A Doctor's 100 Pet Peeves About Hospital Medicine (100-51)
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- Опубліковано 6 сер 2023
- A rundown of 100 behaviors, management approaches, or systems issues that frustrate me as a hospitalist (i.e. a doctor who specializes in the care of the hospitalized patient), ranked according to how frustrating they are, how dangerous they are, how common they are, and how easy they would be to fix.
Pet peeves with evidence or consensus behind them:
#94: Which patients are really at risk for refeeding syndrome: pubmed.ncbi.nlm.nih.gov/32115...
#80: Definition and discussion of "prerenal AKI": www.ncbi.nlm.nih.gov/books/NB...
#78: Things We Do For No Reason: Echocardiography in hemodynamically stable patients with an acute PE; cdn.mdedge.com/files/s3fs-pub...
#75: Most patients presenting with cardiac tamponade are not hypotensive; pubmed.ncbi.nlm.nih.gov/17456...
#73: The presence of hypoxemia or an elevated A-a gradient is minimally diagnostically helpful in ruling out/in an acute PE; www.atsjournals.org/doi/full/...
#72: Things We Do For No Reason: Things We do for No Reason: Routinely obtaining repeat transthoracic echocardiography for acute decompensation of known chronic heart failure; pubmed.ncbi.nlm.nih.gov/36739...
#64: The relative lack of evidence for using the INR and aPTT to predict peri-operative bleeding; from the American Society of Hematology: ashpublications.org/blood/art... (NOTE: While a minority of studies do find an elevated INR and/or aPTT are predictive of peri-operative bleeding, that is not the same thing as saying that bringing down those numbers with pre-operative FFP reduces bleeding risk - which is the real issue)
#63: Should urgent surgery be delayed due to a positive urine drug screen; tsaco.bmj.com/content/6/1/e00... and www.bjanaesthesia.org.uk/arti...
(NOTE: This is not the same thing as delaying elective surgery in patients with a positive urine tox screen for stimulants, which I think is more reasonable)
#53: Benzodiazepine use in the elderly is a bad idea; www.ncbi.nlm.nih.gov/pmc/arti...
#52: Description of the Levine technique for obtaining an accurate wound culture without the need for a surgical incision; msqc.org/wp-content/uploads/2...
#51: Things We Do for No Reason: Prescribing Docusate for Constipation in Hospitalized Adults; pubmed.ncbi.nlm.nih.gov/30785...
I'll post Part 2 (50-1) tomorrow. Feel free to make predictions as to what you think will make the list!
stat rectal bleeding consults at 2 am from hemorrhoids in a healthy person
As a medical student, I love to watch an experienced physician talk about issues that are so important to clinical practice, but cannot be learned from books or classes. A video like this serves as a great synthesis of skills that we learn on a daily basis in various internships, thus facilitating our learning and taking advantage of them.
Rumor has it that a Strong Medicine Peeve Score (SMPS) has a strong positive correlation with the incidence of trichotillomania
I love that you think it would take an act of congress to make consultants clarify when they're signing off 😂
I also loved it. Icu RN here. Especially guiac orders when you totally know there’s blood😂 lol and Talking bad about providers. Not everyone is the same and talking bad creates a poor culture. It’s a hard field and we need to be good stewards of our resources and support each other. I know a doc and few nurse practitioners that won’t give me orders for appropriate pain Managment and although that makes me upset and sometimes very upset I just document and ask another doctor. Belief in getting someone addicted is a cover for their desire to look good on paper showing they aren’t prescribing much. My patients being in tons of pain is unnecessary and I won’t stop asking. I am still learning what irritates my docs but I definitely know what irritates my charge nurses not done chg baths, blood cultures from central lines, no foley care charted, no sbt/sat done before 10 am. My charge nurses are gate keepers of unnecessary stuff and I’m becoming one too. I think about all the money my patients are going to be billed for and thinking that it could be me makes me feel like I must be their advocate.
LOVE the one about the chemoregime failing the patient and not the other way around
This is gold, I could listen to you talk about every point in more detail
dr Strong I wanted to thank you for your channel insight and invaluable info, I started watching in medschool and now I am a hospitalist attending, and I still go back and watch your old videos. Keep up the great work, all in good health, god bless and god speed
I loved it !!!
Classic examples of frustrations !! Can easily relate each one of them !
