35-year-old man admitted for worsening ascites. We know the patient because he had just left AMA 3 days before.  He had HIV with a low CD4 and did not take any anti-retrovirals.  He also had hep C cirrhosis with encephalopathy and worsening ascites.  He did take spironolactone and lactulose and the lactulose was causing diarrhea.

We go to the ED and find these labs:

I ask the team why the bicarbonate is low.  I presented this a morning report also and asked students, housestaff and applicants!

I looked at the old labs and this bicarbonate level was present on the previous admission and had remained stable.  What do you think?

Regularly readers know that I am currently fascinated with Gary Klein's work.  I am currently writing a discussion for a clinical problem solving exercise.  Using Klein's work, I learned the value of mental simulation that he labels a "pre-mortem" examination.  

After we see the results of a decision, we often engage in a "post-mortem".  Klein observed that many experts subject their intuitive plan to a "pre-mortem".  They engage in a mental simulation (or sometimes a team discussion) to imagine what outcomes the decision plan could have.

Many physicians have actually heard of this as many excellent teachers challenge us to imagine the "worst case" scenario.  We should consider the most dangerous situation that the patient's presentation might represent.

This mental simulation technique tells us that we might need to "slow down" in our decision making process.  It often makes more clear data that we must try to obtain.

While I can convince myself that I have understand this approach, perhaps I have not done this often enough in a formal way.  So I present this idea to you for your consideration and comments.

Throughout my career I have worked as a medical school faculty member.  I took my first job with the naive belief that my main job involved teaching medical students and residents.  Over the years I have learned that those who do this job extremely well still may not advance, unless they do the other things like scholarly activity, research grants or clinical income.

This book review caught my eye this morning - The University Of Adam Smith – a book that makes the case for "for-profit" higher education.  While I am not sure about the conclusion, the reviewer makes the case for changing our priorities:

About halfway through "Change.edu," Andrew Rosen relates a story from a consultant who was hired by a small private college to help it implement the once-trendy concept of Total Quality Management. The consultant began by asking the school's administrators and staff a question: "Who is your customer?" The provost said that "basically everyone is our customer." Two of the school's deans named "the faculty" as their main customer. The college president picked "the trustees." The faculty itself found the word "customer" offensive. The consultant was eventually fired.

Mr. Rosen, who is chief executive of Kaplan Inc., one of the largest for-profit higher-education providers in the country, has a way with an anecdote, and "Change.edu" is a lively read thanks to his in-person interviews and firsthand reporting at colleges across the country. As the customer-related anecdote suggests, one of the book's themes is that most colleges and universities have trouble identifying exactly whom they are trying to please and thus what exactly they are supposed to be doing.

And little wonder—think only of the tangled network of income sources and self-interested constituencies that vie for the attention of a college administrator. There are of course students and the parents who pay the tuition bill. There are taxpayers, who underwrite college subsidies in one form or another (including research grants and financial aid). There are alumni, whose donations are a key to university solvency. There are even sports fans, whose enthusiasm plays no small role in college branding and consumer appeal.

Unfortunately, this mix of financial imperatives can lead colleges to focus too little on what students are learning in the classroom. Money and effort, instead, go to moving up the prestige ladder, often by enhancing "selectivity." In a chapter called "Harvard Envy," Mr. Rosen notes: "Under the existing rules of higher education, a college is defined as 'better' by turning away more potential students—no different than a nightclub that's 'hot' because its system of bouncers and velvet ropes leaves a critical mass of people on the outside, noses pressed to the glass."

The book's author makes the case for truly for-profit education.  I would rather challenge higher education to reconsider their priorities.  We owe much to our students and we forget that at great peril.

We who work in hospitals know that most hospitals do not work as well on weekends as during the week.  I have worked at several hospitals over the years, and every hospital is understaffed on weekends.

Patients 'more likely to die' if admitted at weekends

The study, in the Journal of the Royal Society of Medicine, found that patients were 16% more likely to die if they were admitted on a Sunday than mid-week.

The review looked at all admissions to NHS hospitals in England in one year.

The NHS medical director has called for weekend services to be extended.

The research was carried out at University College London and the universities of Birmingham and East Anglia, and covered more than 14 million hospital admissions – both emergency and planned.

The study looked at more than 187,300 patients who died within 30 days of being admitted to hospital during 2009-10.

The researchers found higher death rates if patients went in at the weekend, but a slightly lower death rate if people were already in hospital at the weekend.

