This month on our VA ward team we have had 3 admissions that involved complications of over diuresis for systolic dysfunction.  We also see patients who do not have adequate diuresis.

Diuretics greatly help symptoms in patients with systolic dysfunction and volume overload.  But diuretics are primarily symptom relief medications.

I often ask students and residents to write this sentence, memorize it, and use it:

The purpose of diuretic therapy in systolic heart failure is render the patient not wet, but not to make the patient dry.

The idea here is that we should only give enough diuretic therapy to relieve symptoms.   Diuretics do not help these patients unless that have volume overload.

Here is the section on diuretics from the 2013 ACC/AHA guideline:

7.3.2.1. Diuretics: Recommendation
Class I
Diuretics are recommended in patients with HFrEF who have evidence of fluid retention, unless contraindicated, to improve symptoms. (Level of Evidence: C)
Diuretics inhibit the reabsorption of sodium or chloride at specific sites in the renal tubules. Bumetanide, furosemide, and torsemide act at the loop of Henle (thus, the term loop diuretics), whereas thiazides, metolazone, and potassium-sparing agents (eg, spironolactone) act in the distal portion of the tubule.427,428 Loop diuretics have emerged as the preferred diuretic agents for use in most patients with HF. Thiazide diuretics may be considered in hypertensive patients with HF and mild fluid retention because they confer more persistent antihypertensive effects.
Controlled trials have demonstrated the ability of diuretic drugs to increase urinary sodium excretion and decrease physical signs of fluid retention in patients with HF.429,430 In intermediate-term studies, diuretics have been shown to improve symptoms and exercise tolerance in patients with HF431–433; however, diuretic effects on morbidity and mortality are not known. Diuretics are the only drugs used for the treatment of HF that can adequately control the fluid retention of HF. Appropriate use of diuretics is a key element in the success of other drugs used for the treatment of HF. The use of inappropriately low doses of diuretics will result in fluid retention. Conversely, the use of inappropriately high doses of diuretics will lead to volume contraction, which can increase the risk of hypotension and renal insufficiency.
7.3.2.1.1. Diuretics: Selection of Patients.
Diuretics should be prescribed to all patients who have evidence of, and to most patients with a prior history of, fluid retention. Diuretics should generally be combined with an ACE inhibitor, beta blocker, and aldosterone antagonist. Few patients with HF will be able to maintain target weight without the use of diuretics.
7.3.2.1.2. Diuretics: Initiation and Maintenance.
The most commonly used loop diuretic for the treatment of HF is furosemide, but some patients respond more favorably to other agents in this category (eg, bumetanide, torsemide) because of their increased oral bioavailability.434,435 Table 14 lists oral diuretics recommended for use in the treatment of chronic HF. In outpatients with HF, diuretic therapy is commonly initiated with low doses, and the dose is increased until urine output increases and weight decreases, generally by 0.5 to 1.0 kg daily. Further increases in the dose or frequency (ie, twice-daily dosing) of diuretic administration may be required to maintain an active diuresis and sustain weight loss. The ultimate goal of diuretic treatment is to eliminate clinical evidence of fluid retention. Diuretics are generally combined with moderate dietary sodium restriction. Once fluid retention has resolved, treatment with the diuretic should be maintained in some patients to prevent the recurrence of volume overload. Patients are commonly prescribed a fixed dose of diuretic, but the dose of these drugs frequently may need adjustment. In many cases, this adjustment can be accomplished by having patients record their weight each day and adjusting the diuretic dosage if weight increases or decreases beyond a specified range. Patients may become unresponsive to high doses of diuretic drugs if they consume large amounts of dietary sodium, are taking agents that can block the effects of diuretics (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], including cyclooxygenase-2 inhibitors)436–438 or have a significant impairment of renal function or perfusion.434 Diuretic resistance can generally be overcome by the intravenous administration of diuretics (including the use of continuous infusions)439 or combination of different diuretic classes (eg, metolazone with a loop diuretic).440–443

Oral Diuretics Recommended for Use in the Treatment of Chronic HF
7.3.2.1.3. Diuretics: Risks of Treatment.
The principal adverse effects of diuretics include electrolyte and fluid depletion, as well as hypotension and azotemia. Diuretics can cause the depletion of potassium and magnesium, which can predispose patients to serious cardiac arrhythmias.444 The risk of electrolyte depletion is markedly enhanced when 2 diuretics are used in combination.

