Philip Greenspun’s Weblog

Last week before exams and our first break for the year. Sleek Sylvester, Ditzy Diane, and I are worn out, our motivation waning. We have a new team of residents for the last three days and none of us have the desire to impress them. The senior resident: “Let us know if you have any questions. You guys can just study if you want. We’ll let you know if anything exciting is happening.”

We are actually helpful on Monday during rounds, having previously admitted many of the patients on our service. We provided the only continuity of care for these patients and were tasked with presenting a formal H&P for each of our three patients to the new team.

We also play “Stump the Med Student” on rounds. A 36-year-old gas station clerk, whom I admitted three days ago, has acute renal failure from multifactorial causes — hypertension, uncontrolled diabetes, and three-month long ibuprofen use. He stopped taking his diabetes and blood pressure medications five years ago. The senior resident asks, “Why is his sugar low and his Hemoglobin A1C in the normal range if he is an uncontrolled diabetic?” Sleek Sylvester, Ditzy Diane, and I put our heads together and come up with nothing. “Insulin is cleared by the kidneys,” explains the senior resident. “If you see a patient whose diabetes suddenly becomes remarkably well-controlled after years of noncompliance, it’s likely a result of his kidneys failing, not that he has seen the light and has started to listen to your every piece of advice. It’s ironically the first sign of a serious complication. Our patient likely will be on dialysis for the rest of his life. I don’t think his kidneys will recover.” He concludes: “Well, I’ve done my job for the week; go study.” 

After rounds, we do UWorld questions in the lounge, disrupting the residents who are trying to get their notes into Epic. We relocate to the cafeteria for lunch and find Geezer George and Mischievous Mary. Geezer George is doing his elective orthopaedic rotation. “I’m determined to do ortho. I am ready to be miserable through the application process.” Are you concerned about getting into a residency program? “Yes, but my mentality is if the average step score is 245 for ortho, and I know people with 260 are being accepted, that also means they must be letting people in with 220.” Sleek Sylvester questions his symmetric Bell Curve assumption: “Why stop there. People get in with 270, that means they are letting people in who barely passed!”

Jane has had a slow end to her Ob/Gyn rotation with no surgeries scheduled for Monday. She did, however, enjoy M&M (morbidity and mortality) conference. “The attending was pimping the residents. I was like, Bitch, don’t stop! The residents were squirming, it was great.”

I arrive for the three-hour 8:30 am NBME clerkship exam on Thursday at 8:00 am. Type-A Anita and Southern Steve just finished their radiology rotation. They struggled to stay awake in the dark reading room while getting pimped by the radiologists. “The radiologist would put up a study, and select one of us to give an impression on what is wrong. We would utterly fail most of the time.” Steve: “Do you remember that one abdominal CT? We kept focusing on what we were convinced was a hernia. Turned out to be just a normal penis… Apparently there was small bowel thickening from gastroenteritis.” Anita: “Boy, did he get a laugh out of that.”

Internal Medicine exam questions focused on adverse effects to medications (e.g., Stevens-Johnson syndrome in anti-epilepsy medications), management of acute coronary syndrome, and several rare autoimmune disorders.

On Friday starting at 9:00 am, I had two 15-minute encounters with standardized patients, each followed by a 10-minute write-up. One patient was suffering from new-onset chest pain patient while the other had worsening shortness of breath from CHF versus COPD. We are alone with the “patients” while a video recording is made. Our grade is based on a review from the standardized patient (“Did the medical student empathize with my situation?”; “Did the medical student cover me appropriately during the physical exam?”; “Was the medical student’s interview organized?”), a review of the video by a physician or another standardized patient, and the quality of the write-up, again reviewed by a physician or another standardized patient. This prepares us for the pass/fail fourth-year Step 2 Clinical Skills (CS) exam (good news: 98 percent pass rate; bad news: the all-day test costs $1,290 plus travel expenses to a designated testing location, e.g., Los Angeles, Houston, Chicago, Atlanta, or Philadelphia).

