I’m 3 months into my hospitalist job and I’ve already become that attending who believes a good history, physical exam, and med rec is 90% of the work
A few stories to highlight how investing time into the above can reduce unnecessary work ups and treatments for our patients
Few take aways from my
#EM
rotation
1) The breadth of patients that EM docs can manage is astonishing
2) The undifferentiated patient is both exciting and terrifying
3) When surgeons are needed, they are NEEDED
4) Cocaine is a hell of a drug
5) Ketamine is a hell of a drug
Medicine is a life long learning journey
I recently completed IM training + Chief Year and joined a community hospitalist group
I am little over a month into my new role and have more clinical questions than ever!
I left academia for this very reason: clinical reps
🧵
Dear new interns,
I’m a full time hospitalist and I still forget to order morning labs
It’s okay
If it was absolutely critical, someone would’ve caught it and ordered it
During May I’ll tweet
#TipsForNewDocs
from the perspective of an outgoing IM Chief Resident who has learned a ton from
#MedTwitter
Tip
#1
Residency will make keeping friendships hard. As often as you can, invest in those who have been there for you. They will keep you energized!
Invest in gathering a thorough history
Rephrase your questions if you feel like miscommunication is occurring
Gain collateral on medication history
Don’t underestimate the iatrogenic harm that can occur with meds
Doing this can help our patients avoid expensive testing
Word of advice:
If you have the luxury of documented telephone encounters from outpatient clinics, READ THEM
You gain valuable insight into:
Symptom chronology
Any recent changes to meds
barriers to care that their PCP/outpatient specialist have been working on
It is unfortunate that this attitude re: IM. It is a distinct reason many dislike their experiences on ward teams
It doesn’t have to be this way, but it is our fault as a specialty that this idea persists in 2022
A 🧵…
If you’re in surgery and feeling sad, walk by a medicine team doing their purgatory-esque rounds. Watch your face brighten as you realize you never ever have to do that again
Y’all, I’m so proud!!!
I’ve been teaching my med students about
#ClinicalReasoning
while on wards
We have a pt w/ new pancytopenia
My student CREATED A SCHEMA to help with his diagnostic reasoning and used it in his A/P to discuss his DDx
Med student got excited to see a pt with acute DVT
“I’ve never seen a DVT before!”
Oh to be young again...
There is always an opportunity to learn with every pt
No matter how mundane the Dx, celebrate and join in learner’s excitement
@DxRxEdu
@rabihmgeha
@medrants
Dx a pt w/ CHF and spent several days educating about his new dx
Day of dc he provided me with some new terminology
“Doc, failure is scary. I don’t feel like my heart is failing. I got something for ya”
I like the term Heart Fatigue and think it’s time for change!
Her exam is reassuring. I cancel the brain MRI
We trial off venlafaxine the following morning, dizziness resolves
I walk with her. We have a competition on who can stand on one leg the longest
She wins
We avoid an expensive brain MRI and relief that she didn’t have a stroke
A bit of rambling but…TL;DR
Don’t let anyone tell you community practice is a bad choice. It isn’t. You can learn a lot and feel immensely fulfilled
Good medicine happens everywhere, not just in academia
It’s a personal choice where you choose to work
Ask questions daily
May the 4th be with you! Tip
#4
#TipsForNewDocs
#MedTwitter
You’ve probably heard this one time and time again: “read more” or “read up on your patients”
Yet no one tells you HOW they read more and make that information stick!
A 🧵 on the system I developed in residency
May 3rd = tip
#3
#TipsForNewDocs
#MedTwitter
When pts are admitted, update families. Ideally daily!
Don’t assume they’ve been updated by others
Start w/ “What do you know about the reason for admission/status of their condition?”
This allows you to gauge their understanding
Call wife 2-3 times during the day, tell his nurse to inform me if wife comes to bedside
She arrives with a med list.
She has been in conversation with PCP re: high BP readings at home
PCP doubled Coreg dose two days ago
We observe off Coreg, brady and symptoms resolve
Pt recalled syncope at night when she went to bathroom, stood up, then woke up on bathroom floor
She told others “I don’t know how I collapsed” which is different than not recalling events leading up to collapse
Unexplained syncope was from miscommunication, not recollection
A good diagnostician must ask why. It changes trajectory and lives of patients.
