Discover and read the best of Twitter Threads about #unclebob
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1/ #UncleBob - on giving formative feedback on rounds. First, make it clear in your expectations discussion (day 1) that you will critique many things and label them as feedback. #MedEd @CPSolvers @uabimres
2/ Especially with new presentations, stop after the HPI and both praise the story and provide suggestions on making the presentation better. Emphasize the role of storytelling as separate from having taken a good history.
3/ Understand that when you ask questions - some are hard and some are easy. When a learner answers a hard question well - praise them and note that you are giving positive feedback.
1/Time for a #UncleBob screed. The question Andrew raises is a very interesting one. First I must provide my understanding of the purpose of teaching ward attending physicians.
I divide this into providing excellent patient care & helping learners grow.
I divide this into providing excellent patient care & helping learners grow.
2/ Providing high quality care is a given. Excellent ward attendings evolve with clinical practice (consider the 10,000 hour "rule"). But I would argue that both outpatient clinical practice and inpatient practice are beneficial.
3/ And I believe I learn more in a month of ward attending than if I did a month of solo patient care. Patient care requires attention to detail, diagnostic excellence, management efficiency and proper use of tests and consultants.
1/ #UncleBob recently presented a patient who had a hyperkalemia, normal gap acidosis (type 4 RTA) to @DxRxEdu & @rabihmgeha
But why does hyperkalemia cause a normal gap acidosis?
@tony_breu
But why does hyperkalemia cause a normal gap acidosis?
@tony_breu
2/ Some basic physiology - we metabolize around 1 mEq of H+ daily from our diet. We buffer that acid using titratable (phosphate) and non-titratable (NH4+) acids.
The phosphate pathway does not vary much, but our kidneys can normally control the ammonium pathway
The phosphate pathway does not vary much, but our kidneys can normally control the ammonium pathway
3/ Where does the ammonia come from? Glutamine -> glutamate under the enzyme glutaminase produces NH3
Here is the interesting part. Increased K inhibits this enzyme, thus we produce insufficient NH3 to buffer our dietary intake.
Here is the interesting part. Increased K inhibits this enzyme, thus we produce insufficient NH3 to buffer our dietary intake.
#UncleBob posted this link yesterday. Here are a few thoughts on the article. “I don’t know what’s the matter with people: they don’t learn by understanding; they learn by some other way—by rote or something. Their knowledge is so fragile!”
— Richard Feynman
Reminds me of M1&2
— Richard Feynman
Reminds me of M1&2
"The difference between reasoning by first principles and reasoning by analogy is like the difference between being a chef and being a cook. If the cook lost the recipe, he’d be screwed."
This is so relevant to those who grow and those who stagnate.
This is so relevant to those who grow and those who stagnate.
"Some of us are naturally skeptical of what we’re told. Maybe it doesn’t match up to our experiences. Maybe it’s something that used to be true but isn’t true anymore. And maybe we just think very differently about something." - The best diagnosticians always question previous dx
1/ #UncleBob hopes those on the fence about vaccines will understand this
Weekly COVID-19 death rate via CDC:
Unvaccinated: 9.7 deaths per 100k
Fully vaccinated: 0.7 deaths per 100k
Boosted: 0.1 deaths per 100k
Weekly COVID-19 death rate via CDC:
Unvaccinated: 9.7 deaths per 100k
Fully vaccinated: 0.7 deaths per 100k
Boosted: 0.1 deaths per 100k
2/ Yes you can get omicron even if you are boosted
BUT
You are less likely to get infected
If you get infected you are much less likely to need hospitalization
If you need hospitalization, you are much less likely to need ICU care, and MUCH less likely to die
BUT
You are less likely to get infected
If you get infected you are much less likely to need hospitalization
If you need hospitalization, you are much less likely to need ICU care, and MUCH less likely to die
3/ Would you turn down medical care if you got sick?
I assume no - almost everyone comes to the hospital and ask for everything
Then why would you not accept a free prevention tool?
I assume no - almost everyone comes to the hospital and ask for everything
Then why would you not accept a free prevention tool?