Thank you
( Hospitalist NP )
This is great! A video on various hospital medicine clinical pearls would also be cool, if not made already
You're in luck! The videos in this playlist that are entitled "10 tips on how to be an effective intern..." may be what you are looking for. They are a little basic for experienced clinicians, but may be things not previously heard by interns and sub-Is. ua-cam.com/video/BfWT8n8SaxY/v-deo.html
Thank you! Looks like a lot of great videos, some of which I've viewed already. I will definitely look into them.
Queries and Peet reviews=10!!! For me.
sending stool sample for guaiac when stool obviously has blood in it (which could just be done at bedside) is simply CYA medicine, so if something resulted in a law suit a lawyer would say "In the chart you stated stool contained blood, how do you know if it was not tested". More frustrating, doing a guaiac or FOB screening knowing the pt has a bleeding hemorrhoid.
92. Usually includes “agitated” too.
Let me just go to my number 1. PRIOR AUTH, additional points is being denied by a Physician not in the ordering provider's specialty.
86. Nurses ask for this all the time and it's unnecessary.
reminds me of the doug score from that car video guy lol. #StrongScore
Me, the EMT to whom most of this does not apply: haha yes so funny and relatable 😂
Nah, it's always a good time to hear about the weeds in the grass in other parts of healthcare, and several of them really hit home for me too, especially 65 and 58
fucking same man I just got done with my emt cert and I'm gunna start working once I get a job
most times I see "dirty" urine as it was not done as a clean catch and/or cath.
From the perspective of a non-american internal medicine resident (or the Norwegian equivalent of residency, which to my impression is extremely different) in a medium sized hospital (serving a population of about 150k), some of these pet peeves are quite interesting. I thought I'd write down some regional differences I found interesting, coming from someone with about 4 years of in-hospital experience.
-98: I have never seen or heard of anyone doing this
-94: We are also in the process of joining this trend. It seems to me to have started when we got clinical nutritionists on staff.
-92: Routine 3AM lab draw?? Is this normal? And here I am thinking that 6am was already a bit steep. Also, I have never seen a patient refuse one particular lab draw, it's usually full noncompliance or no issue. Perhaps this is some cultural factor, or the fact that we do not routinely draw blood at 3AM.
-89: This might be the "medium sized hospital" part kicking in, but there is no system here whatsoever to consultancy follow up. Basically unless the consultant specifically says they are following up the patient, one must assume that they are not.
-87: When discussed we all agree that UAs are important, but they are rarely done by doctors except by nephrologists. When anyone else does order them, it's trained lab personell that does them and they are usually precise in their language.
-86: Outside of intensive care, IV pumps at my hospital are exclusively used when precise rate control is necessary, such as in hyponatremia, IV-insulin drips and so on. Otherwise you use a plastic widget with a wheel that squeezes the tube at varying degrees and determine the rate based on timing of droplets. The usual rates are "slow", "fast" and "whatever the nurse feels like".
-83: "Suspend your epic access". The hell? Is this some kind of weird punitive measure used by hospital administration? If so that seems incredibly hostile and counterproductive.
- 79: I am not sure if I am understanding this correctly, but if you are referring to daily labs as "serial" (not completely sure what "qeue day" refers to), then serial CRPs are standard practice (not for ESR). In fact it's uncommon for patients not to have CRP part of the routine labs. CRPs are routinely used as part of the reasoning for when a patient can be discharged (and to where they are discharged), assessing the response to antibiotics, follow up with PCPs and so on. I started writing up a small novella on its use, but it got a bit lengthy. Suffice to say that I am uncertain how exactly CRP is used in the states, but in Norway I would say it's one of the most commonly ordered labs. It's certainly the one that we spend the most time discussing overall.
-77: I have never seen anyone cite their references anywhere in the EMR except for a single IM attending.
-69: I am extremely thankful that this is not a thing here, or really anywhere except the US afaik.
-59: Neither IV Cefazolin or Cefalexin are pretty much ever used in Norway (antibiotic choice is hugely different here I think, ie. first line therapy for non septic pneumonias is penicillin).
-52: Weird to see someone mention MRSA "in the environment". MRSA is a huge deal in Norway in the sense that we routinely screen anyone that has been admitted hospitals abroad for it, if you have a single positive culture at any point with MRSA you will always be isolated from other patients in the hospital, followed up with new cultures even after discharge, and even if you manage to get rid of it hospital personell will forever look at you askew and wear gloves.