For every 100 deaths following admissions on a Wednesday, 116 occurred for admissions on a Sunday – a "significant increased risk", the researchers said.

We can speculate why.  But the data do not provide a clear answer.

When I round on weekends, I note that we must wait until Monday for many tests or consults.  We have good coverage from nurses, but radiology, nuclear medicine, etc are insufficiently staffed.  Consults are slower, because we have one person covering the work of several.

Perhaps the bias is due to patients not coming to the emergency department on weekends unless they are more ill.  Perhaps it is not a hospital staffing issue, but rather a patient selection issue.

Regardless, the study presents an interesting finding.  Do you believe the study?  What do you believe are the many reasons for the finding?

Early in my academic career I became fascinated with decision analysis.  I still like decision analysis as a strategy to make explicit the structure of a problem.  However, over time the major weakness of decision analysis became very clear.  The problem derives from the assumptions.

As usual, I will use pharyngitis to frame the problem.  Most articles and all the guidelines make the assumption that we can dichotomize pharyngitis into group A strep pharyngitis or "viral".  The problem here is that the assumption is wrong.

The assumption states implicitly that only group A strep pharyngitis requires antibiotic therapy.  This assumption might work for pre-adolescents, but in adolescents and young adults group C deserves treatment and as I write repeatedly, fusobacterium pharyngitis deserves treatment.

The assumption really explains the difference between the 2 US guidelines.  It explains many attempts to decrease antibiotic use by only treating rapid test positive sore throat patients.  

The authors of these papers also make the assumption that the rapid test is highly accurate.  That assumption may not work either.  Recent data, cited in this blog, call the quoted sensitivity of 90% or greater into question.

When caring for patients, we must always question our own assumptions and the assumptions of other physicians.  We owe our patients great skepticism.  When we take implicit assumptions and make them explicit, we are more likely to challenge the assumptions and adjust our thinking about the patient (or the clinical condition).

Euclid taught me that without assumptions there is no proof. Therefore, in any argument, examine the assumptions. – E. T. Bell
 

This week my team presented a patient who had puzzled them.  The patient complained of 3 weeks of facial swelling.  She had diabetes mellitus type II with severe gastroparesis.  She had both a feeding tube and a port (she used the port for saline boluses when she became volume contracted).

She had gone to several other hospitals and seen more than 5 physicians.  They had made a diagnosis of community acquired pneumonia and given antibiotics.

She came to us still complaining of a cough and chest pain, but mostly complaining of facial swelling and a hoarse voice.

As I listened to the story, I was confused (perhaps because the presenter seemed confused).  We looked at the CXR and suddenly I knew the answer.  My intuition took over.  

I then proceeded to read about my proposed diagnosis prior to going to the bedside.  

At that point I was not considering a differential diagnosis, because I did not feel that I needed system 2 thinking.

I hope you know the diagnosis by now.  If not I will provide some more clues.

At the bedside the patient had a diffusely swollen face and a hoarse voice.  Her neck was too swollen to evaluate her jugular veins.  Her hands and arms were also swollen.

I look at her feet and they were no swollen at all.

We confirmed the diagnosis that afternoon.

I never left system 1 thinking.  Like Klein explains, I just knew the answer.  I had not personally seen this entity in many years, but yet I knew the diagnosis.

Knowing the answer is not enough as Klein explains.  We must also think through the diagnosis and careful examine that diagnosis for potential flaws.  As I considered the diagnosis, I could not find flaws, but rather found increasing evidence to support the diagnosis.

This process of naturalistic decision making likely better explains most of our decision making in medicine.  

When discussing cognition intuition does not refer to ESP, rather definition #3 in dictionary.com - a keen and quick insight. 

Physicians use this form of intuition often.  We learn patterns and use pattern recognition to make quick diagnoses and decisions.  Sometimes we call these patterns "illness scripts".

One can easily argue that experts develop more refined illness scripts over time.  Given these more refined scripts, experts can continue with system1 thinking unless the script is not totally satisfied.  Incomplete scripts or red flags lead experts to switch to system 2 thinking.

Currently I am expanding my understanding of these phenomenon focusing on the work of Gary Klein.  The link takes you to a long overview of his work in Naturalistic Decision Making.  He studies experts who have to make quick decisions, like fireman.  He describes his big break:

Then in 1984, a notice came out from the Army Research Institute asking for proposals about how people make life and death decisions under extreme time pressure and uncertainty.