Here is what bugs me the most.  The proper use of diuretics for these patients requires an understanding of the pharmacokinetics, renal tubular function in addition to the pathophysiology of systolic dysfunction.  These concepts are not that complex, but we find few students or residents who really understand the entire package necessary to use diuretics for the patient’s greatest benefit.

And yet “heart failure” is the single most expensive Medicare diagnosis.  We should all become experts at managing volume disturbances in these patients..

Several studies have suggested that using more diuretics increase mortality (given the same cardiac function).  Thus, we should strive to use the lowest doses and less frequency feasible for the patient.

This bugs me because too often patients suffer from our ignorance.  Internists and family physicians must all become experts in the management of these patients, and managing the diuretic therapy is a major component.

Rant over – thanks for reading.  Please feel free to make suggestions on things that bug me.  I have a modest list, and will be posting some of these over the next month, but would love your personal things that bug you!

The Atlantic has this article – No Doctor Should Work 30 Straight Hours Without Sleep

After retweeting this article with this text:

Very interesting article that provides much outrage but no data. Many trainees prefer the longer shifts.

Here is a tweet response – I hated 16’s. Much prefer 24’s. But l wouldn’t continue a surgical residency w/o the weekly hr cap.

I work in a program where interns work 14-16 at most, but residents on some services do 24s.  On some services, they have built a schedule so that most residents get sleep most of the nights.  On others they get no sleep.

My current resident made these observations.

1. New second year residents feel less prepared for ICU rotations and supervision – the program had to change some rotations
2. As long as the 80 hour per week rule continues, most residents prefer the longer rotation
3. You can develop a 24 hour rotation that includes a high probability of sleep – and interns and residents will learn more

What will programs do?  How will this impact intern applicants when they develop their match list?

I suspect we will see great variety in how programs handle this potential change.

As an intern I worked every 3rd with approximately 34 hour shifts.  We had no days off.  But we generally could get a few hours sleep.  Getting some sleep does make a huge difference.

I believe education would benefit from the longer shift, given a structure that has the on call intern and resident admitting patients, but not doing the cross coverage, because the cross coverage causes most sleep deprivation.

What we need from our residency graduates is a sense that they have had enough experience to be excellent physicians.  We all benefit from seeing more patients, and from seeing the progression of disease.  The big question is how we can best structure the learning experience.

During my 37 years of inpatient internal medicine teaching, my style has evolved.  Periodically I try something and the feedback that I receive changes my standard style in a significant way.  Students and residents stimulated my recent focus on teaching the HPI.

As educators we should first understand our goals.  Obviously, patient care trumps everything, but once that is accomplished we all want to help our learners grow.  Experienced and inexperienced educators quickly notice the student or intern who delivers smooth informative presentations.  A recent JAMA viewpoint addressed this issue – The Oral Case Presentation: A Key Tool for Assessment and Teaching in Competency-Based Medical Education

The noted clinician educator (and my educational mentor) Dr. Kelley Skeff recently wrote about the HPI – Reassessing the HPI: The Chronology of Present Illness (CPI)

Taking these two important articles into consideration I offer my own observations.  When we think about the HPI, any seasoned clinician will tell you that the HPI helps us answer and understand the patient’s concerns.  An excellent HPI often streamlines our clinical evaluation, decreasing imaging and focusing our laboratory testing.

Dr. Phillip Tumulty in his famous NEJM essay – What Is a Clinician and What Does He Do? Philip A. Tumulty, M.D. N Engl J Med 1970; 283:20-24, July 2, 1970 (note to readers, in 1970 proper grammar used masculine pronouns only).

He is meticulous in accumulating the historical and physical data from the patient. His questioning of the patient is searching and incisive, like that of a wise barrister.

What makes the HPI presentation so valuable?  First, it should reveal the learner’s skill at taking the history (asking the proper questions) with emphasis on the thought process.  What the learner includes lets the other team members understand their history taking sophistication and their development of a relevant differential diagnosis.  As we teach the HPI, the first paragraph gives the story as the patient (or surrogates) have reported, while the second paragraph includes the answers to questions related to the differential diagnosis.  Second, the presentation allows the learner to demonstrate their organizational skill in summarizing the history as well as their thought process.