Statistics for the week… Study: 8 hours. Sleep: 5 hours/night; Fun for me and Jane: visit her sister and one-month-old nephew. Not fun for Jane’s sister: We practiced testing the baby’s primitive reflexes.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Week 5 of internal medicine clerkship. During Monday morning rounds, Formal Frank asks, “Bianca, why do you keep giving Diane the vegetables? Our goal is for medical students to get practice talking to patients.” Diane’s first patient was a patient with primary aphasia, then a patient with dementia that had progressed to aphasia. She once again has taken an overnight admission who cannot speak but a few words due to Lewy Body dementia.

I admit an 85-year-old patient with acute mental status changes brought to the ED after a “fall from standing”. He is accompanied by two women: 40 and 45 years old. It turns out that the 40-year-old is the wife of five years while the 45-year-old is the daughter. The wife is the one who knows everything about his care, answering all of our questions with a heavy Vietnamese accent. Boss Bianca and I check on our patient around 7:00 pm. He was lethargic, but oriented to person, time, and place. After the wife and daughter step out, he calmly said, “I know I am not going to make it to my granddaughter’s wedding.”

I arrive Tuesday at 6:00 am to learn that our patient died overnight, perhaps due to undifferentiated sepsis. The family declined an autopsy. The night team reports he went in and out of ventricular fibrillation twice over a 30-minute code. “We even gave him a bicarb bolus [last resort in severe metabolic and respiratory acidosis]. The family was present and they understand.” This was the first patient death for Tiffany and Bianca. Bianca took it pretty hard: “That’s crazy, we talked to him a few hours before this happened. Isn’t that surreal how he almost knew?”

The residents have their weekly “didactics” seminar this afternoon, so they let us go after we finish our notes at 2:00 pm. Sylvester, Diane and I grab burritos. Sylvester describes his experience on surgery. “We had a patient with Fournier’s gangrene [necrotizing fasciitis of the scrotum]. We performed a scrotectomy [removal of scrotum] leaving his balls hanging exposed with just gauze covering them. As soon as we cut into the scrotum, gas was released, no pus. The entire OR staff gag from the smell at the OR entrance tunnel with the door closed. ” He had a more enjoyable trauma rotation. He describes a stab wound causing a “shish kabobing” of multiple small bowel loops at different sites, and a hemothorax.

Diane, settling on pediatrics after her experience on IM: “I can’t deal with adults. They are just like babies, except they never grow up.” Both Sylvester and I are interested in internal medicine, though I say, “hospitalists sometimes seem like micromanagers with specialists doing the interventions. Sometimes all we do is give the patient IV fluids and send them home.”

With only one week left before exams, everyone is trying to cram in the 25 LCME-mandated online cases. A typical case starts with six photos, one of which is relevant to the medical questions. The other five depict a non-white-male physician and a non-white-male medical student talking to a patient, e.g., an elderly white man suffering from COPD. There are 10 questions (3 short answer, e.g., summarize relevant history and exam findings) embedded in 5 pages of text. Diane says that she is finished with the questions and actually found them valuable. Everyone else clicks randomly through the multiple-choice questions and responds with gibberish to the short answer questions. Due to rumors that some clerkship coordinators look through the student report, including the time spent on each case, Gigolo Giorgio opens four cases in four separate browser windows in order to build more clock time per case. Sylvester has copied this strategy.

Wednesday after rounds, Bianca takes me to remove a jugular vein hemodialysis catheter on a patient with dementia who cannot speak or react to speech. We discuss the steps while walking up the stairs. First, place the patient in Trendelenburg position (feet elevated above head). Why? Bianca: “Air bubbles travel up, we don’t want to send an air embolism to the brain.” Second, pull the catheter out on an exhalation when there is more intrathoracic pressure. If patient is awake, ask him or her to hum. Third, apply pressure to the site for three to five minutes if the patient has no coagulopathy (change in normal coagulation function, e.g., from warfarin or heparin anticoagulation). Apply Tegaderm and a folded “4×4” (standard gauze) for air seal. The patient survives my first removal of this type of catheter!