1/ #UncleBob has tips for newly minted clinician-educators. Today I will focus on teaching how to take and present the history. #MedEd
@uabimres @UABGIM @SocietyGIM @ACPinternists
@uabimres @UABGIM @SocietyGIM @ACPinternists
2/ Learn to define and expand patient words - e.g., diarrhea (how often, what color, interfere with sleep, etc.). Patients describe things in words they understand, but often we interpret those words differently. Many such examples: chest pain, dyspnea, weakness, SOB, PND
3/ Try to understand the chronology and use that during presentation. This requires careful questioning so that the learner really understands the chronology.
1/ #UncleBob has many thoughts about this tragic tale of diagnostic errors!
@UAB_ID @uabimres @acp @sgim @BradSpellberg @PaulSaxMD @AnaerobeSociety
Hard to Swallow | NEJM nejm.org/doi/full/10.10…
@UAB_ID @uabimres @acp @sgim @BradSpellberg @PaulSaxMD @AnaerobeSociety
Hard to Swallow | NEJM nejm.org/doi/full/10.10…
2/ In the very first aliquot we learn that we have a college student with throat pain and chills. We do not know if they were simple chills or rigors. This is actually a BIG DEAL. Rigors (shaking chills) have a high odds ratio for bacteremia.
3/ If she really had rigors, then she needed blood cultures and admission for likely bacteremia. Interesting that she had unilateral tonsillar swelling. I have only seen this once in a patient with Fusobacterium tonsillitis with bacteremia! No data, just an observation
1/ #UncleBob started medical school 50 years ago. Medicine is always progressing. Here are some things we did not have:
Diseases: HIV, Lyme, Takasabu, MRSA
infectious disease Medications: Only 1st generation cephalosporins, no fluoroquinolones, a variety of MRSA drugs, etc.
Diseases: HIV, Lyme, Takasabu, MRSA
infectious disease Medications: Only 1st generation cephalosporins, no fluoroquinolones, a variety of MRSA drugs, etc.
2/Treatment for HFrEF - first study of decreasing mortality in the 80s, no ACE-I, ARB, beta-blockers, neprolysin inhibitors, Calcium channel blockers
No interventional cardiology - CABG or nothing
M-mode Echo was in its infancy - no 2D echo
No nuclear medicine stress testing
No interventional cardiology - CABG or nothing
M-mode Echo was in its infancy - no 2D echo
No nuclear medicine stress testing
3/ No home oxygen, no home IV infusions
No CT scanning, very little ultrasound (clearly in its infancy), no MRI, no PET
Limited endoscopy and colonoscopy
No "scopic" surgeries - think laparoscopic, arthroscopic, etc
I cannot even describe cancer chemotherapy
No CT scanning, very little ultrasound (clearly in its infancy), no MRI, no PET
Limited endoscopy and colonoscopy
No "scopic" surgeries - think laparoscopic, arthroscopic, etc
I cannot even describe cancer chemotherapy
1/ #UncleBob is working to better understand hepcidin. Please critique this so that we can have a better understanding.
Hepcidin is a peptide hormone. Its main function is the regulator of iron entry into the circulation
Hepcidin is a peptide hormone. Its main function is the regulator of iron entry into the circulation
2/ As hepcidin levels increase, iron transport into the circulation decreases. It does this by binding to ferroportin - the transport channel.
Thus - decreased dietary iron absorption. It also leads to iron sequestration in macrophages.
Thus - decreased dietary iron absorption. It also leads to iron sequestration in macrophages.
3/ Why should we care? IL-6 (a proinflammatory cytokine) stimulates hepcidin. Thus the anemia of chronic inflammation results from increased hepcidin which in turn makes iron less available to the bone marrow.
1/ So what is GFR? Glomerular Filtration Rate - how much blood do the kidneys filter per minute
Perfect mGFR -> stable measurable molecule that is perfectly filtered and neither reabsorbed nor secreted
Perfect mGFR -> stable measurable molecule that is perfectly filtered and neither reabsorbed nor secreted
2/ mGFR continued
Measure the plasma value of the molecule and measure the quantity in urine over a specific number of minutes.
Clearance formula - (Um*V/time)/Pm
Since Um is cc and V/time (# of minutes)
The result is cc/ min.
Measure the plasma value of the molecule and measure the quantity in urine over a specific number of minutes.
Clearance formula - (Um*V/time)/Pm
Since Um is cc and V/time (# of minutes)
The result is cc/ min.
