American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, March 31, 2015

HM 15: Meds and CKD

Of course, you know that NSAIDs are bad for the kidneys. But not all patients do, pointed out Hospital Medicine 2015 speaker Michelle Estrella, MD. Or chronic kidney disease (CKD) patients may forget, as they're picking up some ibuprofen at the store. "Hospitalization is a good opportunity to remind the patient of that," she told attendees. They (and sometimes their gastroenterologists) should also be steered away from laxatives containing sodium phosphate.

In addition to the drugs to be avoided in CKD patients, there are a fair number that should be modified for this patient population.  Generally, drugs that are at least a quarter to a third eliminated by the kidneys require dose adjustment, Dr. Estrella said, offering three specific examples that meet that criteria: ciprofloxacin, amoxicillin, and digoxin. And don't forget the hypoglycemics-- they are the most common cause of adverse drug events in ambulatory CKD patients.

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Match Day '15: It never gets old

I keep waiting for Match Day to get old for me. For the giant clock on the wall striking noon, the medical students sprinting for their envelopes, and the emotional pendulum that follows it all to seem blah and played out. At Emory, the location hasn't changed in years. Even the faces of a lot of the faculty members who stand around with our slightly less baited than our students' breath hasn't really shifted much either. Yet every single time, year after year, it feels magical to me. And brand new.

Admittedly the “odd” years are the most meaningful to me. As a small group advisor who has students graduating from the 4-year program on those years, these are the ones I've watched since their first day of medical school. But now that I think of it, the even years can be just as awesome. Witnessing their dreams come true on Match Day is a high that I will never stop enjoying. Ever.

Beyond that is something else though. The level of investment I have in people changed since losing my sister in 2012. It's upped the ante significantly for me. Sure. I went hard before. But now that I realize how short life is and how critical it is to be a responsible steward of my influence and time, I go even harder. I decide more carefully where to pour my energy. And once I decide? I'm all in.

I've talked about this before but it bears repeating. Out of the ashes of some of the most tragic life experiences can come unexpected beauty. I hold on tighter now. I want to water the flowers entrusted to me as dutifully as I can and then watch them grow. I yearn to roll up my sleeves beside the other gardeners who aren't afraid to get their hands dirty with me and then stand shoulder to shoulder with them as we marvel at the spectacular blooms before us. Match Day is a chance to present those flowers to the world in dazzling bouquets. Big, bold beautiful ones that we helped to prepare.


I always take a lot of pictures on Match Day. I'm particularly mindful to snap images of those with whom I had direct involvement, especially during the clinical years and residency application process. I love going back and studying their faces. The elation so unfiltered and unlike what usual happy looks like. I guess it's just that I can see more into those pictures than others might. See, Match Day for most medical students is a day of glory. But me? I know the story.


This year was like always. I met their parents. I met their grandparents, too. Shook their hands and tried to beat them to the kind word punch before their lips could even part. I told them who their children have been in their absence and let them know that they done good. I described the attributes that really, truly matter to parents—the ones that I now realize are the best ones. Especially now that I have children of my own.

“Your son is kind and has a heart for people. He is patient with even the most challenging patients and can find the good in everyone.”

“Your daughter fights for what is right and stands up for those who may not be able to stand up for themselves. She expresses herself well and makes sure our patients are treated with dignity. She has a servant's heart and is an advocate for the least of these.”

I didn't really talk about how smart they were. I mean, they're about to graduate from medical school and, for goodness sake, they got in to medical school in the first place. But since I know and I think their parents and grandparents know that it isn't really just about being smart, I give them those concrete words of affirmation. And for every kind word of gratitude they offer me, I trump them with some declaration of what I've seen in their child and the gifts they will offer the world.

That is, from my perspective as their teacher and mentor. And I win.


This is such a privilege. Each year I try and try to put it into words but feel like I fall short every time. Instead, I will just share some of Match Day 2015 through the eyes of this clinician educator and her trusty iPhone camera. The lens may not be high tech but for you to see what I see, it doesn't have to be. I especially love the ones of them holding up their Match notification letters. I love that in these photos they were looking at me and me at them … and how much of a dialogue is held in their eyes. Or that we were together sharing in a pivotal moment. Perhaps if you look close enough, you'll see it, too. And just maybe you might feel your pulse quicken, your heart skip a tiny beat, and your eyes sting with tears while you do. And even if you don't feel any of that, don't worry … I had you covered.


Best. Job. Ever.

That's it. That's all. Wait—and this. A certain medical student opening her envelope back in 1996.

Almost as exciting as this year.


Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Monday, March 30, 2015

Hospital Medicine 2015: How to stand out as a job applicant

At an afternoon session at Hospital Medicine 2015 today on "Getting to the Top of the Pile: Writing Your CV," Darlene Tad-y, MD, an assistant professor of medicine at the University of Colorado, offered attendees three tips on being a job applicant who stands out.

