Vinod Kurup

Hospitalist/programmer in search of the meaning of life

SHM 2011

Here are some (unorganized) thoughts about my experience at the Society of Hospital Medicine (SHM) 2011 conference in Dallas, TX.

Opening Plenary

The initial presentation dissected the SHM Annual Compensation survey, discussing regional variations in pay and work effort over time. I understand the importance of that stuff, but ever since I got my first $638.36 paycheck as an intern, money hasn’t been an issue for me.

The second talk was by Bob Kocher, an Obama insider during the recent healthcare reformd. Gerry would have loved this one. He briefly described how a bill becomes a law… it apparently doesn’t follow the Schoolhouse Rock model anymore. At one point, reform looked dead, when the Catholic Nuns came out in favor of the legislation allowing multiple congress members to change their vote to “Yes”. As Kocher put it (paraphrasing), “When the Nuns broke with the Bishops, healthcare reform could move forward.” Doesn’t that seem like a statement that should be in a history book about medieval times, rather than a statement about 2010 United States politics? Maybe it’s just me…

Neurologic emergencies

The Neurologic emergencies talk was entertaining, though maybe more useful to an intensivist. David Likosky is hilarious in a geeky kind of way. A few things I learned:

Always maintain a good differential diagnosis and don’t jump to a conclusion too quickly. He described a case of an alcoholic who presented in coma and had dynamic pupils making a brainstem stroke the most likely diagnosis. A lot of time was spent to rule that out, and then his labs came back with a sugar of 13, indicating that the diagnosis of hypoglycemia was missed. He described some of the reasons that happened and I can see them happening to me. Never get fixated on a diagnosis, especially before you’ve made the proper initial evaluaation. A fingerstick glucose should always be done in a coma workup.

A few points on status epilepticus (SE)

  • Convulsive SE is a seizure that lasts more than 5 minutes, and is a medical emergency.
  • Lorazepam is probably better than Diazepam and don’t be afraid to use high doses (Start at 4 IV). We commonly underdose and underdosing hurts.
  • Nonconvulsive SE is considered as a medical urgency. A lot of patients have SE on EEG after convulsions have stopped and many have persistent subclinical seizures after SE is controlled. So, repeat the EEG, and consider transfer to a center that can do continuous EEG monitoring.
  • Absence seizures is really a diagnosis of children. (Not really about SE, but interesting)

Things to make you think that a CVA may be posterior circulation: Loss of consciousness, pupillary abnormalities, superhigh BP. Allow it to stay superhigh and keep the patient flat. Because posterior circulation strokes have such bad outcomes, it’s OK to intervene after the normal time window if there doesn’t seem to be any other hope.

Dermatology images (Paul Aronowitz)

When approaching a rash, ask 3 questions: Did the patient cause this rash? Did we do that to the patient? (Ask this twice). Is this rash a manifestation of some other disease? We often jump to the third question, but should consider the first two.

The snake bite risk factors are pretty interesting: - Male - Age 17-27 - Deliberate attempt to handle, harm or kill snake - Summer months - Alcohol intoxication - Tattoos

DRESS (Drug reaction with eosinophilia and systemic symptoms) usually occurs 2-6 weeks after the drug is started, but occurs quicker after rechallenge with the drug.

Reactive arthritis can be seen after Clostridium difficile infections.

20% of cases of Neisseria meningitidis do not have meningitis.

Poster presentations

The poster presentations are always fun to read, though if I see one more poster about the readmission problem, I will vomit.

Research Abstract Awards

The winning research abstracts were very interesting.

  • UCSF described changes that they made to meet new ACGME requirements while decreasing costs and improving certain quality measures.
  • Johns Hopkins hospitalists modified their CPOE system to show the costs of specific lab tests, hoping to change provider behavior. They were able to show that providers ordered less tests when they saw the cost. Duh, you say, but there is so little cost information available to providers, so this is innovative if only for that reason.

