Obviously I am very biased, hosting a podcast now for 8 months, and being a guest on two other popular podcasts – The Curbsiders and The Clinical Problem Solvers. Given my obvious COI, here are my thoughts on the contribution that podcasts are making for students, residents and practicing internists.
Two or three years ago some students asked me if there were any good podcasts to listen to while on their medicine clerkship. Soon thereafter, two things happened: The Curbsiders started their podcast and the Annals of Internal Medicine asked me to develop a podcast. I had a growing love of podcasts as an accompaniment on long drives. When the Curbsiders asked me to appear on episode #16 of their new podcast in October 2016, I jumped at the chance and started my love affair with medical podcasts.
Now when I make rounds for 1/2 months or full months, I regularly recommend podcasts to the learners. Now that we have released 16 episodes of Annals on Call, I frequently get comments from colleagues and learners about individual episodes. This week at an Update in Hospital Medicine done at our noon conference, podcast episodes were quoted. Earlier this year the CMRs asked me to give Grand Rounds on social media. The response from house-staff and faculty was outstanding.
Why so much excitement about podcasts? I think it follows from the classic way we learn. Storytelling is likely the oldest form of education. We learn best from stories. This concept holds particular in medical education. Patients are our best teachers. The best is taking the history ourselves and then following the process of diagnosis and teaching. Next best is learning from someone else telling us a compelling story about a patient.
I do not think we can overestimate the value of clinical stories to expand our medical diagnostic and therapeutic abilities. As a resident, I loved and tried to never miss Morning Report. I love hearing cases presented at a conference and discussed in depth. That knowledge sticks so much better than reading an article, unless the article helps me understand my patient.
In addition to the 2 podcasts above, I particularly love The Clinical Problem Solvers, because each week they provide a highly selected Morning Report case to solve. They focus on the thought process and schema for evaluating a problem (syncope, eosinophilia, chest pain, etc.).
Other IM podcasts that I frequent include Core IM and Bedside Rounds. I get different things from each podcast, but most of all I get continued learning. Even at age 70, I want to continue to learn more so that I can do a better job teaching and caring for patients.
Podcasts increase learning and (IMHO) the joy of medicine. As internists, we love solving our patients’ puzzles. We all want to be Sherlock Holmes. This gets us closer. And I love that our students and residents are enthusiastic devourers of this teaching.
The problem of admission diagnoses – a guest post
I received this response to a recent post. It is so good that I wanted to share it – so with Dr. Thomas Nielson’s permission I have. He makes the important point that the rush to LABEL the patient with the diagnosis has major unintended negative consequences. He says it so well that I encourage your reading and comments.
Thank you for this post. This is a problem that occurs from time to time, and I believe that the current system in place for admissions is a large part of the problem.
We are asked to diagnose people in the emergency department because we need an “admission diagnosis” so that we can make sure that we meet “admission criteria”. The people in hospital administration who require this have never taken care of patients themselves, and they have no idea what they are talking about.
There is a disconnect between administrative types and doctors, and I do not know how this can be solved in our current system.
Example: Patient presents with AMS and is found to have a massive acid base disorder in the ED. What is the diagnosis? I have no idea! I need to admit the patient to the hospital and run a bunch of tests before I can tell you what the underlying problem is. Is it ethylene glycol poisoning? Is it their renal failure? I don’t know.
The current system puts the cart before the horse in requiring an admission diagnosis. What happens is some random diagnosis is given to the patient so that we can get them into the hospital. Unfortunately, because the system demands that we treat the patient with “quality” care, this diagnosis puts a process in place. Now the patient is run through a bunch of tests relating to the admission diagnosis which may or may not be the actual problem going on with the patient. And at the end the patient is sent home, dazed and confused, without a clear understanding of WTF just happened to them.
Think I am kidding? How about this example: Patient present with shortness of breath and the radiologist in the ER says pulmonary vascular congestion. The BNP is 300. Now the patient is admitted with “congestive heart failure”. Do we know it is CHF? NO! But now, because CHF is a diagnosis which beancounters believe they can treat by protocol alone, the patient is set upon a course in which all of the “quality” measures must be met to make sure that we get paid. The patient does not know what is going on, but all of a sudden they are being put on a low salt diet, being given an ACE inhibitor, and so on. They will (hopefully) get an echocardiogram and then….what happens if the echo is normal? SYSTEM FAILURE
To get back to your post, it is often the system that is running away with the patient when we have a sense that the diagnosis is wrong. And studies have repeatedly shown that pinning a diagnosis to a patient early in the process, which is required by the system, leads to significant bias in the doctor’s treatment process and judgment.
What we need in this country is for the doctors to reclaim their rightful place in the system. All of the quality metrics BS needs to go right out the door.
How do we do this? I am afraid that we are going to have to revert to doctor-run hospitals, with all cash. Let patients deal with their own insurance companies.
The danger of ignoring your instincts
Recently we had a patient admitted for a diagnosis that did not really fit his problem representation. The diagnosis was a convenient one, and easily treated. He initially responded to treatment and we discharged him. The diagnosis assumption nagged at me, but I did not push forward with a test that my mind wanted.
A week later he returned (the dreaded readmission), with the same symptoms. The admitting resident expanded the treatment for the same diagnosis.
The next morning on seeing the patient we were even more uncomfortable than on the first admission.
As often happens, this is a story of community acquired pneumonia that was not CAP. We ordered a CT scan that clarified the abnormal Xrays. We reviewed the CXRs and CT with the radiologist. His symptoms never fit CAP. His CXR could have been CAP. Only the CT scan pointed us in the right direction.
I preach expanding the diagnostic evaluation when the problem representation and the illness script do no match. Yet, doing so is often difficult. Our patient’s diagnosis was delayed a week, with continued discomfort for that entire week.
So I am challenging myself. I “knew” that we did not have the right diagnosis, but “I did not pull the trigger”. I am not unusual. I suspect we all suffer from this error.
The second time I had no hesitation. How do I convince myself to honor my instincts in such patients?
I suspect you all have experienced similar situations. This story (and I have withheld some details for patient confidentiality) likely seems rather common to others.
I hope to do better the next time. Part of not doing better is refusing to rationalize what happened, but rather learn from the experience. The patient improved dramatically when we treated the right process.
My tweetorial collection
You can probably tell that I tweet much more than I write blog posts these days. I have started doing tweetorials – linked collections of tweets that tell a story. Most tweetorials represent teaching or rather online chalk talks.
They are now being collected (along with other tweetorials that I particularly like and want to use. Here is the link: Medrants Tweetorials
If you do not follow me on twitter or use twitter, you can still use this link to read through these teaching sessions.