Given the HPI’s importance, I recently started critiquing the HPI prior to hearing the remaining history, the physical exam, the lab data and any imaging results. At the end of the HPI presentation, I ask the team to point out what is missing or what is unnecessary in the HPI.  After they comment, I often have additional comments.  The presenter gets immediate feedback on how to improve the presentation.

Our learners desired meaningful feedback.  Immediate feedback always trumps delayed feedback.  Learners have told me many times how much they appreciate this immediate instruction.  They and I find that their presentations improve dramatically as a result of this feedback.

The feedback sessions are never punitive – rather they are framed as a method for improving communication with other health care professionals.

We can easily argue that such feedback constitutes deliberate practice.  If you believe as I do that deliberate practice helps learners achieve expertise, then we should look for opportunities to provide immediate feedback.  As learners improve, this method gives us a great opportunity to deliver praise.  We often single out important information that the presenter provides as an example of excellence.

Some have argued in the past that we should not interrupt our learners’ presentations.  If we do not interrupt and help the learners improve, then we are failing our learners.  If we let them present without helpful feedback, how will they learn and improve.

Today an intern particularly wanted feedback on a presentation.  This episode (and similar situations) reinforces this educational practice as particularly valuable.  Through this feedback our learners will impress future attendings and residents and learn the thought process.  I only wish I had learned to do this earlier in my career.

We baby boomers have much in common with our predecessors.  Every generation seems to think that the newest generation does not measure up to their great standard.  My friend and colleague Goop Dhaliwal wrote a wonderful paper in JAMA – The Greatest Generation

It is possible that in the days of giants, the narrator did unsupervised burr holes as an intern and had mastered the physical examination by the second year of residency. Beware, though, that each time we replay those autobiographical memories about our training, we are prone to make the situation more harrowing or ourselves more dedicated or skillful than the last iteration. These war stories are frequently told with confidence, detail, and emotion, which makes them far more believable—but that doesn’t make them any more accurate.

But this is not just Goop’s opinion.   This wonderful article should shatter that myth – Boomers Don’t Work Any Harder Than Millennials

Well, according to a new meta-analysis, there’s no real generational difference in work ethic between millennials and baby boomers (or even Gen-Xers!). Published this week in the Journal of Business and Psychology, a research team led by Wayne State University and Ford Motor Company researcher Keith L. Zabel analyzed a whopping 77 studies and some 105 measures of work ethic.

The researchers were evaluating a secularized version of the Protestant work ethic (PWE), which states that work is central to life, that if you work hard you’ll find success, and that you should delay gratification and rely on yourself. The PWE is kind of a big deal to American history; …

We have heard multiple talks on how we should treat this generation differently.  But my experience suggests that students have not changed over the past 36 years.  Medical students and residents generally work hard, and want to become excellent physicians.  During medical school and residency we had some slackers back in the 70s.  We still have some slackers.  But the majority have always  the same desire and work ethic.

So we should all avoid this new bias when we work with the newest generation.  We should continue to treat students and residents with respect and expect the best.  Generally they will impress us with their work ethic and attitude.  They are special as were we.

You present a patient with a past medical history of CKD, heart failure and type II diabetes.  I hear 3 nouns, but I really do not know much about the past medical history.

Cardiologists and coders demand that we further define the heart failure – left or right, if left systolic dysfunction or preserved ejection fraction.  Is there valvular disease, or restrictive cardiomyopathy.  The nouns do not tell the story.

With type II diabetes we need to know how long and what complications.  With COPD we should know how severe the obstruction and whether they need home oxygen.  Is it mostly emphysema or chronic bronchitis.

This article from the Clinical Journal of the American Society of Nephrology speaks loudly to this problem – The CKD Classification System in the Precision Medicine Era

Chronic diseases of the kidney range from rare inherited disorders, such as Fabry disease, to more common acquired entities, such as diabetic kidney disease. Despite the myriad clinical phenotypes and histopathologic subtypes, even within, for example, diabetic kidney disease, this diverse collective is viewed similarly when estimates of glomerular filtration align. Contrast this approach with that of multiple myeloma, a diagnosis that prompts routine cytogenetic studies, such as fluorescent in situ hybridization, to guide additional diagnostics, therapeutics, and research. Classifying kidney diseases on the basis of eGFR further ignores the complexities of renal function.