Not everyone has done the hard work of asking, so don’t assume
A brief anecdote from the community…
35F admitted to my service for progressive dyspnea and edema. Not new for her, she had HFrEF
1/
#UncleBob
- thinking about clinical reasoning this week (after 2 wonderful weeks of diastole in London, Paris and Cardiff). Listened to 4 RLR this week (
@DxRxEdu
@rabihmgeha
) have done 2 morning reports (2 more scheduled) and attended our big Tinsley conference
@CPSolvers
Where does “quit blowing smoke up my ass” come from?
#MedicalHistory
As early as 1746, English docs used tobacco enemas to resuscitate near dead victims of drowning
Reasoning included warming the body, drying out the insides, and increasing heart rate
@AdamRodmanMD
tweetorial?
A tale of dizziness
Pt admitted overnight for dizziness eval. signout is posterior stroke rule out
I ask, “did anything change in your life when symptoms began?”
She just started venlafaxine from psychiatrist
She got her morning dose of it before I saw her. Still dizzy
Dear students,
If you are on a clinical rotation and not feeling like part of the team, it is NOT your fault
That is your team not cultivating a safe learning culture
That is the system not prioritizing your/team’s experience
It is not you.
<3
@DxRxEdu
@rabihmgeha
A tale of unexplained syncope
I came onto service with signout that pt came in with unwitnessed syncope with no recollection of events. Negative w/u. Pt w/ hx of seizure
Assumed to be breakthrough seizure
I spent 30 min on 1st day asking every way I could about HPI
@mahad_minhas
In med school I had an attending say he wished he could punch certain criminals in the face, “especially if they were a foreigner” as he looked at me
Also had an attending make me defend why Trump should be considered racist during the Muslim travel ban
Word of advice I wish I had received as an MS4 and resident:
Don’t wait till your an attending to learn about personal finance
If you can learn the Kreb’s Cycle, you can learn how to manage your finances and set yourself up for success
Highly recommend following
@olsonplanner
May 6th = Tip
#6
#TipsForNewDocs
#MedTwitter
Improving your history taking skills can prevent unnecessary work ups and expedite care
Residency doesn’t always provide the time needed to gather thorough histories like you had in med school
Thoughts on improving as a historian…
May 5th = Tip
#5
#TipsForNewDocs
#MedTwitter
The hidden curriculum is real
Your students will pay close attention to how you treat pts, RNs, PT, custodians, & every other colleague
Be respectful and kind
Never disparage another specialty or group
We are all here for our pts
Such an important chart!
Meningitis is hard to determine clinically based on symptoms and signs alone
We are often not great at performing these exam maneuvers as well, which worsens post-test probability
Wholeheartedly agree. I used to send an expectations email as a senior resident.
Now I get to send it again, only this time as an attending
Grateful for my role models on setting expectations, modeling a positive culture, and creating a safe learning environment for all
@ChristleNwora
Set your expectations before the rotations begins. Juniors don’t usually get upset about not getting what they want, it’s usually because it’s different than what they expected…
Here was my standard email to welcome juniors onto the service…
You start inpatient service and pick up a 60F w/ COPD a/w hypoxic resp failure
She is on day 3 of admission and has been on CTX/Doxy + steroids for CAP
She feels better. CXR 👇🏾
Do you complete 5d of ABX or do you D/C? How do you discuss w/ pt?
#CommunityMed
#Stewardship
Internists don’t use scalpels to help patients, but they do use their minds -
@abbyWUim
The first way to help patients is to improve our diagnostic skills by reflecting on patient care
Without an accurate dx, you cannot start the therapeutic journey
<3
@DxRxEdu
@rabihmgeha
There is often explicit bias against joining community practices when you leave academic training
I’m here to tell you it can be incredibly fulfilling, rewarding, and help you grow just as much as continuing on in academia
Neither option is better than the other, it’s personal
UTI associated delirium is a diagnosis of exclusion
And even then, it is overdiagnosed
What other conditions come to mind like this?