1/ #UncleBob asks you to consider the implications of the famous Nietzsche quote, “There are no facts, only interpretations” These tweets inspired by following @VPrasadMDMPH
We all interpret data differently weighing the risks & benefits.
We all interpret data differently weighing the risks & benefits.
2/ How else can one explain competing guidelines? Committees look at the same data and make different recommendations. This is the potential flaw in "evidence based medicine".
Confirmation bias influences all these decisions.
Confirmation bias influences all these decisions.
3/ The critical care community developed a very aggressive guideline for early treatment of possible sepsis. The ID community left the joint committee and wrote a strong editorial about the risk of over use of antibiotics secondary to this guideline.
#UncleBob is a huge @UVA basketball fan and very proud of our coach Tony Bennett. He took these 5 pillars of our program from his dad (also a great basketball coach. These are very applicable to #MedEd# . ,.,. .
#UncleBob is a huge @uva basketball fan. Our coach, Tony Bennett learned this 5 pillars from his dad (also a great coach). I believe they will resonate with great educators
@UABGIM @CPSolvers @gradydoctor @DxRxEdu @rabihmgeha @andrewolsonmd @LisaWillett13 #MedEd
@UABGIM @CPSolvers @gradydoctor @DxRxEdu @rabihmgeha @andrewolsonmd @LisaWillett13 #MedEd
1/ HUMILITY: KNOW WHO WE ARE
Never overestimate our abilities, but do not underestimate them either. Humility is not modesty, rather it involves knowing who you are and never pretending to be more. Avoid narcissism.
Never overestimate our abilities, but do not underestimate them either. Humility is not modesty, rather it involves knowing who you are and never pretending to be more. Avoid narcissism.
1/
[How] does aminoglycoside hypomagnesemia?
I've long assumed that aminoglycoside's primary toxicities are nephrotoxicity, ototoxicity, and neuromuscular blockade.
we know a little about potential Electrolyte abnormalities
ARE you ready for a #tweetorial?🧵
#medtwitter
[How] does aminoglycoside hypomagnesemia?
I've long assumed that aminoglycoside's primary toxicities are nephrotoxicity, ototoxicity, and neuromuscular blockade.
we know a little about potential Electrolyte abnormalities
ARE you ready for a #tweetorial?🧵
#medtwitter
2/
First, a question.
Which of the following isn't characteristic of the Electrolyte abnormalities caused by aminoglycosides ? #MedEd
First, a question.
Which of the following isn't characteristic of the Electrolyte abnormalities caused by aminoglycosides ? #MedEd
3/
-Aminoglycoside antibiotics are very effective in the treatment of gram‐negative organisms🦠
-The pathogenesis of aminoglycoside‐induced nephrotoxicity is well documented (Tulkens, 1989; Kacew, 1990).
-Aminoglycoside antibiotics are very effective in the treatment of gram‐negative organisms🦠
-The pathogenesis of aminoglycoside‐induced nephrotoxicity is well documented (Tulkens, 1989; Kacew, 1990).
1/ The classic presentation at morning report for hypercalcemia starts with polyuria, constipation and confusion. #UncleBob wanted to understand why - stimulated by @CuriousClinPod ? @HannahRAbrams @tony_breu @AvrahamCooperMD
2/ Let's start with confusion. Finding information on this is very non-specific but I think this quote helps: High calcium levels can be a catalyst for neuronal demise, possibly due to glutaminergic excitotoxicity and dopaminergic and serotonergic dysfunction.
3/ But colleagues and learners know that I am most interested in the polyuria. I have taught that hypercalcemia can cause nephrogenic diabetes insipidus, but the mechanism was unclear. Let's review how ADH works and then look at an interesting study that suggests an answer.
1/ #UncleBob on treating metabolic acidosis. First, get this article:
Sabatini, S., Kurtzman, N. (2009). Bicarbonate Therapy in Severe Metabolic Acidosis JASN 20(4), 692-695. dx.doi.org/10.1681/asn.20…
@UnremarkableLab @kidney_boy @hswapnil @CPSolvers
@uabimres @UAB_NRTC
Sabatini, S., Kurtzman, N. (2009). Bicarbonate Therapy in Severe Metabolic Acidosis JASN 20(4), 692-695. dx.doi.org/10.1681/asn.20…
@UnremarkableLab @kidney_boy @hswapnil @CPSolvers
@uabimres @UAB_NRTC
2/ Here is the quick chalk talk.