Nearly all of our patients have congestive heart failure listed in the Epic chart, but their last echo often shows only  “grade I diastolic dysfunction,” not clinically significant. During initial interviews, patients are confused when I ask how their heart failure is controlled. They’d never heard about this diagnosis. Boss Bianca, “Don’t take things the notes and problem list in Epic at face value. Just in our time here I’ve submitted five safety reports for medicine issues. Transitional cell cancer, are you sure…? Look at the original doctor note [frequently a scanned image from an outside institution, available under the Media tab]; don’t play Telephone.” She continues, “At my medical school, a patient was labeled for three years as HIV-positive. The patient only found out this was in his chart when he requested his medical record after moving to a new city. It turned out a nurse originally meant to put HCV [hepatitis C virus] in the past medical history, and the physician just signed off on it. Let’s just say the patient won a lot of money.”

(Hospitals have a financial incentive to mark patients as having congestive heart failure and other serious conditions because they are entitled to get paid for more of their readmissions if they are treating a sicker population.)

Friday morning report. A senior resident goes over a recent case of tuberculosis (TB): “An 35-year-old undocumented immigrant presents for several weeks of hemoptysis [coughing up blood] and generalized malaise. She had seen by two urgent care providers who prescribed antibiotics. What risk factors did our system miss?” She answers her own question: “Well, first she is an immigrant with barriers to healthcare access. Her boyfriend recently was in prison. We also learned that she was smoking cigarettes picked up off the ground.” She describes the challenge of caring for this patient because she kept wanting to leave the hospital. “She did not understand the contagiousness of TB. She left AMA [against medical advice], exposing her family [5 kids from 3 fathers] to TB. She frequently would get out of bed and walk around the halls despite pleading from the nursing staff. The boyfriend and cousins would visit, but, despite the provision of Spanish language interpreters, could not be made to understand the need to wear specialized N95 masks when visiting her in the negative pressure isolation room.”

One nurse contracted TB and five more had to go on long-term isoniazid treatment for tuberculosis prophylaxis. The senior resident concludes: “Efforts to reduce TB have been so successful that we forget about TB in our immigrant communities.” The trend is toward U.S. physicians seeing patients with more advanced TB, 18 percent of cases in 1995 and 24 percent in 2006.

[Editor: If the boyfriend was in prison, shouldn’t that have made it easier for her to access health care? One fewer household member to take care of.]

Diane admits a 55-year-old for alcohol withdrawal. His BAC is 0.35 g/dL (blood alcohol content; the legal limit for driving is 0.08). Bianca orders a measured osmolality test, mostly for student benefit. We sit down in the resident lounge to go over the results, which show an elevated osmolality gap (“Osm gap”). “Most osmoles are captured by a CMP [complete metabolic panel] — those are sodium, glucose, and BUN [blood urea nitrogen]. Not many compounds can significantly alter the osmolality of blood, except your solvents: ethanol, methanol, ethyl glycol. So we can calculate the osmolality from a CMP. Whenever you see a severe metabolic acidosis, consider getting a measured osmolar and compare to the CMP-calculated osmoles.” Bianca sends a group iMessage: “Why is this called a teaching hospital? Because we do a lot of tests.” Regarding the concern that our edification was driving up costs for patients, Bianca responded “He’s on Medicaid so he won’t pay anything.”

Last day of Formal Frank. I appreciated his high standards and his professionalism with patients. Further, he engrained the need to not forget basic physical exam skills in the work up of patients. Every patient with a GI bleed gets orthostatics. Every chest pain patient gets bilateral blood pressures to rule out aortic dissection. These are simple low-cost tricks that can significantly change patient care. He had a good understanding of cost and benefits. For example, he mentioned that “we spend about $100,000 for every folate deficiency diagnosis. So rare if the patient is eating any kind of food.” [he still allows residents to order folate work up.] I hope to use the Osler test to prevent the misdiagnosis of hypertension in the elderly when I do my outpatient family medicine clerkship.

Pinterest Penelope promotes a school-run LGBTQ awareness event: “Just because someone ‘doesn’t know’ if a person is trans, does not give them a free pass when they misgender that person.”

Shortly after reading this Facebook post, I had my first encounter with a trans patient. He presented to ED for alcohol detox and, after determining that he had no other medical issues, we transferred him to the inpatient psychiatric unit, which handles all uncomplicated detox cases. He is listed as female in Epic, which shows multiple similar detox visits, one each of which he received a pregnancy test. Formal Frank: “They want to change their sex to their identified gender, but if they succeed insurance will frequently not pay for the appropriate screening tests. Our Epic department has spent a lot of time developing an item for gender and a pop up message to alert the provider about the correct gender. We’ll let psych deal with that.”