We should demand more precision in our history taking and reporting.  Understanding the adjectives helps us better address the patient’s complaints and diagnosis.  We should not simplify our diagnosis list.

November 1973 I had an epiphany.  My first week on my internal medicine clerkship, I realized that I had found my specialty – internal medicine.

Prior to medical school I had worked with emotionally disturbed children in an inpatient hospital.  I really enjoyed the experience, and learned a great deal.  During my first two miserable years in medical school (I disliked how they taught the basic sciences and even more how they tested), I had considered pediatrics, psychiatry, and a great blend in adolescent medicine.  Parts of medicine fascinated me, but getting out of the classroom was freedom.

I started my third year on surgery, and quickly realized that I was not a surgery.  I loved talking to the patients, examining and studying their test results, but I had no interest in the operating room.  One week during those 3 months I had an opthalmology rotation that temporarily attracted me (they had great equipment and interesting problems), but that was a short flirtation.

They I started internal medicine and discovered who I was.  Why do I love being an internist?

Internal medicine allows me to be a detective.  Often on the inpatient service we address diagnostic challenges.  Many internists (this writer included) love the diagnostic process.  We love talking with patients, listening carefully to the story, asking probing questions, reading the body language.  We get excited when a physical exam finding gives us a clue.  We pore over the labs and try to understand how they may help explain the patient’s current status.  We order imaging to help narrow the diagnostic process.

Most internists that I have met love Sherlock Holmes.  We all have patients for whom we have played that role successfully.  Unfortunately, few of us are that good all the time.

Great internists like patients, and I do mean the great majority.  Some patients make developing a positive doctor-patient (or patient-doctor) relationship, but we find them to be unusual.

We like helping patients, providing comfort, decreasing their uncertainty, showing our empathy and often decreasing their distress.  Sometimes we make diagnoses and develop a treatment plan the obliterates the disease (most often with infections); sometimes we make diagnoses that lead to lifelong treatment (think type II diabetes, systolic dysfunction, COPD, etc.) and we can often prevent secondary complications or at least delay them.

We offer comfort and dignity when we can no longer treat the disease.  We strive to treat every patient like we would want ourselves and our family treated.

Internal medicine provides the ideal balance of our never ending intellectual fascination with medical science and our commitment to comforting our patients.  Some classic internal medicine quotes:

“The good physician treats the disease; the great physician treats the patient who has the disease.” – William Osler

“. . . For the secret of the care of the patient is in caring for the patient.”  – Francis Peabody

“No greater opportunity or obligation can fall the lot of human being than to be a physician . In the care of the suffering he needs technical skills, scientific knowledge, and human understanding, he who uses these with courage, humility, and wisdom will provide a unique service for his fellow man and will build an enduring edifice of character within himself. The physician must should ask of his destiny no more than this, and he should be content with no less. ” – Tinsley R. Harrison

“Time personally spent with the patient is the most essential ingredient of excellence in clinical practice. There are simply no short cuts and no substitutions.” – Philip Tumulty

So on this wonderful day of Thanksgiving, I am thankful for family, friends, our wonderful country, and the good fortunate I have had in becoming an internist.  I have tried to help patients in distress.  I have tried to help learners see internal medicine in a positive light, and help them become internists if that fit their aptitude.

Being an internist has always been a great privilege.  Every time we help a patient, even in the smallest way, we do something worthwhile.  Happy Thanksgiving!

Our increased focus on diagnostic errors, while important, needs balance with a spotlight on expertise.  Gary Klein in a wonderful book – Seeing What Others Don’t – teaches us that performance improves when we decrease errors AND increase insights.

Many physicians and especially clinician educators have focused on the reasons for diagnostic errors, but we rarely discuss the road towards expertise and insights.  This blog post from one of my favorites – Farnam Street – addresses that problem – Becoming an Expert: The Elements of Success

This article has many important insights.  One that I want to emphasize is the value of repetition in recognizing chunks.  We have several situations in internal medicine that experts recognize and learners often do not.  These concepts seem basic, yet too often we see a lack of understanding.

How do you interpret the vital signs?  Seems simple and straightforward, yet learners often do not recognize the patterns.  The CBC, the basic metabolic panel, the liver tests, EKGs, Chest X-rays – all of these seem routine and simple, yet experts view these tests in chunks and recognize patterns much more accurately.

