A Doctor's 100 Pet Peeves About Hospital Medicine (50-1)

I'm back with part two of two of my countdown for a hospitalist's 100 pet peeves while in the hospital to recap in part one none of these are about patience instead even when they seem critical of specific Specialties or roles they are really all about the system including how much of what we are taught to do is without evidence is in contradiction to evidence or sometimes even without logic to support it each peep is ranked on a uh on a scale based on how frustrating I personally find it to be how detrimental to Patient Care it is how common it is and how easy it would be to fix many of these are just my personal opinion and the numbers are arbitrary but when there is good evidence or at least a strong consensus on which a particular rests I have a link to a relevant reference in the video description when act with contrast is blocked for the sole reason of an elevated serum creatinine irrespective of other factors including the indication for the scan so you know people you know are still debating how much of an effect that IV contrast for a CT scan has on people's kidney function uh I think there's a lot of people feel that there's no impact whatsoever but even among people who think that maybe there is an impact still you have to consider many other factors if you're worried about contrast induced nephropathy their serum creatinine is not the only factor that goes into determining someone's risk of that even among people who believe that that's even a thing so you have to worry about things like you know concurrent heart failure you know how heavy are they how large are they how how old are they what's their age um and of course worry about the indication for the scan and how emergent is the scan is there a good alternative test that could get the same information or is there not these things should all be considered you should never have a CT scan with contrast refused for the sole reason of a high creatinine joining code status DNR dni and an emission hmp without any indication as to how that decision was made this has become less common now our EMR for example at our hospital will prompt the person writing the hmp and putting in a code status to actually leave a little goals of care note that we sort of very strongly hints at a need to provide some kind of explanation for the code status so this isn't very common anymore my old hospital this used to happen all the time reflexively tracking bid electrolytes in every patient on diuretics this is sometimes appropriate but it's often not necessary documenting a patient's neural exam as quote non-focal when I when I see written down in neural exam was non-focal I interpret that to mean that they did not do a neural exam not assessing the Gate of a patient on admission uh which is particularly frustrating if the chief complaint or the reason the patient came to the hospital was for weakness or Falls when a doctor consistently orders routine fluids meds labs and Radiology studies as quote stat in the hospital if everything is ordered as stats nothing becomes stat ordering acetaminophen as the only PRN pain medication in a patient whose Chief complaint is pain yes that happens refusing to give narcotics to an inpatient with a history of substance abuse irrespective of how severe their acute pain is I understand wanting to be more cautious absolutely that makes a lot of sense but you know if someone has a history of of narcotic dependence and they come into the hospital with a ruptured appendix you know I I think it's not unreasonable to give that patient some acute narcotic to get their pain under control like it's it's not gonna make or break their uh their long-term drug abuse problem um refusing assuming a patient with an irregular pulse has afib without checking an ECG um this is uh you know it's a sort of analogous to the patient who is a smoker in the chronic cough assuming they have COPD um but this one's actually more frustrating I think because with with a regular pulse you know getting an ECG is so much easier than getting pulmonary function tests so there is really there's no excuse to not get an ECG before diagnosing uh atrial fibrillation when the respiratory rate of every patient on the ward is documented as either 18 or 20. I don't know why this like the top like where this comes from and why it happens it seems to be consistent in every hospital that I've worked at and I've seen people online who talk about their own hospitals and they also joke about this phenomenon next uh using pre-albumin to assess nutritional status so uh you know the reason that this is often cited by people as why they do this is that pre-operman has a shorter Half-Life than albumin does so therefore you know when someone's nutritional status gets better or worse pre albumin will change before albumin does but that logic is based on a really really bad assumption not an assumption a bad error I'm thinking that pre-albumin is a precursor to albumin and it is not they're not the same molecule at all pre albumin and albumin have nothing to do with one another it's called pre albumin because of how it migrates on a GL it migrates and sense that it ends up being uh before albumin on the gel thing uh you know when it's exposed to an electric current um and it is not pre-opened it's not a marker of nutrition it isn't admitting a patient for rule out mi and then not mentioning their ECG in the emission hmp um this is so common it's it's so frustrating I think I think part of it has to do with the fact