Tuesday, May 29, 2012

What do hospitalists take home from medical conferences?

I attended a local conference today sponsored by our Department of Pediatrics and Riley Hospital for Children. Many of our residency graduates, especially those who live and work locally, return for this meeting. It really is great to see our graduates and what they are up to. I enjoy hearing about how they have transitioned to practice, and learning about their own successes and challenges.

This particular year, I was not a presenter, nor did I run any workshops. I went to this conference strictly to learn. It was simply wonderful to do so. The day started off with a dynamic visiting speaker reflecting on the state of well child visits and potential innovations around how to be more effective with these, especially given the changes in medicine that are occurring and will continue to occur.

One might think that this topic is not all that interesting (which the speaker himself even acknowledged). Plain and simple, I was inspired! It brought me back to why I chose to go into medicine in the first place: to make a difference. Other extremely well-presented sessions reminded me of things I should be doing when encountering patients with specific conditions. A lunchtime talk on mentoring solidified a successful day for me (and that was only halfway through the day!). Other great "high-yield" topics in the afternoon piqued my interest as well.

When some people come back from conferences similar to this one, they realize that while the conference was wonderful, there is still a stack of paperwork that needs to be completed, that there is more work to be done, patients need to be seen, and e-mails must be answered. I also have all of those things looming over me. But I also gained a sense of purpose, connectedness, and excitement for the future of medicine from the conference. In addition, I learned some new things, was reminded of things I should already know, and also heard about changes coming in the future.

What do you get out of going to conferences besides the acquisition of information? What other "informal curriculum" things get you jazzed up, and how can conference organizers effectively capture that for other attendees? I am curious if others see this similarly or differently.

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

Labels: Alex Djuricich, career choices, guest post, medical education, Mired in MedEd

Dangerous electrolytes, part 3

The patient, a 40-something year old woman, has a long history of alcohol abuse. Recently she has had minimal oral intake with much vomiting. BP 100/60, pulse 120
120, 67, 32, 99
1.9, 21, 0.7, 8.9

pH=7.6
pCO₂=26
pO₂=100
HCO₃=21

I have several more points to make.

First, the patient has clinical signs of volume contraction. The patient has an appropriate increase in ADH. Volume contracted patients when they drink free water can become hyponatremic. This presentation is classic.

Second, we should address the hypophosphatemia. The patient presents with a dangerously low phosphate. We should worry about all phosphate levels below 1. Around 5 years ago, we had a similar patient present with a low phosphate and die. Severe hypophosphatemia leads to 5 possible organ system dysfunctions:

1) Central nervous system, seizures or altered mental status
2) Cardiac, arrhythmias or depressed cardiac function
3) Respiratory, respiratory failure secondary to muscle weakness
4) Rhabdomyolysis
5) Hematological, hemolysis and/or leukocyte dysfunction

The following is a great review of hypophosphatemia: Hypophosphatemia: an evidence-based approach to its clinical consequences and management. Here is their recommendations for treatment.

Indications for different modes of therapy in hypophosphatemia
--Severe hypophosphatemia (less than 1.0 mg/dl [0.3 mmol/l]) in critically ill, intubated patients or those with clinical sequelae of hypophosphatemia (e.g. hemolysis) should be managed with intravenous replacement therapy (0.08-0.16 mmol/kg) over 2-6 h
--Moderate hypophosphatemia (1.0-2.5 mg/dl [0.3-0.8 mmol/l]) in patients on a ventilator should be managed with intravenous replacement therapy (0.08-0.16 mmol/kg) over 2-6 h
--Moderate hypophosphatemia (1.0-2.5 mg/dl [0.3-0.8 mmol/l]) in nonventilated patients should be managed with oral replacement therapy (1,000 mg/day)
--Mild hypophosphatemia should be managed with oral replacement therapy (1,000 mg/day)

Once you have a dangerous phosphate level (less than 1.0) you should prevent further drop in phosphate. Therefore, we must understand why phosphate levels get dangerously low. This patient had a confluence of two reasons. Alcoholics often eat poorly and have total body phosphate depletion. When you provide glucose to these patients, they develop the refeeding syndrome. In this syndrome, patients with total body phosphate depletion use phosphate and further lower the serum phosphate. Quoting from the article: "The proposed mechanism of hypophosphatemia in these patients is increased insulin release that causes an intracellular shift in distribution of phosphorus. Enhanced synthesis of ATP, 2,3-diphosphoglycerate (DPG) and creatine phosphokinase (CPK) might contribute to the hypophosphatemia associated with refeeding syndrome."

Given this problem, while the phosphate level is dangerous, we should stop refeeding. We must first replete the phosphate prior to giving glucose. In this patient, the team stopped the IV glucose appropriately.