  • Hospitalists (in Colorado, I think?) used the Toyota Production System to model problems with current intern work schedules. They then reworked the schedule to minimize waste of resident resources, while improving continuity and resident satisfaction. They were able to basically eliminate moonlighter and jeopardy use. I didn’t understand the schedule because it was presented quickly, but I like the idea of taking a nonmedical thought approach and applying it to medicine. I also like that they optimized for continuity of care, so that after the intervention there was a huge increase in the amount of patients that were seen only by 1 intern during their stay. Very interesting!

SHM promotion

My attention faded during the award presentations and SHM motivational speeches, but Joseph Li, the incoming SHM president, did come clean and acknowledge that he was born outside the U.S., despite his lack of an accent. The birthers were right!

Geographic rounding

Emory Hospitalists then presented a talk which was titled ‘Utilizing Technology to Improve Clinical and Operational Performance of Hospitalists’ but it should really have been titled “Geographic Bedside Rounds: Just Do It!”. They did mention the IT improvements they’ve made to support geographic rounding, but the value of the talk was in describing how they implemented geographic rounding and how it has been received by the involved parties. Moving to geographic rounding helps providers the least. It’s basically an addition to our workload. On the other hand, patients, nurses, and social workers get a lot of benefit and obviously, the patients are the most important factor here. We will have to see the patient more than once and our workflow will have to change, but it seems that the benefits outweigh the extra costs to the individual provider. Paraphrased, “Nurses and social workers would riot if we stopped this system, but even hospitalists wouldn’t want to go back to the old way, if put to a referendum.” Something that only came out in the post-talk questions was how this has improved overall teamwork. They used to have a complicated system about how new admissions were assigned, taking into account census numbers, discharge numbers, and other factors. Now, with the new system, there are days that one hospitalist will have completely unequal numbers or new patients than another hospitalist, but it is understood that things will even out over time. That has encouraged hospitalists to stop focusing on numbers and instead to focus on making things run better, so hospitalists who were previously “anti-teamwork” are now offering to help out when they’re done with their work. Anecdotal, but I like stories like that.

They also mentioned that they created a video dramatization of their bedside rounds. If I can find it, I will link to it.

Updates in Hospital Medicine

  • Oral prednisone 60 mg daily as good as 600 mg IV for COPD exacerbation (Presented at DRH Journal club)
  • OK to extend peripheral IVs rather than change routinely (Emailed to me by DRH Hospitalist)
  • Getting appts for COPD exacerbation pts within 30 days may decrease rehospitalization (duh!)
  • Benefit for tPA in stroke up to 4.5 hours, but earlier is better (DRH Journal club)
  • Gurgling sounds predict pneumonia and ICU transfer (duh)
  • Routine ID consultation in Staph aureus bacteremia significantly improves mortality (HR 0.44) (NEW TO ME)
  • Coagulopathy in liver disease doesn’t protect against VTE (duh)
  • Metformin does not cause lactic acidosis (old news, but nice to be data-supported now)
  • Enteral nutrition better than TPN in pancreatitis (DRH email/conversations)
  • In ICU palliative care situations, only 47% of family members based their survival estimates on MD’s prognosis advice.

I skipped the ICU stuff. Only one of these updates was new to me (listed as NEW in the list above). I attribute that to my colleagues at Durham Regional who have been sharing the knowledge that they’ve been collecting from various meetings and readings this year.

Careers in Academic Medicine

This was a workshop on how to pursue your ideal life in academic medicine. I loved the energy and enthusiasm of the instructors. This probably would’ve benefited from being a longer course with fewer, more involved participants. The basic premise was to document what exactly you are doing now, what you’re getting paid to do, and what you enjoy doing. Reconcile the differences in those 3 lists and try to identify how to make them match.

No wireless

This would have been posted a lot earlier if I could ever get on the SHM wireless network at the Gaylord Convention Center. “Please wait. You will be redirected to the authentication page in 5 seconds.” You lie!