Presenting on a consult service: Rule number four

A while back, I posted three “rules” of presenting on a consult service. I’d now like to add a fourth rule.

Rule Number 4: In patients with chronic disorders, consider more than simply a “disease flare” in your differential diagnosis.

This rule follows up on Rule Number 3. The rule is most relevant to patients with underlying chronic disorders (e.g., inflammatory bowel disease, emphysema, ischemic cardiomyopathy) and is important for fleshing out a broad framework for a differential diagnosis.

After you have gone through a detailed presentation of a patient with a chronic disorder, the path of least resistance when a patient presents with similar signs, symptoms, and findings, is to diagnose a “disease flare.” However this knee-jerk reaction excludes a number of other broad options that may be going on.

Here is the framework I suggest in considering your differential diagnosis in a patient with a chronic underlying disorder. The presentation could be caused by:

  1. The disease;
  2. A complication of the disease;
  3. A complication of the treatment of the disease; and/or
  4. A completely unrelated disease

In virtually any patient, this general schema can be helpful to make sure that you do not anchor your diagnostic possibilities on the chronic disorder.

As an illustration of how I use the framework on teaching rounds, I’ll describe a typical (made-up) case we might see on the GI consult service, a 25-year old man with Crohn’s disease and a possible flare. He was diagnosed 6 months prior with inflammatory ileocecal Crohn’s disease after presenting with right lower quadrant abdominal pain and watery diarrhea. The colonoscopy at the time revealed severe inflammation in the cecum and terminal ileum. He has been treated with steroids and infliximab, and was brought into remission within 3 months. Now, he presents with 3 days of acute watery diarrhea and recurrent abdominal pain. Without giving any more details, here is how I might break down my thinking:

  1. The disease: Sure, it is easy to say that this is a “Crohn’s flare,” but then you’d have to ask yourself, “Why is the disease flaring?” Could the medications no longer be working? Has the patient been adhering the treatment regimen? Are the medication dosages too low? Nevertheless, this is an easy place to stop unless you consider the next 3 broad possibilities.
  2. A complication of the disease: Crohn disease can cause at least 2 complications that can lead to similar presentations: fistulae and strictures. Of course, you could argue that these are the disease itself, but I would refute the argument because the treatment of these complications can be different from treating the underlying inflammatory process itself.
  3. A complication of the treatment of the disease: As much as physicians don’t like to admit it, our therapies can definitely play a role in our patients’ worsening. Surgeons are quite attuned to looking for complications of their surgeries while their patients are recovering in the hospital, but medical therapies also have complications that should be considered, especially in the outpatient setting. In this case, the patient is on immunosuppressive agents. Could the treatment have led to an infectious disease, such as CMV colitis?
  4. A completely unrelated disease: Importantly, this element, sometimes known as “true, true, and unrelated,” is how we are taught to think when we are creating differential diagnoses in medical school and residency training, but can often get neglected in the presence of a chronic disorder. Does he have a young child in preschool, who could have contracted a Rotavirus infection and transmitted it to your patient? Could the patient have taken an antibiotic for a sinus infection and developed C difficile colitis? Here the differential diagnosis can be quite broad, but should certainly not be overlooked when the patient has a chronic disorder.

Acknowledgement: Dr. Arvey Rogers, my first clinical mentor, deserves the credit for teaching me this framework. He is a wonderful clinician, a thoughtful educator, and a gem of a person.

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An empirical scientific viewpoint about gun control

For just a moment, let’s take a scientific viewpoint about gun control here and try to leave emotions (and the Constitutional argument) out.

The best type of study to determine whether gun control and/or regulation would be a Randomized Trial:

  • Randomizing a state or country to regulation or not.

Since that’s not going to happen, the next best type of evidence we have to go by is observational, either case-control or cohort studies:

The exposure is: gun control regulation.

  • This could be considered dichotomously (Yes/No) or continuous (level of regulation from strict to lenient/none)

The outcome is: death by guns.

  • This could be considered in numerous ways: absolute numbers of gun deaths annually; relative numbers of gun deaths adjusting for size of population; number of gun massacres, etc.  We could even consider any violent deaths, if you want to be more general.

In a case-cohort study, we’d look at the outcome first (let’s say, massacres) and look backward for the exposure, then calculate an odds ratio that the outcome was significantly associated with the exposure.