As educators we need to first become experts on these fundamentals, and teach them every day.  We have to understand the illness scripts for all the common diagnoses and the red flags that warn us that we might not have the seemingly obvious diagnosis.

Actually the mystery cases are not the causes of many errors, because we recruit assistance.  When the patient has a complex presentation, we take more time, call more consults, and spend time searching the literature.  But sometimes the presentation seems straightforward until we have enough experience to reconsider because something does not make sense.  As I quoted recently from the BBC Series Sherlock – You have a solution that you like, but you are choosing to ignore anything that you see that doesn’t comply with it . Experts have learned to not ignore clues.

It takes time and repetition to develop such expertise.  If we want our learners to grow towards expertise, we must be discuss patients and their situations deliberately and completely.

Please read the Farnam Street article and carefully absorb the concepts.  These writings are greatly influencing my teaching and learning.

The BBC series Sherlock is brilliant.  In episode 2 (called the Blind Banker) Sherlock enters a crime scene, and hears a rookie detective make pronouncements about a crime.  He quietly asks a few questions about inconsistencies, but the rookie detective is undeterred.  In true Sherlock fashion, he states (in a condescending tone) – “You have a solution that you like, but you are choosing to ignore anything that you see that doesn’t comply with it.”

Diagnostic errors occur in medicine and in other aspects of life.  As I read the post-mortems on the election coverage, this quote comes to my mind.  When I consider my own diagnostic errors, this quote looms large.  When I change an existing incorrect diagnosis, the quote resonates.

Diagnostic errors are not a simple as this quote, but an amazing number of errors do fit this quote.

Read it and re-read it.  Try to remain humble about your diagnostic prowess.  We all make diagnostic errors.  We all focus on our favored diagnosis, and ignore contrary or inconvenient data.  We must train ourselves to worry about these red flags.  If we do not, our patients suffer.

Yesterday, KevinMD reprinted a Medrants post – Will someone actually let actually help patients?  This post has had wide reposting on twitter and facebook.

As we read and listen to “experts” dissect the Trump victory, one theme seems to emerge – the lack of respect for the working class.  While many remain mystified with Trump’s appeal, many opine that he convinced many that he heard them and understood them.  An interesting op-ed in the WSJ – How Donald Trump Filled the Dignity Deficit -contains this paragraph:

Too many Americans have lost pride in themselves. We sense dignity by creating value with our lives, through families, communities, and especially work. That is why American leaders so frequently talk about dignity in the context of labor. As Martin Luther King Jr. taught, “All labor that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.” Conversely, nothing destroys dignity more than idleness and a sense of superfluousness—the feeling that one is simply not needed.

Perhaps I am stretching a bit, but as I talk with physicians in private practice and academe, I too often hear despair.  Today’s NEJM has another article bemoaning the current state of medicine and medical training – Meaning and the Nature of Physicians’ Work

We believe that if meaning is to be restored, the changes needed are complex and will have to be made nationally, beginning with a dialogue that includes the people on medicine’s front lines. Perhaps the greatest opportunity for improving our professional satisfaction in the short term lies in restoring our connections with one another. We could work on rebuilding our practices and physical spaces to promote the sorts of human connections that can sustain us — between physicians and patients, physicians and physicians, and physicians and nurses. We could get back to the bedside with patients, families, and nurses. We could get to know our colleagues from other specialties in shared lunchrooms or meeting spaces.

For many physicians and trainees, we have lost much.  We want to focus on patients, but (and use this term a bit sarcastically) “the elites” have imposed dysfunctional EHRs, performance measures, report cards and an inane payment system.

Patients want healthy interested physicians.  Patients want us to connect.  They want to feel that we care about them a people first, and disease second.  We cannot measure this function, but we all know its importance.  We physicians know the feeling when we hear the patient’s concerns and address them to their satisfaction.  We patients have the same feeling when we believe that our physician has our best interests at heart.

Since we cannot really measure these feelings, we have difficulty convincing the insurance companies and policy wonks, since they want measurables.  There are things worth measuring in medicine, but just because we can measure them does not mean that the measurables define quality.

So I beseech myself and all other physicians to demand a change.  These battles will not be won easily.  “The elites” do not really understand.  But we have a moral obligation to let them know that the current regulatory environment hurts patients and physicians.