Statistics for the week… Study: 10 hours. Sleep: 5 hours/night; Fun: 1 night. Saturday afternoon guitar jam session with Gentle Greg to practice for upcoming coffeehouse medical school open-mic night. He’s going through a difficult time with his girlfriend of three months. They’re both Indian-Americans. He’s studying to be a doctor and she is studying to become a physician assistant. However, her family is Hindu while his is Muslim. She is concerned that her family won’t accept him, despite the fact that he is not observant. (They will later break up and then reunite after she talks to cousins who’ve successfully navigated initial family disapproval.)

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Week 4 of Internal Medicine clerkship, same team. Monday is call day. Our team is responsible for divvying up admissions to the hospitalist service. Our team has a low census (only about 6) after all the discharges so we’ll admit 6 patients today. I take the first admission. A 93-year-old female with Alzheimer’s and vascular dementia and COPD (chronic obstructive pulmonary disease) presenting via EMS (ambulance from the nursing home) for worsening shortness of breath. Typically, the medical student is tasked scouring through the 40-page stack of medical records sent from the nursing home for prescription medications. Fortunately, her three children, one granddaughter, and a great granddaughter are present to give a full history of her health. Her daughter: “She never smoked a cigarette in her life.She got COPD from second-hand smoke; her husband was the chain smoker.” Tiffany: “Now you see the challenge with the elderly. If they don’t live near family, it can be a crisis. Her past medical history is an enigma. We don’t know her goals of care, or if she already has a living will.” 

Her wheezing is audible from the hallway, but she is oxygenating well on 2 liters NC (2 liters oxygen delivered via nasal cannula prongs). We step out into the hall and explain her GOLD Stage 4 COPD (most severe) to her family members. She arrived in actual (as opposed to coding gimmick) respiratory failure. She has a severe acute respiratory acidosis with chronic metabolic compensation shown by ABG (arterial blood gas sampling). We avoid intubation by giving back-to-back DuoNeb nebulizer treatments until IV methylprednisolone (steroid, similar to cortisol) kicks in (about 30 minutes). We order a BiPAP (bilevel positive airway pressure) machine from the resident lounge. Briana emphasizes as we wait for the elevator, “BIPAP is never used unless there is a foreseeable improvement from a specific intervention — when in doubt, intubate. It is the safest intervention.”

We head up to the resident lounge to type H&P into Epic. Two hours later, we meet the attending, Formal Frank, in the ED to present our admissions. Sylvester describes a newly diagnosed lung cancer patient. Diane presents an undifferentiated pericardial effusion (fluid around the heart). In the room with my patient, the attending notes her inability to speak more than two words and that she is using accessory muscles (e.g., between ribs or in the neck) to breathe.

Formal Frank asks the granddaughter, “What is her baseline?” A great-granddaughter responds, “This isn’t her, she’s a stubborn old bat, but she’s as sharp as a whip. She remembers small details from our childhood. Right now she doesn’t even know who I am.” 

Formal Frank asks us, “You ordered BIPAP, but is she using BIPAP?” We stare at each other. “Just because you put something in the computer doesn’t mean it happens. Nurses think of our orders more like recommendations.” He had guessed right. Due to a combination of our patient improving and her dementia, the respiratory therapist had apparently given up after setting up the ($2000 billed to Medicare) machine. 

As far as I could tell, the 45-year-old granddaughter stayed in the room for the entire five-night stay. She worked from her laptop and phone and slept in the recliner chair. Every time a nurse came in, she would ask what the next step would be. She related her concerns about the nursing home. “Her medications are ordered PRN [as needed]. That becomes an excuse for them not to give them,” says the granddaughter. “Their nurses are lazy, not like the ones you have here.” I work with the granddaughter on an updated list of medications, including an inhaled steroid for the GOLD stage 4 COPD.

My next admission is a 22-year-old patient with two-day history chest pain. A CT angiogram performed in the ED showed a pulmonary embolism. She also has numerous skin lesions. She has clear moon facies (swollen “moon face”) from steroids used for immune system suppression since age 9, when she received her first kidney transplant.

