ACP Internist Blog


Tuesday, April 20, 2021

Some thoughts on diagnostic reasoning

Yesterday I tweeted about our success in making some worthwhile diagnoses in the category of unusual presentations of common diseases. As I consider these successes, the principles of diagnostic aggressiveness become central to my thoughts.

For arguments sake let's imagine three types of diagnostic reasoning. The first occurs when there is no diagnosis but we know something is wrong. These patients generally require a broad differential and much clinical thought. We often go back and collect more history, repeat the physical exam and think broadly about labs and imaging. We often need several consultants and often biopsies.

The second version includes the majority of patients – a straightforward diagnosis. We need not spend much time on diagnosis unless the respond to treatment raises warnings that we might have the wrong diagnosis.

The third version involves patients whose presentation involves some subtleties. These are the patients who too often do not stimulate diagnostic curiosity. Yet, when we pay attention to the subtle clues, we often reopen the diagnostic process. The most fulfilling diagnoses that I and my teams have made occur in this latter category.

This fits an Osler quote, “The value of experience is not in seeing much, but in seeing wisely.” The astute diagnostician observes a lab, or physical finding, or imaging finding that does not fit the assumed diagnosis, and has courage to question that diagnosis. Sometimes the trigger finding does not yield a new diagnosis, but we still have the responsibility to wonder, think, and pursue another diagnostic possibility.

We have presented two such cases in our @unremarkablelab YouTube videos: https://t.co/EWwezNBhiE and – https://www.youtube.com/channel/UCVQ3Na5zXk5lpdUfPKhZ_Ew

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Monday, March 29, 2021

Imagining the post-pandemic workplace

Millions of Americans are working remotely during the pandemic. Many of them would have never believed that they could perform their jobs away from the office. I'm one of them. But we all now acknowledge that the basic structure and function of the workplace has been forever altered. This transformation was inevitable, but the pandemic was a potent catalyst to bring it about at, shall I say, “Warp Speed”? Did we really believe that in a world with remote robotic surgery, driverless cars, personalized genetic medicine, exploration of Mars, Alexa and the explosion of artificial intelligence, that we would continue to commute to brick-and-mortar offices each day? It was only a matter of time before the physical workplace would be recalibrated.

The disruption has been monumental and to a great extent irrevocable. While I do believe that there will be some backward adjustment after the pandemic has largely resolved, I do not expect a return to the status quo ante. Do you think that DoorDash will be out of business then?

And as occurs after every disruption and innovation, there will be winners and losers. The printing press came about in the 15th century. Good idea? Probably yes, but it may have been a job killer for many.

Many industries are very nervous now. If you have earned your fortune up to now in commercial real estate, you may not welcome the prospect that your high-priced office space will no longer be in high demand. Indeed, huge companies are leaving New York City in search of more economical alternatives. Will stage theaters and cinemas ever return to full capacity now that most of us have enjoyed these experiences from home? The hospitality industry has taken a body blow and will do its best to stagger up in the coming year or two. Would you want to be an investor in a sports stadium now? Investors may need to factor in that future pandemics may be lurking.

But it's a good time to be in the vaccine business. If your manufacturing company could adapt to produce personal protective equipment (PPE), you probably could have run three shifts of workers. Remember when we couldn't find sanitizer left on the shelf? Those companies really cleaned up. Grocery and restaurant delivery services can barely keep up with the demand. And with all of us hunkered down in our homes, it has been a good season for Netflix and other streaming services. On-line retail was already doing well pre-pandemic, but they have reached the stratosphere. How do you think Zoom fared this year?

We are all aching to return to normal, but the normal of tomorrow will be quite different from the normal of yesterday. And just when we start to get used to the new normal, guess what will happen?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.
Monday, March 8, 2021

Should we pay people to get vaccinated for COVID-19?

I read recently that Kroger, who runs a grocery store chain, has joined with other retailers in paying employees who receive a COVID-19 vaccination. The $100 payment should serve as an incentive for employees to roll up their sleeves.

There is an ongoing debate whether employers can or should mandate COVID-19 vaccinations for their employees. The state of play now is that employers are encouraging, but not requiring vaccines, as mandating vaccines creates legal exposure for employers. For example, if you require that an employee is vaccinated against the worker's wishes, and a complication occurs, is the employer responsible? Can an employee be disciplined or terminated for failure to vaccinate if there are no vaccines available within a reasonable distance? And mandating vaccinations may be complicated when workers are unionized.

The right to refuse treatment is a bedrock medical ethical principle that I support. For example, if I advise an individual with acute appendicitis to proceed with surgery, this patient has a right to decline, assuming that the patient is competent, and I have properly informed the patient of the risks and benefits of the reasonable options.

This right, along with all of our rights, is not absolute. If refusing medical treatment has a public health dimension, then the issue becomes more complex. And the terrain can be murky. If a parent refuses to have his school age child vaccinated against communicable diseases, this right collides against the rights of other children and personnel in the school. Indeed, it is for this very reason that school districts can require students to be vaccinated. If a parent objects, then they are free to home school their youngster.

This is why the failure to wear masks when advised to do so is not just a personal decision. It puts other as risk. I don't object if someone chooses to become inebriated at home. But it's quite different if this individual decides to operate a motor vehicle on city streets.

While no vaccine or medical treatment is 100% safe, and there may be unknown vaccine risks that will emerge later, I recently received the two-shot Moderna series enthusiastically. The only incentive I needed was my belief that I would be much less likely to become infected and to infect others.