that with an EMR when you're writing an admission hmp in the EMR released with Epic it Imports uh Radiology studies automatically and so you really can't have a hmp without mentioning the chest x-ray um if a chest x-ray was done but it does not automatically Import in the ECG report and a lot of people just don't put it in or they'll put in something really really basic like you know ECG uh you know normal sinus rhythm or NSR and like that's that's that's completely not okay when you're especially that's not okay in any patient to write to do that but for your patient who's coming in because they're having chest pain and being a minute for rule out am I you have to describe the ECG um in much more specific terms than normal sinus rhythm um or let alone ignore it all together unnecessary use of oxygen so oxygen is is not benign in the hospital um if someone's not hypoxic there's really very few reasons to treat them with oxygen there's a there's there's not zero reasons there are a few reasons but there are very few and we always joke about oxygen and we would come in uh to a patient room they see that they're sounding 100 on uh you know on four liters and we turn them down to two leaders and wait a few minutes they're still selling 100 we turn it on to room air and take them off oxygen and we sit there and we talk to them for a few minutes and they're still on room air uh they're they're starting 100 and we think oh this patient's fine they're off they're fine off auction and we leave the room and then we come back a few hours later and the patient's back on oxygen again setting 100 with no explanation anywhere as to why they went back on oxygen and we suggest it was like the oxygen Ferry was you know coming by average pay for every patient's room just putting them back on every patient that we would take off oxygen the oxygen Ferry would come by put them back on oxygen again and I think what probably happens is combination of two things one is that um we don't do a good job with telling the nursing staff when we've taken someone off oxygen and explaining why we did that I think if we did a better job with that this would not happen a lot less I think also what then happens is patients on continuous oxygen monitoring unnecessarily um you know sometimes the oxygen levels will dip down very briefly for either because they're sleeping they dips down into like the lower mid 90s for a few moments because of sleep apnea or because um a bad reading you know just not getting a good signal and so it drops down because of that and someone comes in like oh my gosh this person is you know desatting to 90 we have to get them back to 100 or they're desatting to 95 even though it's perfectly fine um and they have to get them back to 100 put them back on oxygen and they just don't document that anywhere um so I think it's a multi it's a it's not just one person or one one role at the hospital who's as fault this is but it still is a pet peeve of mine to see it but now stealth science when house staff sign out to the on-call team and spend 30 seconds on each of 10 patients rather than handing over a list of nine patients with no statement and spending five minutes discussing the one patient who is particularly sick and complicated uh using the heart rate as a primary indicator of volume status yes patients who are dehydrated will get tachycardic patients who are anxious will get tachycardic patients who are febrile will get tachycardic patients in pain get tachycardic patients who are in heart failure get tachycardic tachycardia is not a good sign of volume depletion don't use it to dictate volume management unnecessary polypharmacy in the elderly polypharmacy and anybody that is the term used to describe when a patient is on a lot of different medications which are either excessive and or which are likely to have drug drug interactions that's problematic in all individuals but is particularly problematic in the elderly and they can get really confused uh like like as in like actual confusion from poly Pharmacy so uh really really be cautious when you when you're adding a new medication to an elderly patient who's already on lots of new or already on lots of medications really double check that list make sure every medication is actually needed double check it triple check it for drug drug interactions or ask your pharmacist to double check it when a patient with mild hyperkalemia and no ECG changes is given a full Smorgasbord of hyperkalemia treatment meaning calcium insulin plus glucose bicarb Albuterol and tons and tons of calculate so your risk of of having a fatal arrhythmia from hyperkalemia it's related to a couple things one is the speed with which hyperkalemia developed but the other is whether or not there's ECG changes and in a patient with mild hyperkalemia I mean like you know potassium in the 5.5 to 6.0 range who has an ECG that's that's completely normal or is unchanged from the Baseline um that patient's not going to get some fatal ventricular arabhythmia from their hyperkalemia and the next you know handful of minutes or even a handful of hours and so you don't necessarily need to like throw the kitchen sink at them you know give them you know maybe not calculate give them uh you know sort of a more 21st century medication to bring their potassium down um but you don't understand need to break out the insulin in glucose and the calcium and whatnot like that's those medications don't even they don't even last long enough for it to be helpful like if you're worried about the patient getting