We get a deeper medical history from the mother, although she did not know the cause of the initial kidney failure. Either the kidney biopsy that would be standard today was never done or the mom can’t remember the result (or was never told). After all of the billions of dollars spent on electronic medical records, we’re forced to rely on the memory of laypeople for a continuous history of anyone who has been seen at multiple institutions.

We restart the patient’s immunosuppressive medications and start her on a heparin infusion for therapeutic anticoagulation.

I present the patient bedside to Formal Frank and Boss Bianca. The patient doesn’t have any questions, and we go into the hall to discuss. Formal Frank: “This is an exciting case! Think of everything this could be. What could cause a PE?” Sylvester, Diane, and I can’t come up with anything other than a run-of-the-mill PE from a DVT. Bianca: “Dig Deeper! People on immunosuppression are at a 100 times risk of developing cancer. She could have a nephrotic syndrome that causes you to be hypercoagulable. People with kidney transplants are at increased risk of glomerulonephritis. She’s also on a fibrate, maybe she has a heart attack.” (We don’t get to explore these issues, unfortunately. The patient’s shortness of breath resolves and she is discharged after two days to resume her job at Subway and see her outpatient specialists.)

On Thursday, Boss Bianca corrals the three of us after rounds. We head to the supply room, tucked away in the labyrinthine basement, to get several punch biopsies. “I have a surprise for you.” A patient admitted overnight to a different team may have syphilis. The 26-year-old relapsed on meth two weeks ago after his girlfriend left him. He has had several ulcers, largest in diameter about 4 cm and 1 cm deep, pop up on his body, including on his forehead, elbow, wrist, and back. “Look at me. I can’t go to work or anything.” We each choose a location and perform a punch biopsy. Later, I checked his chart and the syphilis tests came back negative. A dermatology consult did not result in a definitive diagnosis, but noted the possibility of an immune reaction to meth, possibly a necrotizing vasculitis?.

[Editor: Parents of couch-bound Xbox-playing youth nationwide should use this guy as an example. Even a meth head had a girlfriend and was passionate about going to work.]

Bianca and I run upstairs for a code blue for a 80-year-old DNR (“Do Not Resuscitate”) who is scheduled for transcatheter aortic valve replacement on Friday. He went asystole (flatline EKG). Boss Bianca instructs a nurse to get basic labs, a 12-lead EKG, and to get her the family’s phone number. “DNR does not mean do nothing. Check glucose, hypoxia, treatment arrhythmias.” She taps my shoulder to look at his Cheyne-Stokes breathing pattern. He would take 4-5 deep breaths, then stop breathing for several seconds. Bianca speaks to the daughter and explains the situation that he is DNR, and therefore no further interventions are indicated. The family understands, and says that they knew this was likely and that the valve replacement was extremely risky. Bianca instructs Tiffany to call the surgeon and tell her that the patient is dead.

[Editor: Medicare would have paid over $60,000 for the valve replacement, had the patient survived long enough to receive it.]

Friday is the medical students’ “24-hour” shift, from 6:00 am until morning rounds on Saturday (i.e., about 9:00 am). We work with our normal day team with rounds, followed by notes in the resident lounge. We attend a few procedures on our patients, e.g., endoscopy for GI bleeds, and then join the night team at 6:00 pm.

The chief resident functions essentially as an attending. She was asked to stay for an additional “chief” year following PGY3. She and I head to the med/surg floor to perform paracentesis (“tapping the belly”) on two patients with alcoholic cirrhosis.

[Editor: The good news that I learned at Harvard Medical School in 2019 is that these patients are not “alcoholics.” At worst, they are suffering from “alcohol use disorder.”]

I use an ultrasound to locate a pocket of fluid on a 35-year-old alcoholic cirrhosis patient with a belly swollen from ascites. She is animated, intelligent, and sober following two days of detox. It is tough to imagine that she is on disability and suffering from end-stage liver disease. I locate a pocket that is clear of bowel and mark it with a pen. My chief then preps and taps the belly. We get 4 liters, four test tubes of which we send to the lab for albumin ascites gradient (SAAG) to determine if there is portal hypertension or an inflammatory process. 

