Primary Care Doctors View Comments
I used to be a primary care physician, but switched to being a hospitalist in 2007. I loved parts about being a PCP, namely the relationship that I developed with the patient over many years. I miss that. I think PCPs offer huge value in providing low cost, quality care, especially if they can stay engaged throughout the hospitalization process. Atul Gawande recently wrote a powerful article on the Hospice system. It's worth reading to being to understand the complex issues involved in end-of-life care, not to mention for the emotional storytelling that is his strength. But, to me, the unsung hero in that story was Chuck Morris, the primary care physician, who came in at the proper moment and provided perspective to the patient that he knew so well, allowing them to make the sane, yet horribly difficult decision to pursue a palliative path. Reading that made me miss primary care medicine a little. I perform much more actual "medical" work as a hospitalist than I ever did as a PCP. But, when I think of the concept of a doctor, in my head, I'm thinking of a primary care doc.
Hospitalist Notes 1 View Comments
My last night shift was a little less busy than most, so I forced myself to pick something about each patient I admitted and look it up. I tend to do this anyway, but I never keep notes or write about it. Here's what I wrote about that night:
Answer: No. The full report on Micromedex was a little conflicting, because it stated that there may be some withdrawal symptoms from Buspar, but this quote in the same profile suggests otherwise:
Data suggest that buspirone does not cause physical dependence and as such, no withdrawal effects have been noted (Rickels et al, 1988a; Tyrer et al, 1985; Cole et al, 1982).
I always forget the cutoffs for the stages of COPD. There are 2 different guidleines - GOLD and ATS/ARS, but fortunately they are almost identical:
Patients need to have an FEV1/FVC ratio < 0.70. Staging is then based on the FEV1.
Reference: Annals
We always put diabetic patients on an ADA diet and I choose the calorie level by gestalt. I figured there must be some formula to calculate the calorie level based on the patient's weight. Looking it up, I found a different answer altogether. The ADA no longer recommends an ADA diet in the hospital. Instead, they recommend a consistent-carbohydrate diet. In long-term care facilities (i.e. nursing homes), they go a step further and recommend a 'Regular' diet with consistency in the amount and timing of carbohydrate. They specifically state that there is no evidence to support the classic 'No concentrated sweets' diet. These guidelines are from 2007, but they obviously have not been widely disseminated yet.
It is recommended that the term “ADA diet” no longer be used, since the ADA no longer endorses a single nutrition prescription or percentages of macronutrients.
Reference: Diabetes Care
For the remaining 2 readers of kurup.org (one of them being me), let me apologize for the lack of posts here over the past couple years. I have always meant to write more, but most of my writing seems to consist of apologies for not writing, short bursts of writing, and then long stretches of inactivity. We are nearing the end of a long stretch of inactivity now, so it's time for the apologies.
A part of my apprehension has always been that someone will read my writing and laugh at how ridiculous I am. How could I possibly take myself seriously? Yes, I am quite self conscious. But, I figure that now that I've posted just about nothing for the past year, anyone left here is going to be pretty forgiving of what I write.
So, I hereby announce my plan to start writing blog posts again. I don't know what exactly I'll write about, but I don't think there will be much focus. Whatever I'm happening to think about will become the new focus of kurup.org.
Kavi is now 18 months old. He loves to sing, dance and make art. He has about 25 words that he says, although you have to be his father or mother to understand most of them. To my delight, he loves to sit in my lap just before bedtime and listen to me read stories. His favorite at the moment is a book called "We're Going on a Bear Hunt." It's a silly book that has a repeating theme with the words "Uh oh" and "Oh no!" at regular, predictable places in the story. And whenever I get to those words, Kavi sings them back to me as only a toddler can. "Uh ooooooooh!" and "Nu nooooo!". I'm actually going to miss these days once he's speaking coherently someday...
Work has been getting better. I've been at DRH for over a year now and I'm starting to feel more comfortable as a hospitalist. I have much more confidence in my gut feelings than I did a year ago. Medicine, however, is always humbling, so whenever you start feeling comfortable, you can almost guarantee that something is going to blindside you and make you re-evaluate your thought processes and assumptions. I had a case like that the other day, which I'm not going to go into at the moment, since it's too fresh and I haven't had time to figure out what lessons I need to learn from it yet. On the whole, though, I am feeling better about work. I've even volunteered to lead a project to institute online progress notes (Electronic Medical Records) at the hospital. This, to me, is scary. There are so many things that can go wrong with any computerization project in healthcare and this is one that I badly want to go right. If there are any people who have been through this process before, I would love to hear from you.
PS. Thanks Mark
Length of therapy with bisphosphonates View Comments
Sorry for another post linking to Journal Watch, but they really are doing a great job of reading my mind...
In my talk to the residents about osteoporosis, I mentioned that one of the unanswered questions is how long to treat patients with bisphosphonates. Well, a randomized trial published in JAMA says "5 years". Bone density in placebo-users decreased minimally and hip fracture risk stayed the same. Vertebral fracture risk increased, but vertebral fractures are much less significant than hip fractures. I'm sure more studies will be done, but it's reassuring to think that bisphosphonates may not be needed lifelong.
I remember telling people at a dinner party that I often entered symptoms into Google to help me diagnose patients. I remember them being apalled.
Turns out that Google is pretty accurate.