@rabihmgeha
@DxRxEdu
@medrants
I’ve reached official attending status…
Today a patient called their spouse and said “I have the oldest doctor on the team with me. He wants to speak with you”
#thisis30
?
Perspectives from a very early (7 days in) ward attending
Even more rewarding and fun than teaching medicine is cultivating the culture of the team
As an attending this is not only a duty to serve your trainees in this way, but also a privilege
@DxRxEdu
@rabihmgeha
@medrants
#TipsforNewDocs
Embrace asynchronous learning and
#FOAMed
You will learn a lot through residency and didactics, but Digital Education is the present and future
Utilize podcasts, blog sites,
#Medtwitter
, and more
I promise they will enhance your clinical knowledge and skills
Had dinner w/ med school classmates and we discussed how poorly Biostats/Bayesian reasoning is taught in med school
Applying these concepts to clinical practice is a game changer and DOES impact patients
Excellent examples below by
@phlegmfighter
👇🏾
May 5th = Tip
#5
#TipsForNewDocs
#MedTwitter
The hidden curriculum is real
Your students will pay close attention to how you treat pts, RNs, PT, custodians, & every other colleague
Be respectful and kind
Never disparage another specialty or group
We are all here for our pts
May the 4th be with you! Tip
#4
#TipsForNewDocs
#MedTwitter
You’ve probably heard this one time and time again: “read more” or “read up on your patients”
Yet no one tells you HOW they read more and make that information stick!
A 🧵 on the system I developed in residency
A tale of bradycardia
Pt presented to ED w/ weakness, dyspnea, found to be Brady to 40s by wife at home
In ED same sx and Brady to 40s, being admitted for w/u
Tried to get med rec, pt doesn’t recall meds, wife manages
Wife not at bedside, phone goes to VM
I love teaching, but I also love my new role. I really do.
There is something about focusing on being a clinician and nothing else that energizes and motivates me, as this is my only responsibility:
To care for my patients to the best of my abilities
2 things I have seen to be true every week while working in community hospital med
First learned from
@medrants
@DxRxEdu
@rabihmgeha
1. Pts w/ uncomplicated CAP rapidly improve in 24-48 hrs with appropriate ABX
2. Rigors should make you think of bacteremia. Get cultures
One of my goals going into Chief year was to have
@Gurpreet2015
invited for grand rounds or CPC
Thanks to efforts by my co-Chief Dr. John Hickman, that goal is realized (virtually)!
Beyond thrilled for this week’s
@WUDeptMedicine
Grand Rounds with one of my idols in medicine!
55M w/ T2DM, ischemic HFrEF is mowing the lawn and runs over piece of wood and feels immediate pain in his calf
2 days later his leg look like pic (not of pt)
Does the mechanism change your causative bacteria ➡️ cellulitis? What empiric ABX would you choose?
#IDTwitter
Time for my first
#medtwitter
#Tweetorial
on Insulin and Potassium regulation!
This is part 1 of a tweetorial series on K homeostasis/Hyperkalemia. This is a big topic, so I’ll stick to concepts.
Poll: What percent of total body Potassium is within extracellular fluid?
All I’ll say is time off work ⬆️QOL
One of the main differences b/w IM residency &
#hospitalist
life is schedule, not content of work
I went from sometimes having 2days off work a month in residency…
…to having minimum 14 days off a month consistently if I want
MINIMUM!
#Tweetorial
on
#NTProBNP
comes from a case of volume overload
73M w/ hx of EtOH Use Disorder (2 pints bourbon daily), CAD, PVD, HTN, admitted for subacute dyspnea and anasarca
NT-ProBNP 30,000. Cr 2.8 (2.0 1yr prior). Albumin 2
Given these results, what’s your most likely dx?
Hey
#MedTwitter
!
I’m putting together a clinical reasoning skills night for med students interested in IM!
Regardless of specialty, crowdsourcing answers to this question so I can share with them:
Why is diagnostic reasoning important to you?
I want to improve at appraising medical evidence in 2021 (gee, I wonder why?)