hypocloyment more severely like six six or 12 hours later the calcium its effect of hyperkalemia wears off after like an hour so there's like there's really no reason to to give it for patients without ECG changes um next attend alone oh my gosh a tenal uh a tonal is a beta blocker it was used very commonly in the 80s for management of hypertension there is a lot of great evidence that it is no better than Placebo for a whole host of patient-centered outcomes um it it can lower the blood pressure it does not reduce your risk of of heart attacks or death or Etc so why that's the case is an interesting discussion we don't have time for but really you should whenever you see a 10 a lot of problem on a medication list you sure that you should cringe and think about how you're going to get the patient transitioned to a better choice for the 21st century hmm a mention of a patient's face in the chief complaint line this also is really commonly done a long time ago and was really considered sort of conventional practice you know uh Mrs Smith is uh or Mrs Jones is a 50 year old African-American woman or you know Mr Lee It's a 65 Asian man we don't do that anymore we don't recommend that for a number of reasons the primary one is that it actually leads to sort of subconscious bias um either subconscious bias against the patient as an individual or subconscious bias towards or weights or certain diagnoses in a way that is far in excess of what impact that person's race actually does have on that diagnosis so this doesn't mean that their their self-identified race isn't relevant it's something that we typically put into the social history um but I would I would not put it in the chief complaint line um admitting a patient for any pulmonary complaint and relying on the formal interpretation of the chest x-ray without even looking at it oneself um yeah so uh you know anyone in Internal Medicine anyone that's on one of my my teams you know Internal Medicine intern or resident um we know we expect you to have some skill with interpreting a chest x-ray especially since chest X-rays at least as of 2023 are not automatically read by some AI like you might assume ECG machines um do for ECGs so I I really you know in terms of residents they should they should know how to read a chest x-ray they should look at the chest x-ray themselves um and you know like and the reason for that is you know the Radiology report you know obviously the radiologist is going to be more skilled at reading the x-rays than the intern or the resident or even myself but there are sometimes there's some things that aren't that because they're difficult to convey in in words you know a picture's worth a thousand words that's true of Chess x-rays when someone talks about the fact that someone's got you know uh infiltrate at the right lung base like what exactly does that mean does that look like pneumonia does it look like it's aspiration does it look like it's fluid if you like what it what does infiltrate mean um how bad is it how severe is it how convincing is it especially if someone has you know sort of other symptoms and signs of a pulmonary complaint that aren't really pushing You One Direction or another just look at the film it takes 10 seconds to do just take a look at it when the Ed gives antibiotics with without first acquiring relevant cultures um I don't know why this happened this really shouldn't happen I know why it happens it's it's not super common but it still does when a medicine emitting residents and either the Ed or another admitting service argue for an hour about an admission meaning which service the patient should be admitted to without anyone alter alerting a relevant attending so if you know I talk about residents you know if they get into a dispute with another service about who should admit a patient if they can't resolve it in five minutes like don't keep going back and forth for an hour like if you can't reserve yourself in five minutes let me know and that's not because like I wanna I'm gonna get up all up in someone's face about it it's not because I don't trust the resident to to be able to figure out themselves it's just it's a waste of time like when you're admitting you know when you're on call into many patients like there are so many other things going on you don't have time to go back and forth with some silly debate about whether or not someone belongs on internal medicine or general surgery um especially when that debate could be solved by an intending to attending call that takes two minutes so you can't if you can't figure it out in five minutes let your attending know about it um being excessively dogmatic with antibiotic courses and situations of significant diagnostic uncertainty so this one is something that I feel like um is when I bring this up people get confused by what I mean and and I've been meaning to make an entire video about this but never felt like quite enough material to make a video on but in essence it was what this means so if you have someone who you think has um endocarditis and you're going to come you know you and you're 100 sure they have endocarditis you're going to give them six weeks of IV antibiotics you know they have you know how do we determine that six weeks of antibiotics is appropriate treatment for endocarditis that's because six weeks is determined you know maybe with some evidence but with a lot of expert consensus as well and experience that's the point in which continuing the antibiotics longer than six weeks the harm for the antibiotics or including the