For increased anion gap metabolic acidosis, treat the underlying cause. Do not give bicarbonate unless you have an extraordinarily low pH (debate whether this is < 7.2 or 7.1 or 7. And with DKA, NEVER.
For increased anion gap metabolic acidosis, treat the underlying cause. Do not give bicarbonate unless you have an extraordinarily low pH (debate whether this is < 7.2 or 7.1 or 7. And with DKA, NEVER.
3/ For normal gap metabolic acidosis ALWAYS give bicarbonate with a goal of ~ 22 for the bicarbonate.
How?
Estimate bicarbonate deficit = 22 - current bicarb
Multiply by bicarbonate space = TBW = 50% wt in kg (+/- 10%)
How?
Estimate bicarbonate deficit = 22 - current bicarb
Multiply by bicarbonate space = TBW = 50% wt in kg (+/- 10%)
1/ Thoughts on presenting on rounds #UncleBob - #5goodminutes
This is how I do rounds - would love questions and critiques.
I explain my expectations the first day on the service.
@WrayCharles @LisaWillett13 @iMedEducation #MedEd @ShreyaTrivediMD @AdamRodmanMD
This is how I do rounds - would love questions and critiques.
I explain my expectations the first day on the service.
@WrayCharles @LisaWillett13 @iMedEducation #MedEd @ShreyaTrivediMD @AdamRodmanMD
2/ New patient presentations:
Deliver a succinct HPI - start with chief complaint - insert RELEVANT PMH as desired. Tell the story chronologically if possible. Include related review of systems, social history, health behavior history, medication list as pertinent.
Deliver a succinct HPI - start with chief complaint - insert RELEVANT PMH as desired. Tell the story chronologically if possible. Include related review of systems, social history, health behavior history, medication list as pertinent.
3/ Stop after HPI and we will discuss the HPI. The goal of the discussion is to improve how each learner tells the story. The goal is complete, yet succinct. Don't give too much information. Avoid redundancy. We call this discussion IMMEDIATE FEEDBACK.
1/ #UncleBob - how I use the delta gap. Hopefully worth #5goodminutes
@UnremarkableLab
Here is the idea - we have an increased anion gap and want to see if the patient also has either a normal gap metabolic acidosis or metabolic alkalosis. Here are the assumptions:
@UnremarkableLab
Here is the idea - we have an increased anion gap and want to see if the patient also has either a normal gap metabolic acidosis or metabolic alkalosis. Here are the assumptions:
2/ Expected gap = 11 - 2.5*(albumin -4) but that is hard to remember, so we use a reasonable approximation = albumin * 3.
Example, patient has an albumin of 2.3 so we expect a gap of 7.
Example, patient has an albumin of 2.3 so we expect a gap of 7.
3/ Second assumption - the increased anion gap has replaced bicarbonate. - thus treating the gap will restore bicarbonate
2 examples to follow:
2 examples to follow:
1/
#UncleBob was puzzled last night by a very low A-a gradient during an @UnremarkableLab session
Patient had a pCO2 of 55 and pO2 of 76 which calculates as a gradient of 5. That is probably impossible so something must be off.
@anandiyermd @DxRxEdu
#UncleBob was puzzled last night by a very low A-a gradient during an @UnremarkableLab session
Patient had a pCO2 of 55 and pO2 of 76 which calculates as a gradient of 5. That is probably impossible so something must be off.
@anandiyermd @DxRxEdu
2/ Two numbers in the A-a gradient are variable: atmospheric pressure and RQ. The atmospheric pressure in Birmingham is around 745 rather than the 760 we normally use. If you plug that into the equation the A-a gradient decreases to ~2. So that does not explain it.
3/ The big variable is the respiratory quotient. What is the respiratory quotient: "Respiratory quotient, also known as the respiratory ratio (RQ), is defined as the volume of carbon dioxide released over the volume of oxygen absorbed during respiration. "
1/ #UncleBob has thoughts on planning your career for young clinician-educators. Read for #5goodminutes, then consider for longer.
