Hospitalist and Health Blogs

Readers are slowly learning about my admiration for the Farnam Street Blog. The “about” page describes the blog in this way: My goal is to help you go to bed each night smarter than when you woke up. I'll do this by giving you tools, ideas, and frameworks for thinking. I'm not smart enough to figure all of this out myself. I try to master the best of what other people have already figured out. Sounds simple, doesn't it? The best way to do this is to read a lot. And so I make friends with the eminent dead. Along the way I write about what I'm learning. I'd encourage you to look around and decide for yourself if this is something that interests you.

Last week he reviewed The Laws of Simplicity by John Maeda. I read the book, and loved the approach to knowledge. As an educator, he has evolved to a BRAINy approach:

BASICS are the beginning.

REPEAT yourself often.

AVOID creating desperation.

INSPIRE with examples.

NEVER forget to repeat yourself.

I love this conceptualization. These lines seem counterintuitive to newly minted educators, but over time many evolve to understanding the wisdom in these lines.

As I work with medical students, interns and residents, these words accurately describe my evolution as an educator. We should never assume that our learners really understand the basics. Unfortunately (in my opinion) the first 2years of medical school which should emphasize the basics, quickly get too complicated. We have not defined the basic, must know physiology, biochemistry, anatomy, pharmacology, histology and microbiology. Rather we try to teach the basics as well as the more advanced concepts all in one package. This style of teaching makes it more difficult for our learners to separate the important signals from the noise. The national testing (STEP 1) drives how we teach because of the way they test.

So too often our clinical learners do not really understand the basics. We who teach in the clinical years, therefore, must always start with the basics, and not assume that our learners “own” those basics.

Too many educators assume that when they brilliantly explain something that the learners will absorb that teaching. Unfortunately, cognitive psychology teaches us that learning often does not occur at the first exposure to a concept or fact. Try teaching something and asking questions about that teaching a week later. Neuroscience research teaches that we will help our learners actually learn the material when we repeat our teaching. As educators we then must teach the same concepts repeatedly. I have had 3rd year residents who rounded with me as 3rd year students, 4th year, interns and 2nd year residents. When I give the same short talk at morning report about a subject, they tell me afterwards that they have learned new things. Repetition actually works.

As medical educators we must acknowledge the difficulty of learning our field. Internal medicine is difficult. When we acknowledge that and encourage our learners that the road towards excellence is a long road, we decrease their anxiety and therefore increase their ability to concentrate and learn.

Examples in medicine are patient stories. Our teaching always improves when we focus on patient stories. When a point needs emphasis, tell a patient story about success or failure.

Finally, never fear repetition. It may seem that you are boring the learners, but believe me you are not. The learners appreciate your efforts to make certain that they are learning. Separate the concept of teaching from learning. Our job is not to teach but rather to induce learning. Teaching is meaningless if it does not result in learning.

And when in doubt repeat yourself.

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 Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

A couple of weeks ago I flew into Newark Liberty airport in transit to another destination. I had a few hours to spare, and after a very early flight from Boston, felt hungry and in need of a good breakfast. After looking around for options, I sat down in what appeared to be a reasonably upscale restaurant.

The first thing I noticed was that there were glistening iPads mounted on each table. Well, this appeared nice and modern! After activating the iPad, I had to scan my boarding pass, which after some difficulty, the iPad managed to register. I then began scrolling through the breakfast options and shortly afterwards a hostess came by and told me how the process works: I would order my food, swipe the credit card, and then the food would duly arrive. Seemed straightforward enough.

The only problem was that some of the options seemed rather complicated, with various additions and extras, and I had to keep scrolling back and forth to get to different screens. When I finally decided on an option, I attempted multiple times to swipe my credit card, but the reader appeared to be not working. The hostess tried to help, even using another credit card, but still no success. At that point, hungry and frustrated, I got up and told them I would find somewhere else to eat. Ideally, a good old-fashioned bagel shop. However, to my surprise, as I walked around the airport I noticed that almost every single eatery, be it a cafeteria or bar, had this iPad system of ordering.