Just purchased Malignant & Ending Medical Reversal. I listen to
@Plenary_Session
Any texts/resources to help? I have no stats training so basics appreciated
@VPrasadMDMPH
@adamcifu
@reverendofdoubt
#TipsForNewDocs
Perform a cognitive autopsy on cases where diagnosis was changed, delayed, nearly missed, or missed...basically all cases
Discuss cases with trusted colleagues
This will benefit you and, more importantly, the next patient
@DxRxEdu
It’s May 2nd which means tip
#2
#TipsForNewDocs
#MedTwitter
Becoming a great clinician is your first responsibility and is what your pts deserve
Only pursue other endeavors if you want it for yourself
Don’t fall to the pressure that being a great clinician isn’t enough
IT IS!
During May I’ll tweet
#TipsForNewDocs
from the perspective of an outgoing IM Chief Resident who has learned a ton from
#MedTwitter
Tip
#1
Residency will make keeping friendships hard. As often as you can, invest in those who have been there for you. They will keep you energized!
One of the most influential moments in med school was with a general surgeon Dr. Finley who held the door open for med students during rounds.
He was older, nearing retirement. I offered to hold the door for him and he said…
“No, you are paying to learn not hold doors open”
5/
I have never, ever forgotten what that moment felt like.
Instead I swung the pendulum the other way. Every medical student I work w/ deserves my full attention, focus, and dedication. No matter how busy or stretched or hungry I feel.
Their time matters.
#MedTwitter
The inpatient Heart Failure consult attending said this today:
“We aren’t the Heart Failure team, we are the Heart Success team”
It even made it into Epic!
@wustlcardfellow
#HappyFriday
#HeartMonth
Had the incredible opportunity to share why Clinical Reasoning is so important w/
@WUSTLmed
students! We even had a waitlist for the event!
Was inspired and humbled by the mature reasoning skills these bright stars already have.
Thanks to all who attended and made it possible!
If you ever forget what it’s like to be an intern, do a cross cover shift and you’ll quickly get PTSD from all the calls.
Oh but don’t forget, interns also admit while cross covering. And do this for weeks straight on nights. Oh and they are underpaid…and under appreciated.
It is Friday and you get an ED admit call
45M w/ hx of duodenal ulcer p/w epigastric pain, fatigue, melena x3. HR 70s, BP 130/80. No melena on DRE.
Hgb 11 (b/l 14)
BUN/Cr 89/1.5 (b/l 35/0.8)
There is no GI coverage until Monday
What would you do?
#CommunityMed
#GITwitter
Had a long conversation with a close friend who works in finance. We talked about what makes a good leader.
It’s striking how these qualities span professions
1. Intellectual humility
2. Providing autonomy
3. Fostering creativity
4. Positive reinforcement
5. Deliberate feedback
Have you heard of heparin induced thyroid function test abnormality??
Heparin products can falsely elevate fT4 readings up to 5x baseline value within minutes
Heparin releases vascular Lipoprotein Lipase -> FFA production -> displaces T4 with no effect on TSH, total T4, nor T3
The outgoing
@WashUIMRes
chiefs give a series of Grand Rounds
@WUDeptMedicine
Incredibly excited to present next week on The Pursuit of Clinical Excellence!
I’ll be focusing on how we improve Clinical Reasoning!
I may be biased but Indo-Chinese food is the best cross-cultural cuisine in the world.
Paneer manchurian
Crispy mushroom chili
Vegetable fried rice
🔥 🔥 🔥 🔥 🔥 🔥 🔥 🔥 🔥
#DesiMedTwitter
#DesiTwitter
#MedCooking
Tell me you don’t make these decisions at the bedside routinely without telling me you don’t make these decisions at the bedside
Can count on my hand the times I’ve ordered an ABG to make a decision about NPPV initiation
We CANNOT use the carbon dioxide level on a VENOUS blood gas (VBG) to accurately assess the need for BiPap or intubation
Ventilation problems cannot be assessed on a VBG
Don’t be fooled by lab values that are “within normal limits”
On occasion they are “inappropriately normal”
Example: A normal PTH level in the face or hypocalcemia and low vitamin D levels
This is hypoPTH, you expect a compensatory ⬆️PTH
Any others
#MedTwitter
?