The chief lets me do the next one, on a 65-year-old former alcoholic. After sticking a needle into the belly, advancing the catheter, and retracting the needle. The patient feels better after 2 liters, but we keep going until we’ve extracted 10(!). We increase his IV fluids to compensate for the expected dehydration.

We are beginning to fade at 1:30 am, fighting over who will get stuck with the next patient rather than who will get the privilege of taking the next one. The chief sends us home at 3:00 am. Sylvester and Diane both sleep at the hospital in the medical student call room. I decide to go home for 2 hours before returning for Saturday morning rounds at 7:00 am. I finished my notes before heading home so I leave after rounds and sleep.

We get the rest of the weekend off. 

Jane had an exciting week on inpatient gynecology. A 65-year-old patient presented with stage 4 cervical cancer and necrotic tissue in the vagina. She’d been having regular checkups with a nurse-practitioner who ordered labs and assumed that the patient was seeing a Ob-Gyn and getting standard-of-care Pap smears. The doctors were outraged that this had been missed and now this otherwise healthy patient was sentenced to death.

[Editor: Although this patient plainly would have benefitted from screening tests, there is debate about whether the U.S. standard of care is the right one. See “Harms Of Cervical Cancer Screening In The United States And The Netherlands” (Habbema, et al. International Journal of Cancer 2017, 140:5): “Our main finding is that harms occur much more frequently in US than in NL, while the levels of incidence and mortality have been quite comparable between the two countries…” (the Netherlands screens at only about half the rate of the U.S. and only for women 31-60)]

Jane is exhausted and sore when she returns home. She spent five hours total driving the uterus with a uterine manipulator. “I was pushing so hard, my feet were slipping, but they kept saying, ‘Harder. Harder. Lift the uterus.’ Afterwards my hands were shaking. I could barely squeeze.” She continued, “And of course they then asked me to suture. They thought I was really nervous, but actually I was having trouble gripping the instruments.”

Statistics for the week… Study: 6 hours. Sleep: 5 hours/night; Fun: none.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Monday morning, Terrific Tiffany and I admit a 59-year-old HIV-positive patient (my first) with coronary artery disease for a pre-syncopal (nearly fainting) episode and chest pain. His Hepatitis C and liver cirrhosis suggest a history of drug use. He presented because of the chest pain and running out of his nitroglycerin sublingual tablets. During the interview, he also reports a two-month history of black tarry stools. Fecal occult stool test is positive, his hemoglobin is 6.4 (normal: 13.5-15; worry: 9; transfuse: 7). Tiffany allows me to put in the basic orders for practice: 2 prbc (packed red blood cells), H&H (hematocrit and hemoglobin tests) q6h (every 6 hours), gastrointestinal consult, cardiology consult, troponin q6h, normal saline at 1.5x maintenance, protonix 40 mg iv q12h, and 2 large bore IVs.

If he is not having an acute GI bleed, his hemoglobin should increase approximately 1 Hg for every 300 mL prbc bag. Six hours later, his hemoglobin result is 8 Hg and his chest pain has resolved.

Diane, Sylvester, and I join for the afternoon Esophagogastroduodenoscopy (EGD) study in the endoscopy (“endo”) suite. Under supervision from a GI attending, the GI fellow makes the scope do a U-turn to look backwards at the stomach. He points out GAVE (gastric antral vascular ectasia; dilated blood vessels in the stomach antrum leading to a “watermelon appearance”). We find three arteriovenous malformations (AVMs, dense collection of friable vessels) in the duodenum. “GI attendings love to pimp on this,” notes the fellow. The attending requests a pediatric colonoscopy scope to go further into the small intestine to investigate the jejunum (middle part of the small intestine, typically found empty in autopsies and therefore derived from the Latin for “fasting”). The fellow struggles to advance the longer endoscope, so the attending takes over and explores another 3 feet of bowel.