When I finally settled on a small cafe in the food court, there seemed to be utter chaos in the ordering line. Customers were being told to use the iPad, get a receipt and then pay at another iPad. There was total confusion, and when I finally got my breakfast, I spoke to one of the cafe workers, expressing my frustration and asking what happened to normal traditional ordering of food. The young lady, who seemed sincere and hard-working, told me that this new system at Newark airport had been installed just 3 weeks previously. They were clearly having difficulty with it to say the least.

So it appears human contact while ordering food is going out of fashion, certainly at this airport anyway. This is a problem on a multitude of different levels:
• Customers find it more difficult to ask routine questions about their food or make special requests.
• Elderly people in particular have a hard time, as I could clearly see.
• The process takes longer, because the main rate-limiting step is not ordering or paying, but actually making the food.
• We are taking an essentially social human experience, dining, and attempting to computerize it (albeit at an airport).
• On a personal safety and hygiene front, it is a terrible idea—especially in an airport—to have hundreds of people who are about to eat touching the same screen

Undoubtedly this experiment at Newark airport has cost hundreds of thousands of dollars, paid to IT folks and consultants. But has it really improved anything and is it what customers really want? Unfortunately, what many people from the IT world don't fully grasp is that while information technology is definitely the way of the future, not every human process is amenable or desirable to mechanization and technology.

Just as what we've seen at the frontlines of healthcare over the last decade, more IT isn't necessarily always the answer, and at a point actually reduces the user experience and customer satisfaction. Certain technically inclined people, who are happy spending their whole day sitting behind a screen, need to realize this.

Service is a human experience and people appreciate good service. Let's take supermarket checkouts as an example. As much as corporations want to promote self-service kiosks, most people simply have no interest in using them for their weekly shops.

I personally hope that Newark's experiment with this IT system fails. Not just because of the bad experience of customers, but because I also remembered my interaction with that sincere and hard-working cafeteria worker who told me all about this new system. No doubt she was just told by her superiors a few weeks ago, “Here is the new product; make it work,” perhaps not realizing another fundamental truth as she works so hard to get the new system up and running. People like her are just pawns in the process. Because if this works out the way some of her bosses intend, she and many others will almost certainly not be needed there anymore. That's what happens when the bottom line trumps good service and common sense.

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. This post originally appeared at his blog.

With the depths of winter just around the corner, doctors and nurses everywhere know what's about to hit them over the next few months. The inevitable surge in hospital admissions during colder weather is almost as predictable as knowing the leaves will be falling off the trees in the fall.

As someone who has worked in several different hospitals over the last few years, ranging from small rural institutions to large academic medical centers, I've rarely witnessed adequate preparations for the surge in activity that always occurs during December to March. Ironically too, many hospitals in the warmer south also experience a similar phenomenon, as “snowbirds” from the north head down to states such as Florida and South Carolina for the winter. Given this predictability, there's absolutely no reason for hospital administrations or physician groups to be caught off guard every year.

Here's what they need to do:
• Physicians, particularly those in generalist specialties such as emergency and hospital medicine, should create special winter schedules with extra doctors working at the front lines. This should happen well in advance, and not at the last possible minute.
• Ditto above for nurses, especially on medical floors.
• On-call schedules may need to be adjusted to ensure more manpower, and everyone needs to be prepared to chip in to help.
• Bed contingency arrangements should be made, with detailed plans of where to “board” patients when hospitals run at full capacity. Can an extra floor be opened or is there any empty space or rooms to put patients?
• Co-ordinate with other health care facilities in the area (and yes, even if they are technically rivals) to cope with even further unpredictable surges of patients, like during a flu outbreak

Remember too, it's not just all about doctors and nurses either. All hospital departments need to set up detailed plans. The pharmacy, laboratory, physical therapy, food and housekeeping services—are all part of the vital hospital structure!

