True palliative care — the management of symptoms — is part and parcel of everyday medicine. Itching; nausea; constipation; pain. Work them up to make sure there is no serious underlying problem, of course, but for crying out loud, don't tell me you now need another specialist to actually come TREAT them! This is fragmentation of care taken to outrageous extremes.

As for talking to patients and families about difficult decisions when curative treatment is no longer an option, that too is part and parcel of my job. I do it every day in my office, and the only reason I don't come to the hospital to do it is because I can't get paid for it, and I can't afford to work for free.

So I must disagree partly with the Dinosaur.  While I agree that excellent primary care physicians and hospitalists can and should provide the same care that palliative care physicians provide, I still find palliative care very valuable.

What makes our palliative care physicians special?

First, they can take the necessary time to talk to the patient.  I am talking about at least an hour for an initial evaluation.  Our hospitals help support them to perform this function.

Second, they have ongoing relationships with all the relevant agencies, giving them the ability to pull things together much more seamlessly than I can.  They have the team, and the team has great value.

Third, we have an inpatient service that caters to palliative care patients.  The palliative care docs have worked with the nursing staff to encourage them to be comfortable with all the details of palliation.

Finally, they provide the home services that I could provide, but that I find difficult to provide.

Is this a specialty?  I consider that a moot question.  I would rather focus on the value that our palliative care physicians provide to our patients. 

Primary care physicians can do this, but probably not quite as well due to the time commitment involved.  I have done much palliative care during my career, but sometimes having that specialist involved does make a difference.

Related posts:

1. Dazed and Confused – Levels of primary care?
2. Picking a specialty – “what is the next hot field”
3. Must read article on primary care

This is old news.  Students love our rotations much more than they choose internal medicine. 

According to the 2010 National Resident Matching Program report, 2,722 U.S. seniors at medical schools enrolled in an internal medicine residency program, a 3.4 percent increase from 2,632 in 2009. The internal medicine enrollment numbers are similar to 2008 (2,660), 2007 (2,680), and 2006 (2,668). In comparison, 3,884 U.S. medical school graduates chose internal medicine residency programs in 1985.

So we should be honest and evaluate the problem.  Is internal medicine a poor career choice?  Is the material uninteresting?  Why do our graduates not choose internal medicine?

Dr. Weinberger sees the world clearly:

“Because it takes a minimum of three years of residency after four years of medical school to train an internist, it is critical to begin making careers in internal medicine attractive to young physicians,” said Dr. Weinberger. “As America's aging population increases and more people gain access to affordable coverage, the demand for general internists and other primary care doctors will drastically outpace the primary care physician supply.”

Increasing Medicaid and Medicare payments to primary care physicians, expanding pilot testing and implementation of patient-centered medical homes, and increasing support for primary care training programs are ways to increase the number of primary care physicians, according to ACP.

ACP remains concerned about the rising cost of medical education and the resulting financial burden on physicians who choose careers in internal medicine, Dr. Weinberger noted.

As I write repeatedly, we are getting the workforce that our payment system encourages.  We know that excellent internists decrease costs and increase quality, but they are shown no respect from private insurers and CMS. Those payers reward procedures out of proportion to pure cognition and patient relationship.  Those who do procedures certainly use cognition in addition to their procedures, but it appears to this observer that the payment for the procedure greatly outweighs the payment for excellent outpatient or inpatient care.

We can have the desired workforce if we made drastic and necessary changes.  If is a huge word, and therefore I remain skeptical.

Related posts:

1. Does IM training lead to decrease primary care selection?
2. The doctor shortage (hat tip to @FutureDocs and @efalchuk)
3. It’s the job – the only solution to primary care

I have a very short set piece concerning the indications for parathyroidectomy.  There are 2 indications in Primary Hyperthyroidism – symptoms related to the hypercalcemia – "stones, groans, moans and broken bones" or significantly decreased bone density.

I leave secondary hyperparathyroidism decisions to the nephrologists – perhaps a nephrology reader can send me a paragraph to add to this post.