We find 2 more AVMs, none bleeding. The endoscope has a sprayer for liquid nitrogen and they use this to freeze off the AVMs. Each of us is then allowed to practice driving the scope from the stomach through the pylorus. Sylvester: “Just like a video game.” Afterwards, I ask the GI attending, “Do you really think AVMs were the cause? Can he do anything so this doesn’t happen again.” GI attending: “We do not know what causes AVMs, but there is a clear relationship with aortic stenosis [AS]. If you cure the aortic valve stenosis, the AVMs go away! He doesn’t have significant AS, so he just has to live with them. He’ll have to come in every few months and get a transfusion. More importantly, his multiple comorbidities would not make him a good candidate for aortic valve replacement.” 

During lunch, Boss Bianca goes over the REDUCE (Reduction in the Use of Corticosteroids in Exacerbated COPD; chronic obstructive pulmonary disease, typically from smoking) trial with us. Sylvester and I had prepared by reading up on the REDUCE trial… for prostate cancer. Our discussion was delayed 15 minutes so that we could read the correct “REDUCE” study.

REDUCE investigated whether steroid use could be reduced from the standard of care 14-day course of 40 mg of prednisone to a 5-day course without worsening the estimated 33 percent re-exacerbation rate within 180 days of index hospital discharge. Bianca explains, “Before this trial, you would get 20 different answers about duration and indication of steroid use for patients from 20 different doctors. This was a pivotal trial because it allowed evidence to treat quick-responding patients for only 5 days, but you have to treat the patient until they improve. If they are not improving on day 3, by God, you are not going to stop giving them in two days.”

Sylvester, who struggled in our statistics course, tries to impress Bianca. “I am just a sucker for statistics. I loved how they took the stance of the two groups assessing if they were ‘noninferior’ by using hazard ratios.” Bianca stares blankly and continues, “How might our patient population differ from the study population in Switzerland?” Diane brought up one difference: everyone in the study received antibiotics. “We don’t give antibiotics to every COPD exacerbation so this could be a factor.”

Wednesday call day. We have two rapids in the morning. One page was called for bradycardia (heart rate in the 40s). Bianca decides not to initiate any intervention, as the 75-year-old patient, admitted for hip fracture, is asymptomatic. She had received an extra dose of metoprolol due to miscommunication during the medicine reconciliation on admission; she had already taken her AM metoprolol before coming to hospital. (Our attending, Formal Frank: “This is what happens when we put elderly folk on two or three antihypertensives [amlodipine, HCTZ, and metoprolol for our patient] Have you ever heard of the Osler’s sign for pseudohypertension? No one does it anymore for some reason.” He explains how to perform the quick test to evaluate for falsely elevated blood pressure reading from a cuff due to excessively athersclerotic arteries that cannot compress. “We keep adding antihypertensives to the elderly, and our readings don’t go down until they go down. I want you to perform the test on the next elderly patient we have. Remember: Always ask, What did we do to the patient?”)

Rounds continue after the rapid with Sylvester’s 42-year-old obese female admitted two days ago after a pulmonary embolism. She is on oral birth control [OCP] and has well-controlled hypertension. She was initiated on low molecular weight heparin injections and will be transitioned to an oral anticoagulant for at least three months. Formal Frank: “A serious conversation should’ve been had with this woman several years ago. She is obese with hypertension, all risk factors for DVT, and she is still on OCPs. This could have been prevented, now she has to be on anticoagulation for at least three months, which carries its own side effects. Once again, always ask, ‘What did we do to the patient?'”

Do we need a cardiologist or hematologist consult to manage the pulmonary embolism? “I know the guidelines and studies better than most cardiologists do and feel confident in managing this disease. That’s the beauty of internal medicine, you choose what you are interested in, and get consults for things you are not interested in.” Sylvester and I spend ten minutes with our noses almost touching the screen trying to identify the occluded segmental artery on the CT angiogram without looking at the radiologist report. Sylvester: “Ah, we found it. Look at that wedge!”

Diane follows a 38-year-old overweight diabetic mother with depression and a foot ulcer admitted for a foot amputation. Her son has Down Syndrome. She will have fantastic sugar control for 8 months, but then binge for two months on pizza and soda, possibly due to “caretaker burnout.” Her affect is labile: she was extremely cheerful during pre-rounds, but now she is in tears. Formal Frank: “She’s in denial. Wouldn’t you be if you were about to lose half your foot from a small ulcer?” He continues, “If she wants to walk again, she should get a BKA [below the knee amputation] and begin PT immediately. Evidence is quite clear that the best functional outcome is from a BKA. She is unlikely to walk after this partial foot amputation, but the system doesn’t think that far forward. She’ll be back in a year requiring a BKA so what’s the damage besides a few thousand dollars, right?”