I'm curious why Colace is listed as having no benefit "in the hospital". Does this imply that it does have benefit outside of the hospital? If so, what is that benefit, and why the difference in effectiveness depending on setting?
I think it's more a matter of where it's been studied the most, but also, both myself and the authors of the linked Things We Do For No Reason paper are hospitalists, so we naturally focus on inpatient medicine. I would say that I honestly don't know if Colace is helpful in outpatients with chronic constipation compared to placebo, but of the patients admitted to my service who suffer from severe pathologic constipation, none of them use Colace and instead rely on meds like Miralax.
Makes sense, thanks for the response!
Short question on the reasoning behind choosing to multiply the scores instead of adding them?
It was because I realized that if a peeve had a very low (1-2) score on a single one of the 4 measures, it really shouldn't end up high on the list no matter how high the other 3 measures were scored. For example, consider the following 2 peeves
#71: Staying extra days in the hospital because a test/procedure isn't performed on weekends
Frustrating = 8, Detrimental = 9, How common = 6; how easy to fix = 1.
Peeve score = 4.32
#39: Admitted a patient for chest pain and not mentioning the ECG in the admission H&P
Frustrating = 9, Detrimental = 3, How common = 6, how easy to fix = 6
Peeve score = 8.64
#39 subjectively is a much bigger peeve of mine because I recognize how difficult it would be to fix #71. But if I added the 4 scores of each peeve instead of multiplying them, both would have the same total of 24, erroneously implying they were equal in "peeveness".
@@StrongMed "It was because I realized that if a peeve had a very low (1-2) score on a single one of the 4 measures, it really shouldn't end up high on the list no matter how high the other 3 measures were scored."
My thought is quite different. I think numerical value of each quotient have different representative "peeveness" values (i.e DETRIMENTAL, HOW EASY TO FIX have greater "peeveness" than HOW COMMON, and FRUSTRATING would be some sort of function of the other quotients). Of course, this would be difficult to implement. Having said that, multiplying them would overplay the peeveness of low sum peeves of low detrimentalness or frustration, since 3,3,3,3 scores higher than 3,9,1,2 for example.
As for the example, I can see #39 is subjectively a bigger, seeing Frustrating of #39 is higher than #71.
In the end, I need to watch Post 2 in full, but generally FRUSTRATING is in the >5, where it would make less of impact on peeve score than the multiple of how common and easy to fix.
My favorite repeated query is " Why I did not treat a patient with a Type 2 NSTEMI 2' to massive GIB/Anemia with a hgb of 4.5--> with guideline ASPRIN" . Kills me every time.
I'd argue that Type 2 NSTEMI even being labeled "NSTEMI"s are a problem.
😅😬: Me, now as a junior resident tallying up how many of these pet peeves I checked off as an intern 😭😂
Thank you Dr. Strong for providing some preemptive, asynchronous feedback as I enter my first block of leading the ward team tomorrow! I’ll definitely make sure to keep the above in mind!
Predictions for part 2:
- Starting antibiotic treatment before collecting appropriate cultures
- Continuing IV fluids despite regained adequate fluid intake
- Having to call a consult asked by another member of the team despite being not fully convinced of its benefit
- Restarting all medication previously discontinued with admission at the last day of the hospitalization
- Asking stool samples for clostroides without the patient actually having diarrhea
- Contributing every hyponatremia to SIADH without even doing proper work-up
- Prescribing chronic high dose systemic corticosteroids without every associating calcium/vitamin D or checking a BMD
- ....
Let's see!
These are some good ones that I definitely could have included! Particularly restarting 5 outpatient meds at discharge following a month long hospitalization during which those meds were held for incompletely documented reasons.
Some reason I hate the phrase "please advise"
Please don't have the pharmacy get rid of my colace... it works wonders on helping clear ear wax when trying to visualize a pediatric ear canal in the emergency department.
Lol. Alright, you can keep the liquid stuff.
"Colace"
this guy is a classic example of how critical people in medicine are. I bet he will admit he makes the same mistakes too.
In fairness, he kind of does at 0.38
Personally I have issues trusting clinicians who criticize other people's mistakes but minimize or won't admit their own
Not only have I made many of these mistakes myself, I have no doubt that I'm still doing practices that will turn out to be wrong but medicine just doesn't know about them yet.
@@StrongMed and this honesty and integrity is one among many reasons I follow your channel, doc!!!!!!!