Related posts:

1. Will biking hurt my bones?
2. Set pieces on rounds 1
3. Stage III CKD – when to refer

When pursuing a rate-control strategy in patients with "permanent" atrial fibrillation (AF), it's just as clinically effective and a good deal easier, for patient and doctor alike, to treat with beta blockers, calcium-channel blockers, and other agents until the resting heart rate is <110 bpm as to aim for <80 bpm, a prospective study suggests [1].

In the randomized Rate Control Efficacy in Permanent Atrial Fibrillation (RACE 2) trial, more patients were able to achieve the higher "lenient" heart-rate target than the lower "strict" target, and they required far fewer doctor visits. Yet symptoms attributable to AF and drug side effects were about as prevalent in one group as the other, and the lenient strategy was "noninferior" (p<0.001) to the strict approach for a composite primary end point that included CV death, heart-failure hospitalization, stroke, and other major events.

Actually there were more end points in the strict control group.

We live in an era in which we forget that medications carry impacts.  We focus too much on targets, too often ignoring the cost of reaching those targets.  A few examples should resonate with physician readers: tight glucose control in ICU patients; anemia in CKD; and now rate control in atrial fibrillation.

Too often we worry about numbers rather than patients.  This study should both guide our rate control targets in atrial fibrillation and remind us that treatments are rarely benign.  I welcome this study and its findings.  I will immediately adopt the findings. 

Related posts:

1. Atrial fibrillation – stick with rate control
2. Rate control
3. Chronic atrial fibrillation – rate control is more cost-effective

Pauline Chen has a wonderful article in the NY Times – Learning to Keep Patients Safe in a Culture of Fear.

In this article she writes about the problems we have in improving patient safety in hospitals. 

But a recent study indicates that current doctors-in-training may still be hesitant to document errors. Last month, The Joint Commission Journal on Quality and Patient Safety reported that the majority of residents have never written up an incident report. And according to a paper issued this week from a committee of leading experts in medical education and health care working with the Lucian Leape Institute of the National Patient Safety Foundation, young doctors are still going out into practice with little education or training in patient safety.

Changing a health care culture that undermines some of the most important principles of error reduction — trust, teamwork and communication — has proved to be much more difficult than a safety checklist would lead one to assume.

“Young doctors are being educated in a toxic culture,” said Dr. Lucian L. Leape, a leading patient safety expert at the Harvard School of Public Health who was chairman of the report’s committee. “The current environment is hierarchical, stressful for the individual, driven by the fee-for-service payment system and humiliating, all of which works against improving patient safety.” To ensure safer health care, doctors-in-training need time to reflect on their actions, a sense of community with colleagues and other health care workers, and the support to engage freely in disclosing errors.

Earlier this week the NEJM published a report on coronary angiography – Diagnostic Angiography Catches Few Cases of Obstructive CAD.

Now you are probably scratching your head now (if you are still reading this rant) and wondering how these 2 articles fit into one rant.  Here is my hypothesis:

I believe that our rampant subspecialization has led to physicians focusing too much on disease and not enough on patients.  As Osler reportedly said, "The good physician treats the disease; the great physician treats the patient who has the disease"

What has happened to medicine in the last 40 years?  We have had an explosion of knowledge acquisition, primarily funded through NIH.  NIH research focuses primarily on diseases and the biology of diseases.  We have had the development of huge subspecialty divisions in internal medicine (and pediatrics, and ob-gyn, and surgery, …).  These divisions have members who quickly focus on the diseases of that subspecialty and forsake their generalist training. 

The power structure in academics exists either through NIH funding or bringing in "business" due to one's expertise in a specific disease.  We have "product lines" in cancer, cardiology, liver disease, etc. 

The focus on disease unfortunately can take the focus away from the patient and the process of care.  The angiography example recalls the not funny joke that most non-cardiologists tell.  What is the indication for coronary angiography?  A groin (the catheterization starts in the femoral artery which is in the groin).

Those who focus on patient safety are considering the entire process of care, regardless of disease.  They rarely receive grant moneys.  They rarely get major publications.  They merely work hard to prevent tragedies by understanding either tragedies or near misses.

I submit that our focus on disease (btw this is just as bad in community hospitals as in academic medical centers) leads to the culture that does not focus on the entirety of patient care.