In a cohort study, we’d look at the exposure first, looking at level of gun control as a continuous variable.  This could be done retrospectively or prospectively.  As of now, we could only do this retrospectively.  Then look for the outcomes (deaths, massacres, etc.), and determine a risk ratio that the outcome was associated with the exposure.

Either way, the data would indicate that countries with increased exposure (increasing regulation) is associated with a decreased odds/risk of the outcome (fewer deaths, massacres).

Please NOTE that I did NOT say that increasing regulation CAUSED fewer deaths, just that it was ASSOCIATED WITH fewer deaths.

Now, I do not have numerical data, so I am only going on what I understand to be true, the empirical data.  For those who would not believe this to be true, the best way to deal with this is to show data that decreasing the exposure to gun regulation (i.e., increasing the populace’s ability to acquire firearms legally) is associated with fewer gun deaths.

Therefore, my preference is the following: until evidence (not raw emotions, beliefs, or Constitutional Amendments) that decreased regulation (including eliminating gun zones) results in decreased odds/risk for the outcome (gun death) is found in other countries, then there is no reason to accept the notion that we need to stop advocating for strict gun control.  For that matter, stricter gun control has evidential support (even if not emotional support among some) and should be advanced.

If you choose to comment on this in the opposite direction, please think before you do. The anecdotal evidence currently being provided by those who would oppose stricter regulations is purely speculative.  I am open to hearing the data to refute the above contention, but it needs to be at least as strong methodologically.  In other words, “case reports” (testimonials by individuals) or “case series” (testimonials by groups, including lobbyists) are weaker forms of evidence scientifically, and I will not consider them as valid as the comparative empirical data I have put forward as an argument.

 

Update: July 20, 2016

A large study with sound methodology has been published in JAMA this week with data backing up this blog post.

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A Rapid Rescue for a New Mnemonic in BLS

In reviewing for my upcoming ACLS recertification through the American Heart Association‘s HeartCode ACLS program, I learned that the classic mnemonic for the Basic Life Support (BLS) primary survey, the “ABCs”, which stood for Airway, Breathing (including Look, Listen, and Feel) and Circulation, had recently been modified.  The purpose of the change was to decrease time until chest compressions and defibrillation.

However the change leaves us without a simple mnemonic for easy recall for the primary BLS survey.

Thus I introduce my mnemonic for the primary BLS survey, and how much more appropriate could it be:

R-A-P-I-D

  • R (Response): Assess the patient’s responsiveness. This includes scanning the chest for movement.
  • A (Activate/AED): Activate the Emergency Response System & get an AED (if available)
  • P (Pulse): Check for a pulse
  • I (Initiate): If there is no pulse, initiate high-quality CPR
  • D (Defibrillate): Check rhythm (via AED) and deliver a shock if indicated

You could also remember “RAPID Rescue”.  The addition of “Rescue” should help you remember that if you are successful in restoring spontaneous circulation, give Rescue Breaths.

Please disseminate…RAPID-ly!

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Are Twitter-savvy students “privileged”?

At this week’s AAMC meeting, Alex Djuricich (@MedPedsDoctor), Terry Kind (@Kind4Kids), and I presented a workshop that dealt with using Social Media/Twitter in our roles as medical educators.  During a breakout session within the workshop, I heard an interesting concern that I had not previously considered.

One participant’s administration was concerned that students who are not using Twitter, Facebook, or other social media venues would be excluded from the information provided by the faculty on these sources.  Their concern is that the students who are involved on social media would thus have an advantage over those who do not use the sites.

Although I understand the worry, I am not concerned. Social media is simply a different way that faculty and students can communicate.  After classes, students often come up ask questions or clarify areas of uncertainty with their teachers.  Many professors hold office hours, sometimes even with groups of students.  On a personal note, for years I have been answering students’ emails on a one-to-one basis.

If a significant area of concern arises, it surely is the faculty member’s responsibility to make sure the problem or misunderstanding is not a systemic issue that all students are having.  Social media simply expands the ability for students to communicate efficiently with their faculty.  The faculty members’ responsibilities to clarify information for all their students doesn’t change.  Social media simply helps break the barrier between the two groups, not increase it.

Posted in medical education, Social Media | 2 Comments

My Med 2.0 (#med2) Experience

This weekend I attended my first “med-tech” conference (Medicine 2.0). What an eye-opening experience it was for me!

