Monday, April 27, 2015

Iatrogenic polyuria

Dr. William Reichert commented on a recent post of mine. I thought he told an interesting story and with his permission, I am featuring it here so more of you might see it.

He wrote

Some time ago, I was consulted on a patient because of excessive urination. The patent was putting out 4 or 5 five liters a day and nobody knew why. I checked out all the usual suspects, diabetic ketoacidosis, hyperglycemia, diabetes insipidus, etc. and all the medications listed on his chart. No diuretics. Finally, at my wit’s end, I entered the ICU room and noticed a number of med bags, some full, some empty hanging there on the IV pole. I checked each and discovered a bag labeled "dopamine” slowly dripping in.

I went to the nurse and asked how long the patient had been on dopamine. She said "He's not on dopamine." I said, "Come with me" and showed her that he was in fact getting low dose dopamine, a drug that behaves like a diuretic.

Friday, April 24, 2015

So you want to be a Radiologist

A student writes, I've been following some of your posts and noticed some of the comments by others mentioning that radiology residencies/jobs are drying up and even face the possibility of disappearing completely. Could you explain why? I am currently a senior pre-medical student who's taken a recent liking to radiology after following a few radiologists in a hospital, so I would just like to get some input.”

A colleague, Dr. Saurabh Jha, an Assistant Professor of Radiology at the Hospital of the University of Pennsylvania, has graciously agreed to respond. He can be followed on Twitter @RogueRad.

Should I go into radiology?

I used to be a surgical resident in the UK. One day, I was a little dispirited during a brutal call, and my senior resident asked “do you love surgery?”

“I like surgery,” I replied.

“If you don’t love surgery, love it unconditionally I mean – like loving your child – you will be unhappy.” He warned.

I really liked surgery. I like radiology. I’m happy as a radiologist. Radiology fits my temperament. You don’t have to love radiology like one has to love surgery, but you have to like it. It helps if you like it a lot.

The worst reasons to go in to radiology are to make lots of money and to avoid patients. The days of radiologists making $500 K + 12 weeks of vacation after reading 20, 000 studies a year are over. Radiologists doing interventional, ultrasound, mammography and fluoroscopy (such as barium enemas) must speak to patients, and speak well.

Radiology is a tech-heavy field. If you’re excited by technology, you will like it. Radiologists are leading healthcare in IT. If you have an interest in health IT, then some programs will integrate informatics with your training.

Residency involves substantial reading. You have to master anatomy, radiological pathology, and physics, as well as have a decent knowledge of clinical medicine. Prepare for 20-30 hours of reading a week. Radiology is now 24/7. Calls are intense – 12 hour shifts are non-stop. But when you are off, you are off.

Believe it or not, international health – if you are into that – increasingly asks for radiologists. Although you won’t be parachuting in to Sierra Leone or quarantined in Fort Hood.

Will there be jobs when I graduate?

Wednesday, April 22, 2015

Externships or observerships: Can they help an IMG get a surgical residency slot?

A woman writes [some non-essential details have been changed to preserve anonymity. Permission to post this was obtained.]:

I am a non-US citizen medical graduate from The University of The West Indies in Trinidad and am currently an intern in a Caribbean nation. Although UWI has produced great students, you may not be familiar with it.

I would like to become a surgical resident in the US. I have no US clinical experience, but my USMLE Step 1 score was >235.

What do you think about my doing a post-intern year externship (hands on clinical) as opposed to an observership (just observing) in the US? I know that an externship carries more weight as far as applications go, and the only reason I would want to do either of these would be to get recommendation letters from surgeons in the US.

However, since I have already graduated from medical school, getting into an externship will be more difficult because this will no longer be a medical school rotation. I believe that observerships will be easier to get into but are they worth it?

Do you know of any IMG-friendly programs that facilitate this? Do you think that this is a good idea? Do you feel that I will be able to get an externship?

Other than this idea for externship/observership, I am blank for ways to improve my chances of matching to a US program in surgery. Do you have any suggestions?


Wednesday, April 15, 2015

Should every man over the age of 65 be on a statin?

If you believe the latest arteriosclerotic cardiovascular risk calculator, the answer is yes.



A previous version seemed to recommend statins for everyone over a certain age. I decided to plug in the optimal values, conveniently stated in a footnote beneath the data entry fields, for a 65-year-old man. Here is what the data entry looks like.



As you can see below, the risk calculator recommends "moderate to high-intensity statin therapy."



Below the recommendation, it says, "Adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL with no diabetes and estimated 10-year ASCVD risk ≥7.5% should be treated with moderate to high-intensity statin therapy." This is a apparently high-level (A1) evidence-based recommendation.