I recently heard a story about a patient on multiple medications with multiple physicians who had altered medical status.  One of the consultants insisted that his medications not be changed because he finally had the patient's disease under control.

Our job should focus on the patient and not the disease(s).  If we focused on patients then we would all embrace safety.  And we should.

Related posts:

1. More on safety and root cause analysis
2. Hospital safety and root cause analysis
3. Reform residency but intelligently

The patient is an 81 year old man found with altered mental status.  He has known diabetes mellitus, hypertension, COPD and CHF, but has not taken any medications for the past year.

Alb 3.1

ABG on 4 liters nasal oxygen

So please address these questions:

1. What is the acid-base disorder?

Great job here.  The patient has an increased anion gap – defining an increased anion gap metabolic acidosis.  Note that has expected gap is approximately 9 (quick rule of thumb – multiply the albumin by 3 to get the expected gap) with an observed gap of 25.  Thus his "delta gap" is 16.  Adding 16 to the measured bicarbonate of 21 we get 37.   Thus he starts with either a metabolic alkalosis or compensation for a respiratory acidosis.  Since he now hyperventilates I strongly favor metabolic alkalosis.  Finally, doing the Winter's equation his pCO2 is lower than expected.  Thus he does have a triple disorder – metabolic acidosis, metabolic alkalosis and respiratory alkalosis.

2.Provide a differential for the causes of the acid-base disorder?

Another great job.  We must exclude salicylates – any time you have an anion gap acidosis and respiratory alkalosis salicylates enter the differential.  He could have ketoacidosis or he could have lactic acidosis.  As I have written once before I prefer KILU to MUDPILES – An iatrogenic cause of increased anion gap acidosis.

Students find KILU easier to remember because it organizes anion gap acidosis into physiologic causes.

The metabolic alkalosis is usually secondary to volume contraction.  His BUN/creatinine ratio strongly supports that.

The respiratory alkalosis is puzzling.  We need more information.

3. What other information do you need?

1. Vital signs – he was relatively hypotensive – supporting severe volume contraction
2. Ketones, lactic acid and salicylate results – ketones negative, lactic acid high, salicylates negative

When presented this patient at morning report, I had this reasoning – diabetes untreated for a long time – leading to osmotic diuresis, severe volume contraction and the volume contraction causing both lactic acidosis and metabolic alkalosis. 

The team caring for him added that with volume expansion he revealed a septic picture, probably explaining his respiratory alkalosis.

If admitting this patient I would start with aggressive normal saline and low dose insulin.  He does have a free water deficit, but I must first restore his volume prior to addressing the free water deficit. 

Thanks for the comments.  You stimulate me to find more cases to present for your discussion.

Related posts:

1. AMS – an acid-base problem II
2. 17 days at the VA – day 12
3. AMS – an acid-base problem solution

I cannot answer every question about this patient, but I can answer some key questions.

Related posts:

1. Duty hours – no easy answers (h/t @FutureDocs)
2. 15 days at the VA – day 2
3. March 8, 2010 – an acid base challenge

Alb 3.1

ABG on 4 liters nasal oxygen

So please address these questions: 1. What is the acid-base disorder? 2.Provide a differential for the causes of the acid-base disorder? 3. What other information do you need?

Related posts:

1. My thoughts on March 8 acid-base
2. AMS an acid-base problem – part 1
3. A new acid-base problem

I appreciate the difficulties related to pain control in outpatients.  I did not mean to have my comments have any impact on any situations other than the specific one that I outline.

Related posts:

1. Pain control
2. Thoughts on accountability and quality
3. Does IM training lead to decrease primary care selection?

My palliative care colleagues have stressed that we should schedule pain control rather than provide "as needed" in those circumstances when patients will clearly have ongoing pain.  They taught me to write orders as scheduled with a may refuse provision.  More recently I have added a "do not awaken" clause from a couple of bad experiences.

When the patient really has pain, do not make them hit the button and wait for someone to bring them their pain medication.  What would you want for your pain control?
 

Related posts:

1. 17 days at the VA – day 9
2. Much ado about something important
3. Odynophagia