The second factor leading to the initial hypophosphatemia is the respiratory alkalosis. Respiratory alkalosis leads to decreased serum phosphate. Usually alcoholics present with normal phosphate that decreases over the next two days from the refeeding mechanism. This patient presents with severe hypophosphatemia likely secondary to chronic respiratory alkalosis. This presentation put the patient at great risk. Fortunately, my colleagues did a great job and the patient recovered from all disorders.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

Labels: db's Medical Rants, diagnosis, guest post, Robert M. Centor

Mentoring in medical education takes its cue from the movies

A big part of medical education is mentoring. The term mentor originates from Homer's the Odyssey and refers to an advisor. The role of mentors vary, but generally serve to guide mentees through work, support them during the process, keep them grounded and focused on the task at hand, and provide general moral support.

Over the weekend, at the Pritzker Revisit session on Scholarship and Discovery, our own students stated the number one thing to consider when finding a project was finding a great mentor.

How does one find a great mentor? Well, our students are encouraged to seek "CAPE" mentors; think superhero mentors. The mentor should be Capable, Available, have a Project that is of interest to the student, and Easy to get along with.

Capable means that the mentor has the skills to not only be a good mentor, but also to carry out the task or project at hand. This may sound like odd, but sometimes faculty are so excited to have a medical student work for them, they may make the false assumption that the medical student will help them with tasks (i.e. statistics) that they themselves don't know.

Availability is especially important as it is the number one reason our students state they had a less than optimal experience in the summer doing scholarly work is that their mentor was not available. While availability of all doctors is an issue, the question is often whether faculty make themselves available when they can (i.e. answer student email, take phone calls, meetings). Setting expectations for when and how to meet can be very important.

Ideally, the mentor has a project that is interesting to the student since if the work is not interesting, it will be even harder to make progress.

Last but not least, the mentor has to be easy to get along with, meaning that their style meshes well with their mentees. Some people simply do not work well together do to different personality types. So, I often tell our students to consider that when meeting potential mentors or deciding between two mentors.

As I was thinking about ways to highlight effective mentors, I recalled some classic movies with mentoring relationship. In relooking at these scenes this weekend, it struck me that there are some interesting reasons why they are good mentors that correlate with our model. Some of them are a stretch but they are still fun to watch!

Yoda in Empire Strike Back encourages Luke Skywalker to not just try, but do. When Luke fails to resurrect the wing fighter, he does not allow Luke to make excuses but instead demonstrates that he can do it, showing that he is CAPABLE.

Mr. Miyagi with the Karate Kid mentors through teaching small movements related to everyday house chores, "wax on, wax off." While he is certainly gruff and challenges Daniel, Mr. Miyagi also makes himself AVAILABLE to Daniel at that moment and in the future by saying at the end "Come back tomorrow" to continue the training.

Remus Lupin goes so far to use a simulated Death Eater to challenge Harry Potter to learn the patronus charm (and making all standardized patient experiences seem like a cake walk). When Harry fails at first, he is patient and nurturing, stating that he did not expect Harry to get it on the first try. He also makes suggestions to the technique which turn out to be the key. Since Harry really needs this charm, this is a PROJECT THAT IS OF INTEREST and Harry ultimately succeeds in casting the spell.

Gandalf in Lord of the Rings provides consolation to Frodo during a moment of despair by highlighting that it his job and also showing that Gandalf is sensitive to Frodo's needs and EASY TO GET ALONG WITH.

In addition to these highly acclaimed superhero and superstar CAPE mentors, let me know if you know of other model mentors from the movies.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She 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, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

Labels: career choices, FutureDocs, guest post, medical education, mentoring, residency training, Vineet Arora

Learning the best way to assess jugular venous pressure

Of all of the physical exam findings that are often taught in medical training, I think one of the most important is the ability to judge volume status from examining neck veins. It's a skill that a lot of medical students and residents strive to become competent in; often many trainees will ask their attendings to verify their findings from their morning rounds.

Finding the level of the jugular venous pressure is hard, but I think it's something that's really worth mastering as it will inform your decision making more so than many other aspects of a daily exam.

To prove my point I ask you, does the quality or quantity of bowel sounds matter in a patient without bowel complaints? Is there any part of the head exam that would change in the course of an inpatient admission? The lung exam may change in a case of pneumonia but isn't the fever curve and the general appearance of the patient better and more important to note? The rales of heart failure may improve in a case of congestive heart failure, but I'd say that when your patient is sleeping flat, no longer dyspneic, and no longer tripoding, the pulmonary finding of rales is irrelevant.

Here is a great website about jugular venous pressure from the University of Washington School of Medicine. Where I got the information at the bottom of this post.

Here is a classic film about the JVP:

I think all of us as internists, hospital and ambulatory, nephrologists and cardiologists should have a good sense of how to find and measure the top of the jugular venous pressure in order to monitor the volume status of our patients on a day-to-day basis. The great challenge in interpreting neck veins, the expert clinician, is to be able to perform wave analysis as Dr. Wood does in this video.

The "a" wave represents the atrial contraction, the x decent represents atrial relaxation, the "v" wave represents ventricular contraction, and the "y" descent represents ventricular diastole.

The most prominent aspects of the neck waves are not the contractions or waves themselves but their troughs: the x and y descent.

Timing of the descents can be done while palpating the carotid or when listening to the heart. The x descent falls into the dub of S2. Lub-clap-dub. The y descent falls during ventricular diastole so it comes after S2. Lub-dub-clap.