I pick up a 58-year-old patient admitted by the night team. He is admitted for acute hypoxic respiratory distress secondary to congestive heart failure (CHF), undiagnosed COPD, and atrial fibrillation with rapid ventricular response (fast heart rate). Coding for acute hypoxic respiratory distress leads to significantly enhanced revenue.

We discuss his prognosis, and if we should order an echo. The patient is on minoxidil, an old antihypertensive that is seldom used (except topically for baldness). He is also not on any CHF medications, e.g., a beta blocker or an ACE (angiotensin-converting enzyme) inhibitor,  that have a survival benefit. Formal Frank asks the team to check the chart for the name of the patient’s outside private cardiologist. “Ah, well I assure you he has had an echo in the last six months. Anything this guy can bill before the end of his patients’ life.” Sure enough, after several hours on the phone we get his outside records faxed showing echos and carotid duplex studies every six months. Although we typically do not make major changes to medications prescribed by outpatient doctors, we discontinue the modafinil and begin beta blocker and ACE inhibitor. 

This patient exemplifies the dangers of overspecialization in healthcare. The patient does not see a general internist. His (mediocre) cardiologist is essentially his primary care doctor. The cardiologist ignores everything except cardiac issues. So there are great images documenting the continued ejection fraction decline, but he is not even on the simplest albuterol inhaler for COPD. Most of the problems likely originate from the patient’s uncontrolled COPD. Over several years this leads to pulmonary hypertension, thereby leading to CHF and atrial fibrillation. We perpetuate the specialization blinds by placing an outpatient consult to pulmonology to manage his COPD rather than a consultation with a general internist. Part of this is due to insurance, Medicaid, and Medicare realities. The specialist can bill far more for the same management that could be provided by an internist, thus reducing internists to a screening function.

The nurses don’t like Sylvester’s patient, admitted for alcohol withdrawal. She and her husband have moved into the hospital. There are suitcases strewn across the room, with clothes on the floor marking a path to the hallway, despite pestering from nurses that these make it harder for them to use the blood cuff, CPAC, and other machines. Security was called after a fight over mealtimes. The patient is medically stable for discharge, but requests the ride home to which she is entitled. The social worker informs us that there are no more “Medicaid taxis” available for the afternoon. Boss Bianca: “We should’ve gotten our discharge note signed earlier. No reason to waste a whole bed for one more night.” She orders a $15 Uber on her own account to pick the couple up. The nurses cheer.

I get out around 4:00 pm on Friday. I meet Jane’s two college friends at a local brewery. Her best friend is still using U.S. student loans to complete her master’s degree in New Zealand, primarily as a way of staying in the country to be with her boyfriend. She’s writing a thesis on “sex workers” and explains the power dynamics between workers and cultural oppression.

She cites Jane’s other friend at the table as an example of a “forgotten sex worker” because she’d been hugged while working as a waitress in a small-town diner. “This older gentleman who was the diner’s best customer would expect a hug from all the younger female employees. These are the forgotten sex workers oppressed by cultural norms that I am writing about.”

[Editor: In February 2019, the New York Times covered an incident involving commercial sex at a Florida strip mall. The (undocumented) immigrant women working there were described as “prostitutes.” Native-born women working in the same industry, however, were described in previous articles as “sex workers” (example).]

We are joined for dinner by Lanky Luke and PA wife Sarcastic Samantha, and Jane’s sister and her veteran boyfriend for dinner. Jane’s sister has been completing the 22-pushup challenge for veteran suicide awareness, posting a daily Facebook video to increase awareness that an average of 22 veterans kill themselves daily. Her boyfriend was initially supportive, but now is concerned about creating a stereotype that the typical veteran is suicidal. “Few of the veteran suicides were combat veterans from Afghanistan and Iraq. They are Vietnam vets, most of whom didn’t see a day of combat. This whole PTSD phenomenon has been hijacked by non-combat vets trying to get on disability. It takes away resources from the people who actually struggle.

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