Do not plan your career, rather strive to be the best you. Excellence gets recognized. Opportunities will appear.
Do not plan your career, rather strive to be the best you. Excellence gets recognized. Opportunities will appear.
2/ Have a trusted mentor who will listen to you explain the opportunity and help you decide if it works with your goals.
I just finished listening to an episode of Broken Record - an interview with Huey Lewis. He become a very successful singer and band.
I just finished listening to an episode of Broken Record - an interview with Huey Lewis. He become a very successful singer and band.
3/ As he told his story, it was clear that early in his career his goal was to make good music. Eventually, opportunity shone on him. Because he had worked on his craft he was able to both succeed and not get sucked into the fame trap.
/1 #UncleBob has great optimism about Internal Medicine. My initial love started when I understood that our job was to solve the mystery for the benefit of the patient. Over the years i have had colleagues with that same passion. So why is my optimism particularly high now.
2/ What excites me is the community response to learning during COVID-19. @CPSolvers Virtual Morning Report has involved so many learners - students and young physicians. Their enthusiasm to learn tells me that so many have what I consider "the right stuff".
3/ This morning I check our YouTube video of our first @UnremarkableLab episode - and already >160 views as I type. This quest to improve is the hallmark of great physicians. Our goal as educators is to help our learners (and ourselves) regularly improve.
1/ #UncleBob presents a #5goodminutes tweetorial on the FeNa. The idea is simple, with normal kidneys and volume contraction, the kidney should avidly reabsorb sodium. With acute tubular injury, the problem is that the tubules cannot reabsorb Na.
2/ Here are the cautions - with a non-oliguric patient the stimulus to reabsorb Na is either not there (patient not volume contracted) or the patient has underlying CKD. When you understand the concept of fractional excretion, this will make sense.
3/ Here (from Wikipedia) is a good definition of FeNa: The fractional excretion of sodium is the percentage of the sodium filtered by the kidney which is excreted in the urine. You can substitute any measurable for sodium.
1/ #UncleBob believes your job is to help them grow. Make clear your expectations for rounds. If they are not presenting well, suggest improvements. Sometimes you need to restate the HPI as an example - the same goes for daily rounds - teach them how to meet your expectations
2/ Almost all interns will improve quickly if you are explicit and immediate in feedback. BTW - tell them you are giving them feedback on how to improve. When they do improve - now you can give them positive feedback on their progress.
3/ Ask them each day what they learned (1 or 2 things) and encourage them to spend #5goodminutes reading to own that new knowledge. Learn their strengths and what they need to work on. Help them grow every day. Let them know that July is the biggest growth month of GME.
1/ #UncleBob is so proud if his former intern, now excellent ICU attending! #5goodminutes on this patient
Let's start with the acid-base status.
Let's start with the acid-base status.
2/ The ABG clearly shows respiratory alkalosis. I suspect it is secondary to oxygen stimulus. The patient has a huge A-a gradient (suspect secondary to her IHD). Suspect she is volume overloaded & due to ESRD the only way to correct her volume would be dialysis. Call renal
3/ We can probably explain the mildly low Na from the hyperglycemia - will not spend more time on that. Would love an albumin for 2 reasons - to assess her anion gap and the decreased Calcium. Suspect it is low and her gap is even more significant than it appears.
1/ On Chalk Talks - #UncleBob opines for #5goodminutes
I consider the development of chalk talks a very useful (perhaps even essential) activity for successful clinician-educators.
@Sharminzi @AnnKumfer @IgG4thewin @CPSolvers @DxRxEdu @rabihmgeha @tony_breu #MedEd
I consider the development of chalk talks a very useful (perhaps even essential) activity for successful clinician-educators.
@Sharminzi @AnnKumfer @IgG4thewin @CPSolvers @DxRxEdu @rabihmgeha @tony_breu #MedEd
2/ Chalk talks evolve over time, and can be used in shortened or full form. I will use 1 of my favorite chalk talks to illustrate their development and use: Anion Gap Metabolic Acidosis (I do love the practical use of renal physiology.)
3/ Many years ago, I was determined to have a good way to teach Anion Gap Metabolic Acidosis. My learners quickly note that I love developing categories as that is how I best use my memory. So I developed KILU (Ketoacidosis, Ingestions, Lactic Acidosis and Uremia.)