What am I not understanding here?

I would very much appreciate it if some cardiologists would comment and explain to me how such a sweeping recommendation came to be.

Is this accepted as gospel? Do all cardiologists recommend statins in the above situation?


Monday, April 13, 2015

What are the chances of international medical grads matching in surgery?

Anyone considering attending a Caribbean or any foreign medical school should do due diligence. An Internet search is step one. If the school does not list residency match statistics, that could be a red flag. It would not be easy to accomplish, but try to speak with some current students or recent graduates of any schools you are thinking about.

If the school won't give you any names, use caution, and remember, they are not likely to give you the names of dissatisfied students or alumni.

If a school does not require Medical College Admission Test (MCAT) scores, I would advise extreme caution. That suggests they probably take all comers.

Wednesday, April 8, 2015

How does a 16-year-old boy receive 38 times the normal dose of an antibiotic?

If you are a doctor, nurse, patient, or just someone interested in patient safety, you should read a five-part story called "The Overdose: Harm in a Wired Hospital" excerpted from a book "The Digital Doctor" by Dr. Robert Wachter.

Dr. Wachter and the hospital are to be commended for publicizing this incident so others may learn from it. The hospital staff, the patient, and his mother, also deserve credit for allowing their stories to be told.

A synopsis does not do justice to this well-written account of the boy's near-death experience in a top hospital in San Francisco. In short, he somehow received a massive overdose of the antibiotic Septra despite the presence of a sophisticated electronic medical record and multiple systems in place that were supposed to prevent such a thing from happening.

After the patient recovered from receiving 38½ pills when he should have been given only one, a root cause analysis found numerous faulty system issues such as an electronic ordering program that was overly complex, a nurse "floating" to an unfamiliar floor, a satellite pharmacy that was too busy and susceptible to distractions, "alert fatigue" among hospital staff, and a culture, like that of most hospitals, that may have discouraged questioning both authority and the almighty computer.

Thursday, April 2, 2015

Are guidelines a "safe harbor" against malpractice suits?

Several months ago, Physician's Weekly featured an article describing a bill that was introduced into the House of Representatives called HR 1406 The Saving Lives, Saving Costs Act. It would create a "safe harbor" for physicians who could show that they followed best practice guidelines when faced with a malpractice suit. At the end of the piece, a question was asked, "Do you think this bill will help safeguard physicians against the influx of federal rules and regulations?"

Knowing little about the bill at the time, I tweeted that such a bill would never pass.

I couldn't list the reasons in a tweet, but here are a few.

Although guidelines are useful, they can be controversial too. Take the guidelines on screening mammography and PSA testing. When they came out, there was so much criticism that it would be difficult for any lawyer to use them as safe harbors. Plaintiffs' experts would simply say they disagreed with any guideline. A seed of doubt would be planted in the minds of jurors, and the safe harbor defense would fail.

The Dr. Whitecoat blog published a conversation between an emergency physician and a plaintiff's lawyer. It should be read in its entirety, including the comments, to be appreciated.

The conversation was mostly about the Choosing Wisely campaign, in which specialty societies publish guidelines listing certain tests and treatments that they feel can be avoided.

The lawyer said, "There will be a lot of bad discharges, refused admits, procedure delays, diagnoses delays, all in the name of ‘costs.’ Your societies and hospitals are masking this as evidence based practice, etc. But I can get a jury to see that very differently. A lot of physicians will be paying out before long, as will hospitals…Testing is what makes diagnoses, saves people.

"I have a pretty set script here. To the effect of ‘so Doctor, you just didn’t care enough about my client to order this test?’ Or ‘so my client was just a statistic, just a percentage to you?’… [Juries] love that stuff!”

A post I wrote last year about a supposed set of common goals shared by lawyers and surgeons had these comments from another plaintiff's lawyer.

Regarding the use of guidelines as a malpractice defense which some have labeled a "safe harbor," the lawyer said, "The safe harbor concept becomes unacceptable if it allows guidelines to be used as a 'get out of jail free' card. Guidelines must be useful in exonerating and implicating clinician wrongdoing." My interpretation of what he said was that it's OK to use a guideline to prove a clinician did wrong, but following guidelines should not be a fail-safe defense strategy.

Just for fun, I looked up HR 1406's history. It was introduced on February 27, 2014 and immediately referred to three committees—the Energy and Commerce Committee, The Judiciary Committee, And the Subcommittee on Health. On March 20, 2014 it was referred to the Subcommittee on the Constitution and Civil Justice, and it hasn't been heard from again.

A website that tracks bills lists its status as "Died in a previous Congress."

I don't think you will be sailing to a safe harbor any time soon.