I got to meet some phenomenal people whom I never would have otherwise met just by staying in my silo of gastroenterology and esophageal diseases over the last decade.  Many of these people I’d previously “met” online through Twitter. For the most part, that was the extent of our relationship. Nonetheless our interactions on Twitter made the real-life meeting seem completely natural, as if we’d known each other for years.

I also got a rejuvenated exhilaration about advancing my work at the intersection of medicine, technology, and the digital space. It has been somewhat difficult as a junior faculty member at a medical school to get the sense that working at this crossroads could be considered “scholarly” and productive by traditional medical academic standards.

At Med 2.0, I encountered a phenomenal group of innovative physicians, nurses, scientists, informational technologists, and communications experts (among others) who have made this field a major part of their life’s work. Creators of digital apps for medical and educational uses have figured out how to get scholarly production our of their work.

Since medical training and research tends to focus on epidemiology, risk factor modification, and patient care interventions like medications and surgery, Medicine 2.0 helped me realize that there is a lot of valuable scholarly work to be done dealing with the intersection of medicine and digital technology. The collaborations that have emerged as a result of Twitter and Medicine 2.0 will be priceless.

Thank you for letting me be a panelist this weekend and asking me to share my experience over the last 2 years. And thank you for welcoming me into this great community.

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The internist as a puzzle solver: my (a)vocation

I’ve been getting GAMES magazine for years. Decades, actually, on and off.  I remember doing logic games way back in elementary school, and I still do them first in my GAMES magazines.  When I was a kid, my grandmother and I would do jigsaw puzzles together, and I now find myself doing them with my own children.
During a lunchtime panel of the Internal Medicine (IM) Interest Group at UNC today, I was drawn to something that one of my colleagues on the panel said. He noted that if you separate the “medical” specialists (internists, pediatricians, etc.) from the “surgical” specialists (orthopedic surgery, urology, etc.), there is often a difference in the type of intellectual arguments the two groups have.  Paraphrasing, he said:
Medical specialists argue more about what diagnosis the patient has over what the treatment of the diagnosis is.
Surgical specialists argue more about what the treatment should be, often whether or not to operate, over what the diagnosis is.
Of course, this is an overly broad generalization.  He did not mean to say that internists don’t argue over treatment plans or that surgeons don’t argue over diagnosis.  Clearly both do.  He pointed out that some medical specialists, like oncologists, tend to keep their discussions more focused on the latter type (e.g. “Should this patient with breast cancer receive chemotherapy?”), and surgeons similarly have to make sure the diagnosis is correct before they operate.
Nonetheless at general internal medicine “morning report”, residents often focus on creating a broad differential diagnosis and then figuring out what data they’d need to get the right answer.  In other words, using their logic to solve the puzzle the patient is presenting to them.
Thinking back now, I find it interesting that I made a conscious decision in the latter half of medical school to change my career path from surgery to medicine. Puzzle solving has occupied a good portion of my recreational time since childhood.  Maybe my choice during medical school to go into IM was my subconscious way of making sure I would enjoy my career.  I’m certainly glad I made that choice!
Posted in medical education | 2 Comments

Introducing #medsm, a new unifying hashtag for the intersection of Medicine & Social Media

As you read this, you might be asking yourself why Twitter needs this new hashtag. The reason is simple: to permit anyone to follow a single unified stream of medical content.

Currently, many people use #hcsm to disseminate medical tweets, but also since it may seem to stand for “healthcare in social media”.  However the actual definition of #hcsm is “healthcare communications and social media,” really meant to discuss the practice of communication of healthcare information, not the actual healthcare information itself.

Even though #hcsm tends to be one of the most widely used healthcare hashtags and subsequently a way to get one’s tweets noticed, it can be quite difficult to filter through the #hcsm stream to find medical information, especially as Twitter grows in popularity.

Therefore, #medsm is being introduced as a new umbrella hashtag for posts related specifically to healthcare and medicine topics.  The #medsm hashtag could be include content with links to studies, stories about patient care, etc.  The more broadly it becomes used, the more likely Twitter users will be able to identify your healthcare-specific content.

Here’s an example of a great use of the #medsm hashtag, by Howard Luks (@hjluks):


I hope you’ll use #medsm and find the new hashtag helpful!

Acknowledgements:  Many thanks to @hjluks, @Doctor_V, @FarrisTimimi, @RichmondDoc, @SeattleMamaDoc, @DoctorNatasha, and @drmikesevilla for their feedback and support of the idea for #medsm!

Posted in Social Media | Tagged , , , , , , , | 21 Comments