cost of antibiotics outweighs the benefit from the antibiotics so in other words most patients will be cured at six weeks and a tiny tiny fraction that won't be cured by six weeks that still need more longer courses um that's going to be more than outweighed by all the extra harm given to everyone else you already was cured by unnecessarily extending the antibiotics longer so if six weeks is the optimal length of time for someone who with whom you're 100 certain that has endocarditis what do you do for someone who you're maybe 50 sure they have endocarditis that patient you know if you treat them for six weeks of antibiotics they're still going to have as much harm for the antibiotics because they're still getting the antibiotics they're still getting the harm from a risk of you know PICC line infections risk of C diff colitis you know the the cost of the of the medications Etc but the expected benefit is literally going to be 50 percent of the expected benefit of the person who in whom you are 100 sure of because there's only a 50 chance you've gotten the diagnosis correct and so it would not make sense I'm not suggesting that person should be on 50 as long of course you know unless I just give that person three weeks but it doesn't make sense for that person to necessarily get six weeks you know what does that mean does that mean five weeks I mean five and a half weeks I don't know maybe and what if you have a patient on whom you're like 10 sure they have endocarditis and for some reason for whatever reason you can't further estimate you can't further clarify the estimate that's that's a good investment that you're gonna get do you really want to treat that patient with six weeks of antibiotics and whom you're 10 sure you have endocarditis I I would argue no I would argue that that was that's a mistake and people push back on this a lot uh ID docs in particular they like they like to be dogmatic with things like endocarditis but to me it doesn't make any sense like I said one of these days I get around to um making a longer video about it next starting lactulose in a patient with myocerosis and no history of symptoms attributable to encephalopathy so lactulose um it's don't give lactose as as for primary prophylaxis um you know it is uh it treats the symptoms of encephalopathy don't use it to prevent symptoms and stuff like that that's just lactose unpleasant medication to take gives you a lot of bloating it gives you diarrhea the diarrhea is not a side effect of lactulose diarrhea is its mechanism of action so um you know it's very prominent feature of lactose treatment it's really unpleasant so don't don't use it unless you only need to deciding against the use of Metformin in a patient solely because the creatine is above a relatively low and arbitrary cutoff so like with IV contrast and creatinine people get really freaked out about metformin and creatinine um people think like oh my gosh my form is going to cause lactic acidosis Etc um I'm not saying that it's never a concern and that you should ignore kidney failure and Metformin ignore that combination but I think people exaggerate uh they have to I should say they exaggerated um impression of how bad a combination is of metformin and a mildly elevated creatinine continuing four times a day finger sticks for weeks in The Chronic patients whose type 2 diabetes is controlled well enough to never require insulin um you know figure sticks suck they're uncomfortable they're unpleasant it takes time for the nurses to do um they have to then record the results which you know if someone's not requiring insulin for many weeks you're probably not even checking what those results are that the nurses are having to document so just let's get rid of the finger sticks altogether you know and if you need to if you if you're worried about something flaring up their diabetes getting worse or whatnot um you know just check it once a day with the the chem seven in the morning and that's that's probably sufficient for patients who have been stable for a long time well the reason for a patient's admission and or their documented Chief complaint is Alter mental status without any further description so I have a whole uh I have a whole discussion of all different forms of alternative status in a video uh appropriately appropriately called an approach to alternate status so if you wanted to understand what I meant by that you can check out that video and I have a very detailed discussion the discussion of it there placing a patient on Two hemodynamic drugs simultaneously which have direct antagonizing effects such as midodrine and hydralazine or you have someone on intravenous fluids and furosemide at the same time which maybe has like one relatively uncommon indication for but for the most part you really shouldn't be doing that kind of thing or dopamine and metoprolol I've seen patients on that combination before and that just doesn't make any sense ordering 25 different Auto antibodies in the patient presenting with a vague multi-system disease just to be sure it's not autoimmune um and then inevitably what happens is in a comes back positive with a tighter of 1 to 40 and that then triggers a Rheumatology console to see when the patient's got lupus despite the fact the patient has absolutely no clinical signs of lupus whatsoever if you need to order more than three or four Auto antibodies at a time I would say you're probably not being thoughtful enough with with your ordering like you're probably haven't thought through the patient to figure out what is