Ideally, hospital administrations and physician leaders should hold meetings in November or early December to discuss these contingency arrangements. With the ageing population, planning for increased sickness during the adverse weather becomes more crucial and pertinent with each passing year. To prevent the chaotic scenes that unfold in thousands of hospitals up and down the country every winter, to quote Benjamin Franklin, the healthcare world needs to realize that by continuously failing to prepare, we are preparing to fail. And sadly, that means failing our patients.

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. This post originally appeared at his blog.

Most readers have familiarity with the phrase “fog of war.” In hospital medicine we often exist in a complex, chaotic situation. We have many patients, in various stages of their admission, beepers beeping, consultants consulting, sign outs and discontinuity. I have experienced this problem too often. Last week was a classic example.

The patient had a past history of IV drug abuse, but now had staph septicemia. He was in the middle of a 6-week hospitalization for IV antibiotics. He had several complications that were improving.

I joined his care on a Monday. That day he had no major complaints. The housestaff team asked for help in treating his new hypertension.

The next day he complained of shoulder pain. On examination he had full range of motion (both active and passive) but some tenderness with palpation.

On the third day the medical student reported that he had developed hyper-defecation and abdominal pain. The blood pressure remained poorly controlled.

The entire team expressed their puzzlement in trying to understand his complaints.

Then I recalled from day 1 that his IV morphine had been discontinued on Sunday.

His symptoms of opiate withdrawal had blossomed as we saw him each day. I asked him if he had ever had opiate withdrawal before, and he told us that his symptoms then were identical to his present symptoms.

A modest dose of opiates for 2 days and starting methadone have cured his hypertension and all his other symptoms.

As I write the story, I suspect many had suspicions before reading the answer. The presentation reads much easier than it felt. We had various clues but they did not come in a simple bundle.

As we rounded on 15 patients, he seemed more stable than many. We probably did not devote enough time to trying to analyze his symptoms.

Diagnostic errors and delays seem so simple in retrospect, but all seasoned clinicians know better. When you do not know that you are searching for a new diagnosis, you would love for someone to tell you that 1 exists. Too often in the fog of war, we fail to attend to some clues that we need to reopen our thought processes.

A computer program could have taken the symptoms and discovered the correct diagnosis, if (and only if) we knew to enter the symptoms.

I was confused, until I had a sudden epiphany. I knew the symptoms of opiate withdrawal, but I had to make the important leap of tying various symptoms into 1 knot that need unraveling.

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 Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

Readmissions to hospital, especially within 30 days of discharge, are on the radar of all health care organizations in the United States. This is due in no small part to stiff financial penalties that are now imposed on the worst performers by the federal government. On the surface, it may seem like a reasonable thing to penalize hospitals that don't successfully “get their patients better enough” to avoid readmission. However, the problem is highly complicated, and such a crude way of thinking about the problem (i.e. blaming it all on the hospital and the doctors) obscures from many of the real issues behind high readmission rates. These include factors such as an ageing population, lack of social support for many elders, the rising incidence of chronic incurable morbidities—all against the sad backdrop of the inevitability of sickness in old age. Battling nature can indeed be hard.

Most statistics suggest that approximately 1 in 5 Medicare patients (20%) are readmitted within 30 days. As shocking as this number may sound, it may even be an underestimate, because it doesn't include many patients under the age of 65 who are also stuck in the revolving door of frequent readmissions.

One of the key areas of focus has got to be better community care and follow-up, but how do we go about identifying these high-risk patients in the first place? Frontline hospital physicians, including myself, are all too familiar with the fact that a huge proportion of patients we admit to the hospital have been discharged in the not too distant past, sometimes as soon as the day before. It's the first thing we see when we scroll through the records of our new admission—what we call a “bounce back”. Equally, most physicians (and for that matter nurses and case managers) will instinctively know as soon as they discharge a patient, who is likely to be back very soon.

Over the last several years, there have been lots of clinical tools developed by academics to try to predict which patients are at the highest risk for readmission. Some in the “health care innovation” world have also tried to get computers and information technology in on the act. But at the end of the day, one can develop clinical tools till the cows come home, but rarely does it outstrip the good common sense of the people working at the frontlines.