What he describes runs counter to my previous understanding.  Decision makers under pressure (like physicians) intuitively pick one diagnosis, and then start mentally testing it against their illness script.  If the match raises questions, then they look for an alternate diagnosis.

Experts do not always generate a long list of potential diagnoses.  They only do this when the intuitive process tells them that this problem is too complex for an intuitive answer.

As I read more about this approach, the relevance to internal medicine and family medicine are becoming very clear.  We who teach need to learn to describe our illness scripts.  We need to make explicit the red flags or omissions that make us reject an intuitive diagnosis.  Only through an explicit understanding of a trainees illness script and that script's deficiencies can we help them develop a more advanced script.

I like how Klein describes the process:

That became part of our model — the question of how people with experience build up a repertoire of patterns so that they can immediately identify, classify, and categorize situations, and have a rapid impulse about what to do. Not just what to do, but they're framing the situation, and their frame is telling them what are the important cues. That's why they're always looking, or usually looking, in the right place. They know what to ignore, and what they have to watch carefully.

It's telling them what to expect, and so that's why performance of experts is smoother than the performance of novices, because they're not just doing the current job, they know what to expect next, so they're getting ready for that. It's telling them what are the relevant goals so that they can choose accordingly. 

Time to share a frustration.  While some diseases and symtoms have clear causes, not all do.  If you smoke for 30 years, 2 packs a day, and develop COPD, or coronary artery disease, or lung cancer, then I know why.  If you drink 2 pints of vodka daily and develop cirrhosis, I likely know why.  

If you are promiscuous, or use IV drugs, and develop HIV, I can explain why.

But often I cannot explain why someone develops a disease.  As a physician I have learned that some problems remind me of the old Beach Boys' song – "God Only Knows".

Many patients cannot accept that explanation.  They KNOW that they have a disease because of something they ate (or did not eat).  They are mystified that suddenly they have an illness.  So here is my secret – often we too are mystified.

My advice to patients, if your physician does not have a clear explanation of your disease's origin, then perhaps the origin is not known in 2012.  Maybe in 2020 we can answer the question.

We know more than we did when I started my career.  We now know that most duodenal ulcers arise because of an infection with Helicobacterium pylori.  We now know that cervical cancer follow Human Papilloma Virus infection, that is spread through sexual contact.

Please be patient with us.  We do not have all the answers.  If we say we do not know, please do not ask us probing questions.  We hate saying that we do not know, but sometimes that is just the truth.

Bravo!  As regular readers know, ACP is championing high value, cost conscious care.  Browsing some blogs today I find that the American Journal of Medicine has started a new feature that physicians should consider when trying to provide HVCCC.  Here is the editorial introducing this new feature - Diagnostic Imaging: Powerful, Indispensable, and Out of Control

Today marks the inauguration of a new quarterly venue in The American Journal of Medicine, focusing on Diagnostic Imaging and a wide range of imaging issues germane to the practice of clinical internal medicine. We intend to bring you articles outlining appropriate utilization parameters for different modalities and disease entities; clinical research articles identifying the causes, effects, and costs of suboptimal imaging strategies; cost-benefit analyses of various imaging strategies, and global overviews of the economics of imaging in both the hospital and outpatient settings. Our aim is to educate and inform. More importantly, we hope to initiate an earnest dialogue in the internal medicine community about the proper role of various imaging modalities in clinical practice and begin to understand how we can best approach problems that are well known, easily identifiable, but not yet properly addressed.

So we must congratulate the "green journal" for this important undertaking.  The secret to slowing down and even reversing the continuing increases in health costs will require many interventions.  We must use diagnostic tests more intelligently.  We must use less expensive pharmaceuticals when possible.  We should try to use less prescription meds.  We can only make a difference in health care costs if we pay attention to all these issues and more.

The "green journal' has made an important statement with the release of this feature.  The first entry tells us that we are likely too quick to order repeat abdominal CT scans - 

Dr Ivan Ip et al directly approach the specifics of over-utilization by analyzing the parameters of rapidly increasing repeat abdominal imaging, highlighting the complexity of the larger issues by focusing on one small component, and thereby demonstrating the multifactorial approach that will be needed to address all aspects of this seemingly inexorable problem.

So read the articles and look forward to further entries in this series.

Several readers nailed this one – valproic acid (Depakote).  Valproic acid does cause hyperammonemia

This syndrome can occur with overdoses, but can also occur on apparently stable dosing.