Today, we received two 3rd year medical students starting their IM rotation. I told them I would give them a list of podcasts that should help them get oriented to internal medicine. This is my podcast v1.0 list:
From the Curbsiders:
142 Cirrhosis TIPS for Acute Complications
104: Renal tubular acidosis with Kidney Boy, Joel Topf MD
92: Pulmonary Embolism for the Internist
86: COPD: Diagnosis, treatment, PFTs, and nihilism
76: Pneumonia Pearls with Dr Robert Centor
61: Vasculitis and Giant-Cell Arteritis: ‘Rheum’ for improvement
52: Anemia: Tips, and tools for diagnosis and treatment
20: Hypertensive urgency and severe hypertension
From the Clinical Problem Solvers:
Hypokalemia
Hyponatremia
Abdominal Pain
Syncope
Hypercalcemia
From Core IM:
Stress Testing
Hepatic Encephalopathy
From Annals On Call:
C. Difficile
Diverticulitis
Diuretic Resistance
Each podcast above has many more excellent episodes. I picked these out on a first pass, quick suggestion for my new 3rd year students. Would appreciate suggestions for improving this list.
Lessons learned from the National Champions
All physicians have failures. The best physicians learn from those failures. They become better physicians and work on continuous improvement.
Everyone who knows me well knows that I have had a 52 year obsession with UVa basketball. While I love all the sports teams, basketball is my true love. Better wordsmiths than me would have a difficult time explaining my joy in Monday night’s championship game. You can imagine my dark place after last year’s loss in the first round.
So what does this have to do with medicine. Maybe nothing, but we can learn important lessons from literature, music and sports. In this case I will likely stretch the lessons, but in my post game euphoria, please indulge me.
Lesson #1 – do not let a failure define you, rather let it motivate you. Focusing on diagnostic errors (which we all make), learn from those errors. Every diagnostic error happens for a reason, explore the reasons and own them. Perhaps you (like Virginia) will need to modify some procedures.
Lesson #2 – pay attention to the details. Virginia’s coach, Tony Bennett, stresses playing each possession without regard to future possessions. Stay in the moment, analyze where you are, without regard to what you were thinking yesterday. Has the patient gone down the path expected? Does the diagnosis still make sense.
Lesson #3 – do not be scared to change your approach. Learn from your mistakes and try not to repeat them.
Lesson #4 – embrace humility. We are never as good as we desire, nor as bad as we fear. Understand who you are, and work to better yourself, even if you really are pretty good. We can always improve. We can always learn something from others.
Lesson #5 – value everyone on the team. Nurses can make us better; clerks can make us better; the cleaning staff helps everyone. As an attending physician, I learn from the residents, interns and students. My first goal is to help everyone improve and to focus both on the patients and the learners. We learn from our patients. Minimize hierarchy and then everyone benefits.
I hope that I have provided some food for thought. I cannot describe my happiness with basketball today. But almost every day I have that same happiness with internal medicine. I continue to make mistakes, but do not fear them. We all try to minimize them, but when they occur we must learn from them for our own sake and more importantly for the next patient’s sake.
Fictional detectives as diagnostic models
Like most internists, I love a good mystery novel, TV show or movie. Mention Sherlock Holmes and internists smile. When Dr. Mark Shapiro wanted to complement Dr. Gurpreet Dhaliwal for his diagnostic expertise, he labelled their podcast discussion – Gurpreet Dhaliwal, The Sherlock Holmes of Medicine
Studying fictional detectives helps me understand some basic principles of diagnostic excellence. A common trope in detective novels is the misdiagnosis. Someone has been falsely accused or even convicted of a heinous crime. Superficially, the evidence points to the accused, but the fictional detective has an uncomfortable feeling because of something in the case that does not fit.
In the BBC series, Sherlock, Season 1 Episode 2, Sherlock states, “You have a solution that you like, but you are choosing to ignore anything that you see that doesn’t comply with it.“
It’s that uncomfortable feeling you get about a patient’s diagnosis. Many years ago I described this as reading the textbook description of the patient’s diagnosis and finding that it does not fit. When that happens, the patient is not wrong, rather you are reading on the wrong page.
When this happens, we need more data, or as Sherlock said in the Adventure of the Copper Beeches, “Data! Data! Data!” he cried impatiently. “I can’t make bricks without clay.”
Sometimes the data comes from questioning the patient again. When stumped go back to the bedside. Or as Agatha Christie wrote for Hercule Poirot, “It often seems to me that’s all detective work is, wiping out your false starts and beginning again. Yes, it is very true, that. And it is just what some people will not do. They conceive a certain theory, and everything has to fit into that theory. If one little fact will not fit it, they throw it aside. But it is always the facts that will not fit in that are significant.”
When the diagnosis does not make sense, start over. Michael Connelly’s great character Harry Bosch said, “I’ve learned over the years that sometimes if you ask the same question more than once you get different responses.” And this really happens at the bedside.
These wonderful, entertaining detectives give us permission to be skeptical of accusing a particular disease as the cause of the patient’s illness. We owe our patients a dispassionate, dogged approach to the truth of their diagnosis. We have great role models from whom we can all learn.
And remember the wisdom of Dashiell Hammett in the Thin Man, “The problem with putting two and two together is that sometimes you get four, and sometimes you get twenty-two.“
Confusion after gastric bypass with Roux-en-Y
At at recent case conference, we discussed a woman who had had a gastric bypass 20 years previously, and now had confusion. To remind you of the details of a gastric bypass:
First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.
I posed this question on twitter, but unfortunately did not give enough specification of the problem. Restated, a patient with progression confusion presents years after the procedure (very successful at weight loss) and no apparent infection.
Our leading differential included hyperammonemic encephalopathy, thiamine deficiency, B12 deficiency and d-Lactic acidosis.
We excluded d-Lactic acidosis become the symptoms were not episodic and the electrolyte panel did not have a moderately increased anion gap (usually around 18). A B12 level was normal, excluding that possibility.
The patient did have both hyperammonemia and thiamine deficiency. She also had several vitamin B deficiencies and low levels of copper, zinc and selenium.
After adequate replacement, her confusion eventually improved.
The problem of hyperammonemia is very dangerous. This paragraph from a recent article explains it well.
Patients presenting with hyperammonemic encephalopathy after Roux-en-Y gastric bypass surgery presented with overlapping clinical and laboratory findings. Common features included: (1) weight loss following successful Roux-en-Y gastric bypass for obesity; (2) hyperammonemic encephalopathy accompanied by elevated plasma glutamine levels; (3) absence of cirrhosis; (4) hypoalbuminemia; and (5) low plasma zinc levels. The mortality rate was 50%. Ninety-five percent of patients were women.
Likely the zinc deficiency is a major culprit here. Studies of the ornithine transcarbamylase cycle show that zinc is an important co-factor. Like to many patients with successful bypass surgery the patient presented was not taking supplementary vitamins with trace metals. Several companies make vitamins labeled as bariatric vitamins that have adequate trace metal supplementation.
The patient presented at our conference eventually did well after receiving supplementation that included zinc.