Patients at a higher risk of readmission can easily be predicted by their recent history, clinical state, and social situation. The world of healthcare should identify these patients early on and immediately plough resources into working out what can be done upon discharge to keep these patients healthy in the community. There also needs to be better communication between the hospital and primary care teams, the patient's family, and also all of the specialists that may be involved in follow-up. And although we are focused on 30 day readmissions, because that's what the system uses as a measure, frequent admissions even within 60 or 90-day periods are also just as much of a problem and shouldn't be ignored. By zeroing in on these high-risk patients and keeping them healthy and out of the hospital, we are being the best doctors possible.

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. This post originally appeared at his blog.

This cohort found patients age >65 undergoing elective colorectal or cardiac surgery who had a history of falls in the past 6 months had significantly higher 30 day rates of complications, readmissions, and need for institutionalization. Asking about a history of falls pre-op may help assess post-op risk of adverse outcomes (abstract).

This randomized trial found induced hypothermia was associated with higher mortality in patients with bacterial meningitis (compared to standard care) (abstract).

This cohort of 20 surgeons were videotaped and rated on their skill performing laparoscopic gastric bypass surgery. Lower skill ratings were associated with significantly longer operations, rates of reoperations and readmissions, and higher rates of complications and mortality (abstract).

This study compared morbidity and mortality in adults hospitalized with RSV or influenza and found overall length of stay and mortality were not significantly different between the 2 infections (with 30 day mortality at 9%) (abstract).

This small trial of 150 patients with sepsis and tachycardia found those randomized to an esmolol infusion (with heart rate goals 80-94) had significantly lower mortality than those in the control group (49% versus 81% at 28 days) (abstract).

This large analysis of US hospitals found those with higher VTE prophylaxis rates were associated with higher VTE rates, and hospitals with higher VTE surveillance testing had higher VTE rates. Publicly reported VTE rates may be more reflective of VTE surveillance patterns, and not actual patient quality (abstract).

This large trial randomized ICUs to gloves/gowns for all patients, or usual care, and found no difference in MRSA-VRE acquisition (abstract).

This single site retrospective analysis found 58% of patients with a urinary culture did not fit evidence based criteria to have the culture sent; reducing unnecessary testing is an opportunity to reduce hospital acquired UTI rates (abstract).

This cohort of patients with new onset seizures found epileptogenic foci in 28% of patients with true seizures (abstract).

This prospective analysis of sepsis patients found those that had antibiotics appropriately de-escalated had lower mortality than those that did not (OR 0.55) (abstract).

In this cohort of ICU patients, 3/4 developed ICU delirium; at 3 months 40% had cognition scores 1.5 SD below the mean, and 25% were 2 SD below the mean. By 12 months, ~1/3 had scores similar to mild traumatic brain injury, and ~1/4 had scores similar to mild Alzheimers disease. The longer the delirium, the worse the cognitive outcomes (abstract).

This patient flow study found that as ICU “strain” increases (admissions, acuity, and census), patients are more likely to be transferred to the floor 6 hours earlier, and this increases the risk of ICU readmission by 1%; but there is no evidence that this increases mortality or hospital LOS (abstract).

Due to the black box warning of higher mortality compared to other antibiotics, tigecycline should be reserved only for use when other safer antibiotics are not feasible (FDA warning).

In this trial of patients with in-hospital cardiac arrest, they were randomized to vasopressin-steroid-epi combo or epi alone; those in the combination group had significantly higher chance of survival to discharge with good neurologic outcomes (21%) versus the epi group (8%) (abstract).

Managing coagulation in cirrhotics is very difficult. A new practical guideline gives the following advice: For invasive procedures, keep platelets >50K, avoid FFP, and consider ddavp for dental extractions; for bleeding varices, also keep Hb around 7, and keep fibrinogen >100. Acute portal vein thrombosis requires anticoagulation, but chronic does not; inpatients should be given prophylaxis for VTE (abstract).