrolyte disorders are), we can graph 1/creatinine versus time to get a reasonable estimate of expected progression. Here is the idea. For a majority of patients the endless progression t...
Source: DB's Medical Rants - March 25, 2018 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