If a hundred bucks is a necessary incentive, and a business has the will and resources to expend on this effort, then good for them. We're familiar with similar strategies, such as paying kids to do homework.

Should we also pay people to be honest or to be polite or to stop at red lights or to be on time for appointments or to observe speed limits? What should the per diem reimbursement be for wearing a mask?

In other words, should we pay folks to do stuff that they should be doing for free?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.
Thursday, October 15, 2020

Sinking in Bed Syndrome has been made worse by COVID-19

There's a condition that I call ”Sinking in Bed Syndrome,” which is one of the biggest epidemics affecting U.S. health care facilities (I am actually going to patent that term). And sadly I have only seen it get worse because of COVID-19 restrictions, both in acute health care facilities (hospitals) and also sub-acute (rehabilitation). Patients are moving around less and sadly becoming more and more deconditioned. If you have a loved one who has suffered because of this, and have a story to tell, please do get in touch with me. Because I feel very strongly that it's such a simple thing that most health care facilities are pretty terrible at. I am reposting this piece I wrote on the ubiquitous syndrome, from a few years ago, and intend to keep doing so every so often until I see some progress.

There's a huge problem we have right now affecting our nations' hospitals. It's not a disease you've ever heard of before, or something that cutting edge research or treatments are going to solve. It's a seemingly simple issue that has been lacking in every single hospital I've ever worked in, whether it be a large academic teaching hospital or a small rural medical center. It's rarely talked about, but endemic nevertheless. I'm hereby going to assign it a name: “Sinking in bed syndrome”

What on earth is it you may ask? Well, the scenario goes something like this. A patient, usually elderly, is admitted to hospital with an acute medical illness. During the first few days of treatment, they are basically lying in bed while receiving all their treatments. They get more and more sunk into their bed, becoming weaker and weaker at the same time (even though their actual illness is improving). As they recover, they find it more difficult to get up out of bed and start walking again. The longer they are in bed, the more difficult it will be. Muscles have become tense and joints are stiffer. Because of this deconditioned state, recovery will be prolonged and patients will spend longer getting back to their baseline state.

All hospital-based doctors see this type of scenario unfold on a weekly basis. Sadly, lots of these patients actually report having quite reasonable and independent function prior to their admission. Of course, they have been unwell, and their illness itself will set them back. But having seen how we leave patients “sinking” in their bed for days at a time, I'm of the firm belief that keeping them in this state really sets them back even more.

In short—we just need to get them up much sooner. Unfortunately, it's not in our systemic culture to do that, and in almost all places I've worked—I sometimes need to plead just to get our patients up out of bed to the chair simply to make sure they are not lying down flat all the time. Sometimes sadly, it's family members who are the ones voicing their concern to me that their loved ones have become weak and need to sit up and walk more. It's a shame too that many health care institutions only think of getting physical therapy involved when discharging from the hospital is imminent—when actually it should be done much sooner.

Only a few decades ago, the culture was to keep patients who were sick in the hospital on complete bed rest for an extraordinarily long amount of time. Patients having heart attacks would be kept in and observed for several weeks. We now know that such a prolonged hospitalization is not only unnecessary, but also very bad for our patients.

So why do we not get our patients up sooner? I believe it's not a question of laziness or lack of resources. Nurses and nurses' aides are the most hardworking people I've ever encountered, and most nurses are aware that it's good to get patients up and moving. However, in the haze and hustle of a hospital admission—with intravenous lines, telemetry monitors, strong medications and constant tests—we lose sight of the simple little things that can make an enormous difference. In my experience, patients even just look so much better sitting up in a chair as opposed to lying in the bed!

So here's what the world of health care should really push for: A National Ambulate the Patient Week. This should involve:
• Education for all health care professionals about the importance of ambulation. Physicians should be encouraged to write “OUT OF BED TO CHAIR AT LEAST THREE TIMES DAILY” as an order for nearly all hospitalized patients as soon as they can, usually from hospital day 2. With that order should be assumption to “ENCOURAGE AMBULATION”, either with or without assistance depending on the circumstance;
• Invest in more physical therapy services and also dedicated PT-aides, also known as “walkers or mobility aides”, to get people up and moving early;
• Administrative oversight from charge nurses and unit supervisors to raise a red flag when they see a patient who potentially has “sinking in bed syndrome”;
• Posters around hospitals encouraging early ambulation and walks around the hospital floor; and
• More comfortable chairs! This may sound rudimentary, but a common complaint I hear everywhere is that hospital chairs are very uncomfortable. However much they are purportedly designed for hospitalized patients, just glancing at them and testing them out myself—I'm very skeptical about how comfortable patients can feel sitting in them. I get the same feedback from relatives who test them out. If healthy people don't feel comfortable in any given place, how on earth do we expect sick people to?

There are certain departments that are actually already very good at mobilizing their patients. One such example is orthopedics, where surgeons are almost obsessive about getting people up as early as possible after hip or knee surgery. If they can do it, so can everyone else.

Richard Asher, the British endocrinologist and forward-thinker from the early part of the 20th Century once said, ”Look at the patient lying long in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul.”

That quote was from 1947. I will leave it to your imagination to think what scybala is!

Seventy years later, while we are not as bad as we were in the 1930s and 1940s, we can still do a lot better. So let's make it a national priority get all our hospitalized patients up and moving earlier. Starting from today.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.