actually likely to be the case because if you order we start ordering like dozens and dozens of these Auto antibody tests what ends up happening is the probability of a false positive becomes unacceptably high so much so that like a a a positive result is much more likely to be a false positive than a true positive and that just causes a ton of confusion diagnostic confusion that is for everyone involved in the case ignoring the nurse during walk rounds despite he or she's standing right there at the bedside uh I I really try hard to make sure that doesn't happen if you know I tried to let the nurses know when we're rounding it doesn't always happen for a variety of reasons but I tried to let them know um and if the nurses comes over uh then I definitely will want them involved in the discussion they know a lot of things about the patient that we don't they have all the up-to-date information they're there with the patient you know much much more frequently than we are um and they they're they have this incredible wealth of knowledge about the bedside condition of the patient that we are going to totally miss out on if we don't actively engage them in rounds referring to professional Society guidelines as if they were laws that must be followed um guidelines or guidelines they're not they're not rules they're not laws they're they give you an idea of what is typically done for a patient by most physicians in a given situation but there's going to be lots of reasons that you may not you know in which following the guidelines is not the best course of action and so you shouldn't necessarily feel compelled that you must necessarily follow them all the time ordering a PPI for a soft reason which will likely be continued for years before another doctor re-examines whether it's appropriate for some reason ppis are just one of these medications that doctors they don't discontinue it for some reason it just stays on forever and ever for and and uh it they're not benign drugs like they have side effects they have toxicities um and you know you shouldn't use them in this unless patients really needs them insistence on always using the same temperature cut off as constituting a fever and reacting to every fever in the same way such as sending blood cultures on every patient whose temp is above 101.0 Etc or or no patients whose step is less than 101.0 so I have a whole video about how our definition of fever is extremely fraught and why we should have a much more nuanced approach to diagnosing someone with a fever and identifying a fever and for people who want to know more about that I'll just put a link to the video uh in the description to this one using a higher than normal hemoglobin threshold for transfusion simply because a patient has a history of CAD so the war studies years ago that found that patients with active ischemia did better with a higher transmission threshold than other patients often the patients will cite uh sorry doctors will cite a hemoglobin threshold of 9.0 as being where you should consider transfusing red blood cells but that is in a patient with active ischemia not anyone with a history of ischemic heart disease and active ischemia means they're having chest pain they're having elevated troponin they have ischemic changes in the ECG it does not mean they once had an abnormal cath five years ago reflecting reflexively giving Lasix to every patient with pulmonary edema so while this was true for many this would be helpful for many people um not all pulmonary edema is caused by hypervolemia you know pulmonary edema is not it's not necessarily fluid it's not necessarily too much fluid in the body it's too much fluid in the lungs and you know for example patients who have a hypertensive emergency you know where the blood pressure skyrockets for some reason you know because of I know they they're intoxicated with cocaine or other stimulants um that's just one example they have a few chromocytoma or whatever and they develop flash pulmonary edema and they suddenly have this this very very quick development of fluid in the alveolar space the problem is not that the patient's volume overloaded you know given the elevations Lasix it's not going to clear their lungs out any faster giving them medications to reduce their blood pressure reduce their afterload that will clear out their lungs and so when someone has pulmonary edema you really have to think about what is the mechanism of this pulmonary edema before deciding whether or not Lasix is or is not appropriate reflexively transfusion at an transfusing at an arbitrary hemoglobin irrespective of symptoms or other medical problems so like I said you know some people will transfuse at an inappropriately high hemoglobin threshold for patients with a history of coronary disease some doctors will wait until the patient has gotten down to an inappropriately low hemoglobin before transfusing so for example they'll say oh appropriate hemoglobin transfusion threshold is 7.0 because of some trial 20 years ago that showed that and that's all fine and good but if your patient is having shortness of breath or extreme fatigue with the hemoglobin of 7.5 like like even if they not necessarily have a a study proven mortality benefit to being transfused at a hemoglobin of 7.5 they're going to feel better so so if someone clearly has symptoms from their anemia at a hemoglobin that's above the conventional transfusion threshold it's okay to transfuse them that's the bottom line continuing low value non-comfort focused medications in hospice patients um