Alternatively if you can time the carotid pulse with the x descent by saying C every time you feel the carotid pulse. Then start staying down quickly after every C; C-down, C-down. The x-descent will be occurring as you say down.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

Labels: cardiology, guest post, Justin Penn, medical education, Musings of an Internist, residency training

Slow medicine

I can't tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren't sure of the difference between the two, then "God's Hotel" is the book for you. It's an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco's Laguna Honda Hospital, the last almshouse in the United States.

Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Dr. Sweet discovered, was to the benefit of the patients.

Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, "slow medicine," as Dr. Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.

Sweet realizes that the inefficiencies of this old-fashioned hospital, from the doctors who had time to fully research their patients' complicated histories, to the nurse who knitted a handmade blanket for every charge on her ward, to the chicken that wandered regularly through the AIDS ward, bringing a spark of life to even the most demented patients, were actually its secret weapon. The inefficiencies were actually quite efficient, if your metric was healing patients.

Then arrived the consulting firm of "Dee and Tee, Health-Care Efficiency Experts." Horrified by the rambling open wards and the old-school style of medicine, never mind the chicken, Dee and Tee quickly cut out excessive head nurses, consolidated departments, speeded up discharges and created committees, PowerPoint presentations and forms with 1,100 boxes. The consulting firm never consulted with any staff members who actually took care of patients, but they did stand to earn 10% of any savings engendered.

Thus Laguna Honda was rapidly schooled in the inefficiencies of efficiency, as patients without nurses grew sicker, and enthusiastically discharged patients spiraled downward, had multiple ER visits and were eventually readmitted to the hospital. Dee and Tee, of course, did not have to pony up for any additional costs the consultancy caused.

Over the course of Dr. Sweet's 20 years as a staff physician, Laguna Honda made this painful transition from the practice of medicine to the delivery of health care, and it was the patients who suffered most, followed by their caregivers.

During this period, Dr. Sweet found solace in her doctoral studies of Hildegard of Bingen, the medieval healer, nun, mystic and composer. Hildegard's pragmatic and thoughtful approach to medicine appealed to Dr. Sweet and even informed her own practice of medicine. Stymied by an oddly agitated patient who'd already been given a full diagnostic workup, Dr. Sweet had a What-Would-Hildegard-Do moment, and decided to simply sit with the patient.

She sat with the patient for a good long time, watching her, thinking about her, being in the moment with her. There was something frankly medieval about the patient's twisting and writhing, as though she were trying to expel something, as though she were poisoned.

Reviewing the chart, Dr. Sweet realized the woman was indeed being poisoned, by her own medications. A toxic brew of antidepressants, antipsychotics, pain meds and sedatives had led to serotonin syndrome. Dr. Sweet decreased the patient's medications, and within hours the patient improved. She eventually stopped nearly all the medications, and the patient became well enough to go home.

Untangling the mass of medications that most patients arrived with became Dr. Sweet's hallmark. She found that nearly all her patients could be relieved of a portion of their accrued medications. But this could only work in the setting of "slow medicine," of having time to watch patients carefully over an extended period, of digging deep into the convoluted lives of these patients, of having time to "just sit" with each patient.

This, of course, is highly inefficient, if you are Dee and Tee. But it's remarkably efficient if you are a patient and are interested in being cured, cared for and comforted.

You might not expect a book about San Francisco's most downtrodden patients to be a page-turner, but it is. With its colorful cast of characters battling the tide of history, "God's Hotel" is a remarkable journey into the essence of medicine.

In 1925, Dr. Francis Peabody told a graduating class of medical students that, "the secret of the care of the patient is in caring for the patient." Simple, eh? If Dr. Peabody were practicing medicine today, he'd surely be consolidated with a midlevel provider to deliver health care with maximal quality indicators and operational excellence. Sigh ...

(from The San Francisco Chronicle, April 22, 2012)

Danielle Ofri, MD, PhD, FACP, is the author of three books, including "Medicine in Translation: Journeys with My Patients," which is about learning the individual stories of patients. She is an Associate Professor of Medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review. She is currently writing a book about the emotional life of doctors. This post originally appeared at her blog.

Labels: Danielle Ofri, diagnosis, guest post, Literature in medicine

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Contact ACP Hospitalist

Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internist and 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.

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.

CasesBlog
Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients.

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.

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

DrDialogue
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.

FutureDocs
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
ACP Member Mike Aref, MD, PhD, ACP Member, 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.

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.

KevinMD
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, ACP Member, 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.

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).

Musing of an Internist
Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident.

Prescriptions
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.

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.

White Coat Underground
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.

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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Related ACP Resources:

ACP Hospitalist

Tuesday, May 29, 2012

What do hospitalists take home from medical conferences?

Dangerous electrolytes, part 3

Friday, May 25, 2012

Mentoring in medical education takes its cue from the movies

Thursday, May 24, 2012

Learning the best way to assess jugular venous pressure

Wednesday, May 23, 2012

Slow medicine

Contact ACP Hospitalist

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