A curious case of sinus arrest
Follow along for my reflections on a patient I evaluated in the hospital
33M w/ poorly controlled T1D w/ vascular complications p/w OM/septic arthritis s/p AKA day prior
Called to bedside after syncopal episode w/ tele showing sinus pauses
1/8
I wanted this kind of exposure to broaden my clinical skills and push my limits
I’m so glad I did. I’m caring for patients and conditions I never once saw in residency, even at a tertiary referral center
I learn something new every day
The onus is on attendings to fix perception that IM rounds are inherently long
Read overnight events/labs before rounds, take time to read full H&P from NF or call team, etc
Do this so rounds are not stuck in the past of reporting data, but rather focused on eval of reasoning
May 3rd = tip
#3
#TipsForNewDocs
#MedTwitter
When pts are admitted, update families. Ideally daily!
Don’t assume they’ve been updated by others
Start w/ “What do you know about the reason for admission/status of their condition?”
This allows you to gauge their understanding
It’s May 2nd which means tip
#2
#TipsForNewDocs
#MedTwitter
Becoming a great clinician is your first responsibility and is what your pts deserve
Only pursue other endeavors if you want it for yourself
Don’t fall to the pressure that being a great clinician isn’t enough
IT IS!
Why not? Because they didn’t ask why?
Why would a 35F have HFrEF? Why was she not improving?
Getting to the why is at the core of being a good diagnostician, internist, generalist, and patient advocate
Got consulted for acute hyperkalemia management while on
#MedConsults
...
...Dx an RTA Type 4 after calculating a +Urine Anion Gap and TTKG i/so NAGMA
As an intern, RTA was so abstract and only in textbooks
Now it is on my ddx. Talk about
#diagnosticgrowth
#clinicalreasoning
Also a plug: consider community practice if you are academically trained.
Your training goes a long way for patients and you can influence their care in a very powerful way by bringing evidence based practices and improving the quality of their management
In the era of EMRs, ability to access on our phones, constant communication with care teams, attendings should not be asking what basic lab values were overnight nor playing a game of telephone on what the echo showed, consultant said, etc.
Excellent 🧵 here
Soon to wrap up another go around on ID consult service, and some observations to share. Some may be controversial, but things humming along and the team running like a well-oiled machine, thought I'd begin a dialogue. 2 major observations, with detail for both.
May 9th = Tip
#9
#TipsForNewDocs
#MedTwitter
One of the biggest lessons from intern year is getting a gestalt for sick vs not sick
This relies on recognizing signs and symptoms that should give you pause
A brief list and crowdsourcing to add to this list!
May 8th=Tip
#8
#TipsForNewDocs
#MedTwitter
Intern yr you may be on several “off service” rotations
Some of my most impactful rotations were not in my specialty (IM)
Soak up as much knowledge & perspective as you can
You’ll inevitably work with that specialty in the future!
#TipsForNewDocs
Find your Joy in Medicine à la
@DxRxEdu
but also...
Find your Joy outside of medicine to keep you grounded
Mine is gardening, cooking, and the outdoors
What’s yours?
Join us this Monday (August 22th) for another Clinical Reasoning VMR at 6pm EST. This time with
@Gurpreet2015
discussing a case by
@MohitHarshMD
.
@MadellenaC
will be facilitating the session.
It's free to join us! Hope to see you all there (:
As promised, pt 2 in Potassium
#Tweetorial
series. This time, Aldosterone and Potassium Homeostasis
Another large physiology topic, so I’ll be brief and stick to highlights from reading
#BurtonRose
textbook, which I highly recommend for all levels of learner
Thread ⬇️
Next time, we’ll take a deep dive into the role of
#Aldosterone
in K Homeostasis.
Ref: PMID 355876, 27756725, 1146998
Happy to take in any feedback since this is my first venture into tweetorials!
My rounds never lasted more than 2 hours and that included ample teaching. I can make a 🧵later on how I achieved this but just goes to show it is possible if attendings took time to know data and interpret it themselves before rounds
One of my responsibilities is organizing
@WashUIMRes
noon conference
I made a goal to ⬆️ representation of lecturers who are
#WomeninMedicine
and
#URM
Proud to say thus far 60% of lecturers are faculty/fellows who identify as women or are URM!
I plan to keep that % growing!