  1. Check your social network. Make sure you've posted nothing that is inconsistent with how you want to be portrayed as a job candidate (for example, embarrassing pictures of yourself or inappropriate information about your job or your patients). 
  2. Highlight your accomplishments rather than just your job titles. "It's great that you had that title, but tell me, in those 2 years you were doing that job, what you were able to do," Dr. Tad-y said. 
  3. Leverage your network. "If you want a job at University of Colorado and you know somebody who knows somebody, leverage that network," she stressed. "Ask that person, 'What can I do to make myself more attractive for the job at your place that I want?'"

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Friday, March 27, 2015

COPD exacerbations and respiratory syncitial virus--maybe a huge problem?

We're having a curtailed winter and early spring here in the inland Northwest, or so it seems. We could still get a snowstorm or 2, but the crocuses are blooming and the redwing blackbirds are singing by the unfrozen ponds. Despite the mild temperatures and sunny skies we are still having an influenza epidemic and many of our patients with chronic lung disease are becoming sick with wheezing and low oxygen levels. We have rapid tests for influenza and for another lung infection, respiratory syncitial virus (RSV) and I am presently seeing less flu and more RSV.

I have never routinely checked my patients with asthma and COPD exacerbations for respiratory syncitial virus. I thought that it was one of those tests that would take so long to come back from the lab that the patient would be well before I ever found out the result. It is possible, though, to get a result back from a rapid antigen detection test (much like a home pregnancy test) using a sample of mucus from the back of the nose, in 30 minutes.

Last week 2 patients with severe wheezing and uncontrollable cough who were in the hospital with worsening of their COPD tested positive for RSV. Yesterday another 1 did. It is RSV season. In fact, it is even more RSV season than it is flu season. We are smack dab in the middle of RSV season, which stretches from January to April. RSV is best known as the virus that causes acute lung disease in infants and children. In the U.S. alone, over 80,000 children are hospitalized each year due to this virus and worldwide it kills more children under the age of 1 than any other infectious agent with the exception of malaria. More high risk adults, such as those with lung disease or immune suppressing diseases, contract RSV than they do the flu.

RSV is, for most of us, just a cold. It causes a stuffy runny nose and a cough, sometimes a fever. In small children or people with lung disease it can cause respiratory failure. It is very contagious. It is most often contracted by directly touching an infected person or objects with infectious secretions, even when they are dry. It is very important to avoid transmitting it in the hospital, and since we don't routinely test adults for it, we are probably very efficiently spreading it from infected to uninfected patients. The time from exposure to symptoms is 2 to 5 days. There is no vaccine, and people who get RSV can get it again, even during the same season, though perhaps more mildly. In very susceptible babies, a monoclonal antibody, Palivizumab, can be given monthly to prevent disease, but it is terribly expensive. For a baby it might run $1,000 to $3,000 per dose, but since it is dosed by weight, it would probably cost around $30,000 per dose for the average size adult. Not an option.

Prevention involves good hygiene, avoiding exposure to infected people, hand washing, and avoiding cigarette smoke which can make a person more susceptible. There is an antiviral medication, ribavirin, which is active against RSV and sometimes used, primarily for immune suppressed patients like those with bone marrow transplants. Ribavirin costs about $30 a pill, would be dosed twice daily, has a black box warning for causing hemolytic anemia. It is not known if its use improves symptoms.

I think that it is likely that many of the winter adult lung disease admissions that I see are related to RSV. It is much more common than I believed. Since there are no really useful pharmaceuticals to treat it, none of the economic forces that lead to mass education are at work to raise awareness of its importance in the aging and chronically ill population that we internists see in the office or hospital. There is talk of vaccine development, but if natural infection does not give long term protection, it is unlikely that a vaccine will. It would certainly be nice if we knew whether ribavirin helped improve symptoms. Old-fashioned and low-tech prevention is probably the key to reducing its impact. I certainly need to be checking for it more often and thinking about taking precautions to avoid spreading it in the hospital or waiting room!

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Wednesday, March 25, 2015

One down, forever to go

First day of the hospital rotations for Small Group Delta. I pressed them to send me a “selfie” photo to capture this day. “You'll be glad you did,” I said. And I meant that.

Time flies. Especially when you are watching from the seat I'm in. If you don't slow down, you'll miss it. Or maybe forget some parts that you should have savored.

We met up tonight for a debriefing of day one over tacos, ceviche, salsa, and chips. And all of it was good and all of it was warm. Just like a family dinner table. They shared about their winter breaks and recent travels. Jessie, my advisee who is taking a detour to work on a PhD, enlightened us on her new life as a PhD candidate. And you know? That part was really great, too.

I'm going to blink and they'll be graduating. This I know for sure. But I will blink as slowly as I can.

As slowly as I can.

I love this aspect of our curriculum design. And tonight, once again, I was reminded that I love every single one of these people, too. They are a part of my family.

How cool is it to have family ties built into your medical school requirements? I'll answer that.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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