you know sometimes patients with unhospice they will feel connection to their their chronic medications and they won't want to come off them like they'll choose to stay on their Statin for example because someone has told them years ago that the Statin was going to prevent them from getting a heart attack and just because they're on hospice doesn't mean they want to have a heart attack in the next day or two and and even if you know as a physician that taking them off the Statin is not going to make any difference at all if if it means something to the patient you can leave them on but as as the treating you know clinicians if you can get patients off of unnecessary medications when they're on hospice you absolutely should do so over Reliance on antipsychotics for delirium before first attempting non-pharmacologic strategies so there's a whole bunch of literature about this about how antipsychotics help delirium far less than we think that it does or they they do and in fact in some studies that show that antipsychotics may not even help delirium at all they are definitely harmful in the sense that they can cause ventricular arrhythmias uh through through QT prolonging effects and so they they can kill patients so antipsychotics for treatment of delirium in the elderly um I'm sorry particularly in the elderly but also in all patients um is is something that you should really try to avoid unless you've exhausted all other non-pharmacologic strategies when an outside Hospital transfers a patient and fails to include a discharge summary and this is particularly frustrating if they do include over 100 pages of nursing notes this seems like it should be a really easy problem to fix in the sense that if we get a transfer from you know Hospital X in the community transfers in one year that were lacking a discharge summary and I think it's perfectly legitimate for a hospital to say they're not going to accept transfers from another facility anymore because of the documentation that they've sent over has been inadequate I think that's 100 fine thing for the hospital to do routine overnight vitals and stable patients awaiting sniff transfer so if a patient is stable enough to go to a skilled nursing facility that is a nursing home they are stable enough to not wake them up at four in the morning for vital signs period now we're finally getting to our top 10 pet peeves getting into the home stretch here daily routine labs in stable patients um sales patients don't need routine Labs like don't do it like give the patients a lab holiday you know check Labs you know two or three times a week or once a week or stop all together if they're just waiting for a nursing home placement that's okay just because someone's in the hospital does not mean they have to get a CBC and a metabolic panel every single day uh number nine when an ecologist declines to consult on a patient with a high suspicion of malignancy until the malignancy is confirmed via pathology so uh oncologist please don't do this like I understand you don't want to waste your time on uh seeing a patient who doesn't end up having a tumor and I understand you don't want to scare a patient into thinking they have cancer by just showing up and announcing the oncologist if they end up not having a tumor but there's a lot of value to having an early oncology input there are many tests that we can we can order on a patient with a suspected malignancy that is not going to be super expensive but will expedite the subsequent decisions that are made sometimes primary teams also need to know like what actual biopsy we should get you know sometimes we need your help to determine to do biopsy the primary Mass you could biopsy the lymph node like does it make a difference this is patient even need a biopsy or can we assume that because they have a prior history of a different tumor that this is just recurrence of that tumor which I mean in short you shouldn't assume that but that might be a question a primary team has so you know if the primary team you know calls for an oncology consult don't reflexively decline it just because there's no final path report in the chart next placing a hospice patient on an unnecessarily restrictive diet you know and that but I don't mean necessarily just like like a low salt diet I mean things like you know uh nectar thick liquid semi-solid mechanical soft pureed etc etc you know my uh I've talked about this on this channel on a different video uh with my own father when he uh was on hospice he was on hospice for for five months about five years ago and you know he had Speech Pathology come by and realized he was an aspiration aspiration risk and they recommended that he be on a very restrictive diet I think you know pureed with thick and liquids or something like that and my dad didn't want to do that my dad wanted to eat what he wanted to eat and uh and he that was both consistency and with this and with you know uh with other aspects of his of his diet for example he you know he has a cardiac patient so you know they recommended low-fat diet Etc and you know he ate when he wanted to eat and he had like I think he had a McDonald's milkshake like literally every single day um for four months straight at least of those five months um but it did give him a lot more um I think it gave him a lot more pleasure in being able to eat what he wanted to eat in his final days so um someone's on hospice just let them eat whatever they want to eat it's okay fluent restricting patients with heart failure exacerbations there was a really great