American College of Physicians: Internal Medicine — Doctors for Adults ®

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Wednesday, April 23, 2014

Principles of critical care medicine for non-intensive care specialists

I just got back from Boston where I visited friends and went to a really good and useful Harvard Medical school continuing medical education course. Harvard is one of the few institutions that I have found to have consistently good classes for practicing physicians, with a few exceptions.

This Spring I wanted to get myself to Boston and so I went to the online list of Harvard CME courses, which is more exciting than a candy store. In the time block that I had available they offered 2 delicious options. One was a week long course on everything anyone ever wanted to know about internal medicine, which would have earned me over 60 hours of credit while crushing my soul with 10-hour days of densely packed information mainly intended to help practicing physicians pass their board exams. The other was the course that I chose, which delivered almost 20 hours over 2.5 days, leaving me time to walk along the waterfront and eat a little lobster and even frolic with my friends.

The course, the 2nd Annual Principles of Critical Care Medicine for Non-Intensive Care Specialists was designed with the knowledge that much of the intensive care delivered in the U.S. is by physicians who don’t do intensive care medicine as their main thing, and haven’t received fellowship training in it. Many of us have become pretty good at it, but we sure can benefit from hearing what highly intelligent and rigorously educated intensivists have to say.

Three intensive care and pulmonary medicine specialists from Harvard’s Beth Israel-Deaconess, Drs. J. Woodrow Weiss, Jeremy Richards and Peter Clardy, along with guest speakers, shared information that was geared to what I really needed to learn. They gave us evidence-based recommendations, but more importantly they told us how things worked in their hospital’s intensive care unit, what they had done to improve patient care and outcomes and what that actually looked like. They focused on some of the most deadly diseases, sepsis and acute respiratory distress syndrome, and about some relatively dismal long-term outcome information for the patients who are saved from their dread diseases in intensive care units, often to be faced with long term physical and mental disability. They taught us to manage ventilators more skillfully and to actually engage our brains by remembering how human physiology is reflected in some of the data which is presented to us so copiously in critically ill patients. They taught us how we might prevent delirium in patients who frequently become confused and have a very hard time coming out of it. We were gently encouraged to give blood products only to patients who could really benefit from them, which is still a bit of a moving target.

In skills workshops that were wound into the lecture and small group problem solving sessions we had a chance to use ultrasound to practice procedures and image the hearts of a few live volunteers. We were taught the standard bedside echocardiographic views and used “phantoms” to practice placing central venous catheters and sampling fluid in the abdomen and chest. Having attended many specific ultrasound training workshops I was a little disappointed in the cursory nature of these workshops, but the course was short and there truly was not enough time to cover everything that people should learn. The fact that bedside ultrasound was a part of the course means that the organizers not only feel that it is part of what should be done in intensive care units, but also that it is at the core of what anyone who practices intensive care medicine should be able to do, even (or maybe especially) at small community hospitals. This is a good message.

The course was small enough that it was possible to talk to all of the speakers and ask individual questions. The folks who attended were an interesting mix. We were primarily physicians who managed patients in hospitals where there were no intensivists, but we were also emergency physicians and advanced nurse practitioners and physician’s assistants. It is unusual to run into many of these people at conferences because they are often too busy to attend, and we are a small minority of physicians in the U.S.

There was a feeling in the course of trying to make sure every recommendation was based on some kind of reputable research. Since only a minority of interesting questions have been addressed adequately by reputable researchers, this approach was impractical, and as the course wore on we more often treated to experience, deduction, good sense and critical questioning. There was a nice mix of research results and practical recommendations.

The course was held in the World Trade Center on the water in South Boston, where not too long ago only warehouses and fishing boats lived. It is near a beautiful museum of contemporary art, is served by $3 ferries to all sorts of destinations on the Boston Harbor, and has easy walking access to excellent restaurants. There is a very long foot path called the Harbor Walk, which makes it easy to get exercise at the edge of the water. The Seaport Hotel where conference attendees stayed was large, well appointed, expensive but not ridiculously so. The World Trade Center was also hosting the Boston Flower and Garden Show, so parking would have been terrible, but renting a car was superfluous so it didn’t matter. The show was really interesting, if you like that sort of thing, and it was possible to walk in from the conference without paying the $20 entrance fee, which was probably not intentional, but did not appear to be forbidden.

What I learned is readily usable. I look forward to treating my next intensive care patients to what is presently the cutting edge at one of America’s best hospitals and sharing some really great ideas with my doctor colleagues.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

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

Suneel Dhand, MD, ACP Member
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.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

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

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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