um thing we do for no reason article on the specific question that was done by some of my colleagues here at Stanford I'll put a link to that in the video description attempting and failing to control a diabetic's blood sugar with an instant I'm sorry with only an insulin sliding scale you know it's it's one thing if someone comes in and they're on like you know either their diet control diabetic or they're only on one oral medication and you want to have on a sliding scale just for a day or two to get an idea what their insulin needs might be you know that you know I don't know if I would advocate for that but I think it's okay strategy to do that but if it's like Hospital day number four and someone's blood sugars are consistently in the 200s or worse and they're still only on an insulin sliding scale like that's a major problem so that really shouldn't happen we flexibly repeating every patient's Kate to about four and information's magnesium to above two I don't know where I don't know how this started I wish I wish someone who was really into the history of of medicine hospital-based medicine uh like you know maybe Adam Rodman for example knows why this happens I don't know why this is so common where these numbers come from it feels like totally arbitrary made up um and it's not necessary you know so patients having active cardiac ischemia having active arrhythmias I think the consensus is that the strong professional consensus is that you should get those patients to a high normal K and potassium K and magnesium levels but for the average patient who's not having any arrhythmias whatsoever that's probably not necessary you know like low normal K low normal mag is actually okay when The Medalist and the discharge instructions men listen the discharge summary and the official outpatient medication list in the EMR all disagree this should not happen in 2023 the EMR should not allow this to happen it still dies I don't get it it's super frustrating it's really dangerous for patients because patients get home and they have like you know the list of medications they get from the pharmacy the actual pill bottles and they have the discharge instructions that they're given to when at the time of discharge and there's if they don't match that leads to a lot of of danger because patients don't know what to do and they're just gonna sometimes they'll call in and try to try to figure it out sometimes I just take a guess um and that's guess is sometimes wrong dosing narcotics less frequently than their duration of action uh you know a patient comes in with acute pain and they get put on you know oxycodone q12 oxycodone does not last 12 hours I don't know why people do this I don't know if it's because you're afraid of overdosing them you're afraid they're narcotic dependent or you're trying to wean them off and try to get them down off narcotics you keep spacing out the frequency um that's that's fine to a degree like you want to space out oxycodone Q2 to Q4 like okay that's that's fine but oxycodone does not last 12 hours you know like Dilaudid or Hydromorphone does not last 12 hours like don't space it out that infrequently all it's going to do is upset the patient their pain is not going to be well controlled it's going to frustrate the nurses um and there's no reason to do it we're getting really close here we are at the number two pet peeve of mine in the hospital it is PRN IV hydralazine um I know why people do this in the sense that like okay someone's you know it feels like it's a good medication to use for patients with um you know high blood pressures because it's it works fast the nurses usually have it on the floor ready to go people feel comfortable with it um why is PRN IV hydrology a bad idea well there's two little reasons one is it can actually work better than you wanted to it can actually bring patients blood pressure down too quickly um but the second is actually it's not necessary like the 99 of the time when someone's got appear in IV hydrology order it's written for asymptomatic hypertension and asymptomatic hypertension in the hospital is very uncommonly an issue like maybe if you have intracranial hemorrhage or maybe if someone's had recent neurosurgery you know maybe it's a different story and someone needs to be on you know PRN blood pressure medications but for someone that comes in for something completely unrelated to their blood pressure uh completely unrelated to you know the brain a stroke or neurosurgery not having aortic dissection you know they come in for like pneumonia they come in for cellulitis so they come in for pancreatitis and their blood pressure ends up being 170 over 90 you don't have to emergently treat that with IV medications like you can either just wait it out and see what happens you can either give them an oral medications a little bit sooner you can change their oral medications you can put them on a new oral medications if you think that the hypertension is going to be there to stay but there is almost never reason to give IV uh blood pressure lowering medications to a patient who is not having symptoms related to their hypertension it's just it's not a necessary thing to do before I reveal my number one pet peeve in medicine I'm going to discuss three dishonorable mentions these are certainly not the only three things that could fit here but they each represent a category of behaviors or aspects of the system that don't quite fit into this ranking system first are actions that I think are mistakes and are relatively common but which I don't get that frustrated by because I understand why people do them and the representative for this is prescribing Tramadol again I don't endorse the use of Tramadol I think it's not very effective it has a lot of side effects and notably it's a dirty drug owing to its multiple mechanisms of action multiple Pathways of active metabolites and overall unpredictable pharmacokinetics but I understand why people use it treating chronic severe chronic pain is challenging and I understand the appeal of something which is perceived to be stronger than over-the-counter options and supposedly non-addictive so I get it which is why it doesn't make it to my pet peeves list uh the second category are long-standing practices that have been overturned by data that is too reason to expect to have yet transformed everyone's management and the representative in this category is overly cautious up titration of goal-directed heart failure therapy following at admission for acute heart failure for decades a common Mantra on heart failure therapy was start low go slow with the idea that overly aggressive initiation and up titration of ACE inhibitors spironolactone and in particular beta blockers would lead to hypotension and readmission I think you know to be honest I think I may even have an older video on this channel which endorses this belief however there was a landmark trial on this topic called the strong HF trial the paper of which was published in Lancet in November 2022. there is some Nuance to this trial that I don't mean to brush over but in short the trial demonstrated that by nearly any measure of success rapid titration of heart failure medications was superior to the traditional gradual titration if I were to repeat this pet peeve list in five years which I won't but if I did I suspect this would be on it but for now this finding hasn't fully permeated into common practice yet and the last category of dishonorable mentions are the really big problems big picture problems that is that color the entire practice of Medicine I could easily represent this by saying the completely dysfunctional absurdly expensive for-profit American Health Care system however this spot instead is reserved for the legal scam that calls itself the American Board of internal medicine particularly but not solely due to its maintenance of certification program which is arguably legalized extortion kbim doesn't make the pet peeveless because it doesn't really affect my daily practice of medicine as much as it is something which causes a vague existential dread anytime I happen to think about it if you have no idea why the abim and Moc program are so awful I have links that explain the whole thing which now brings me to the number one spot on my pet peeves as a hospitalist notes in charts that are full of outdated and inaccurate copy and paste information and other meaningless garbage assumed to be required for building and coding or for monitoring quality improvement metrics if you are a physician or other Medical Professional you already know this but for everyone else in the United States the medical notes in your chart within the electronic health record are an atrocious mess I don't care if you are at Stanford or a Kaiser facility a VA Hospital some private secondary care hospital in a rural area or a large big city safety net Hospital documentary documentation is just it's flat out terrible everywhere in 20 years I have never seen the chart of a patient who has been in the hospital for at least 24 hours who did not have at least one error in their chart due to autofill templates and excessive copying and pasting of outdated information plus notes particularly discharge summaries are full of boilerplate text that is usually irrelevant to the patient at hand now this harms patients in two very notable ways first and most obviously inaccurate documentation is going to lead to errors in conclusions about what's going on with the patients and thus errors and management decisions but second the sheer volume of information on the screen is so great that important information what you actually care about is easily lost in the noise a typical discharge summary that a primary care doctor has five minutes to review before seeing a patient for Hospital follow-up visit can easily have 10 000 words of which only 500 to 1000 are actually relevant so five to ten percent of a massive document is useful to the PCP who is its most important audience irrespective of what insurance companies and the coding Department think and this is a solvable problem you know for one thing hospitals can revise or discharge summary templates to eliminate boilerplate text and the garbage that's necessary for the coding department and monitoring metrics should be in a separate document there is no logical reason that insurance and quality specific information needs to be bundled together with what's necessary for a patients outpatient doctors to understand what happened in the hospital and to provide appropriate follow-up care it just it makes no sense for this two completely different types of information to be interwoven into one document that is sub-optimally useful for both parties anyway so there you have it my list of one top 100 pet peeves like I said there's a lot of opinion in there and there's a lot of room for disagreement if you think I left out something notable let me know below

Channel: Strong Medicine

Views: 3,215

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Id: 0OOLMOdiBHU

Length: 45min 14sec (2714 seconds)

Published: Wed Aug 09 2023