My mother called me in a panic (and how that call helped me understand Medicare Advantage):

"Robert, they told me I have bad blood flow in my legs. What do I do?!"

Woah. Wait, what? Who told you that? "A nurse that came to our house."

A nurse? A nurse from where?

"Our insurance company."

Why did a nurse come out from your insurance company?

"I don't know. They called us and said it was part of the benefits of being with them that they would do a nursing check on us."

Daily rounding can be overwhelming for med students and residents.

As a full time hospitalist, here are 3 steps I use every day to stay organized with a full census: Step 1: Check that thing you need to follow up.

Was a CT ordered yesterday? A daily weight for heart failure? Etc...

Check those first to make sure you don't overlook them. That's typically high-level info.

But don't stop there...

In SOAP notes, mistakes dominate assessment and plans.

To stand out and prevent mistakes, you need to understand the principles behind accurate yet efficient notes.

Here are 4 habits for mastering a mistake-free A&P: 1️⃣ Format for easy editing

A&P's have assessments....and plans. Don't mix them together.

Keep them separate. This way you can
🔹Delete the reasoning the next day (if it was accurate) for conciseness
🔹Quickly edit versus sifting through a paragraph - saving you time ⌚

Ex👇

Imagine a loved one being treated incorrectly for their MI.

Yet...do YOU even understand when an NSTEMI is really an NSTEMI?

Finally understand it in 2 minutes: First, pay close attention to the three I-words:

1️⃣ Injury
2️⃣ Ischemia
3️⃣ Infarction

They have three distinct meanings and easy to get them mixed up.

"CHF" doesn't cut it anymore.

You have to classify heart failure to truly know how to treat the patient.

3 tips to classifying heart failure and ensuring proper care: 1 / Ejection Fraction

🔹 HF w reduced EF (HFrEF): LVEF ≤40%
🔹 HF w preserved EF (HFpEF): LVEF ≥50%
🔹 HF w mildly reduced EF (HFmrEF): LVEF 41–49%
🔹 HF w improved EF (HFimpEF): LVEF ≤40% + ≥10 pt increase from baseline, w/ 2nd >40%

But what about systolic vs diastolic?

A patient can be harmed by a bad discharge summary.

But writing a good discharge summary can be a strain on your time.

3 tips to writing an efficient yet affective discharge summary: 1 / Write it near the time of discharge.

Patient going to a SNF? Or PCP follow up in 3 days?

A discharge summary written 7 days later doesn't help.

Plus, it's quicker to write when it's fresh in your mind.

Don't put it off.

Are you overwhelmed as a senior resident?

You DON'T have to know everything.

7 Tips for being a great senior resident Senior residents can fall into several traps. You may:

🔹 Forget your importance as a role model
🔹 Let your ego get in the way
🔹 Be anxious about what you don’t know

But ultimately your role is to support.

Let's dig in ⤵️

Delivering bad news isn’t easy.

Unfortunately, this isn’t taught well.

6 tips to make this easier for you and the patient: The problem?

Most struggle with delivering bad news. They:

🔹 Don’t know how to start the convo
🔹 Don't want to upset the patient
🔹 Are uncomfortable with silent pauses
🔹 Don’t know how to end the convo

As a result, many delay or avoid the conversation.

Let's dig in ⤵️

How most HPI's are written:

Details of a chief complaint. That's it.

5 tips to using the HPI to make you a better doctor. The HPI can be used as both a
🔹 Diagnostic tool
🔹 Therapeutic tool

But you must know the beginning, middle, and the end.

AKA The patient's story

Let's dig in

How to avoid queries 101:

“History of" = No longer present. Ex: “history of diabetes.” Is their diabetes really no longer present?

“With” = Still active. “Patient with diabetes” is better. "Ruled out" = Never existed (during that encounter). Do not use this language to say that something was treated and now resolved.

“Resolved” = Existed, treated and no longer active.

What should you call that low H/H?

Not "low H/H" for starters...

3 tips to avoiding the top mistakes with anemias👇 For anemias, you must be specific about 3 things:

1️⃣ Acute vs chronic
2️⃣ A diagnosis (if known) versus a pathologic description
3️⃣ The source of a bleed

GI bleeds are a top reason for admission. Let's start with those ⤵️

I asked, “What do you like to see on discharge summaries?”

I received 100+ responses.

I used these to make a template.

Steal my template + 5 tips on writing the ideal discharge summary First, more people read your discharge summary than you think 👇

https://twitter.com/2284420200/status/1659332621069873160

Have time-based requirements for billing really gone up?

Yes.

Below is a screenshot of the AMA document.

The next tweet is a comparison of the old times⤵️ However, what you can include for time is more extensive (next tweet)⤵️

Many terms for pneumonias, like CAP & HCAP, don't mean what you think they mean for coding.

Here's what matters:

1️⃣ Causative organism guides coding
2️⃣ Cultures are NOT required for causative organism
3️⃣ A SUSPECTED organism can be based on RISK FACTORS

There are 2 categories: 1️⃣ Simple pneumonias
2️⃣ Complex pneumonias

Simple includes haemophilus, strep, mycoplasma, typical viral pneumonias, and non-organism-based terms such as
🔹 HCAP
🔹 CAP
🔹 Bilateral
🔹 Bacterial, etc

What's complex?

The 7-day rule and why determining baseline Creatinine is critical for diagnosing AKI: The problem?

🔶 People don't know criteria for AKI
🔶 Determining baseline Cr is unclear
🔶 ATN is underdiagnosed
🔶 Poor documentation sabotages your AKI diagnosis

Let's dig in ⤵️

What should you call heart failure?

Systolic & Diastolic?
HFrEF & HFpEF?

The answer might surprise you.

A thread 🧵 The problem?

🔶 There are "new" classifications of heart failure
🔶 ICD10 Coding is outdated
🔶 But those codes dictate how you get "credit"
🔶 People still use "CHF"

But don't worry. There's good news!

Let's dig in ⤵️

Don’t do it.

Don't lower your standards because of other’s behavior.

Some days you may not live up to your own standards. That's okay. Forgive yourself and do better tomorrow.

But a career in medicine can be brutal, and one brutal truth is this: You are not recognized nor rewarded, especially financially, for good, compassionate patient care.

Its SO easy to recognize this fact and lower your standards because "no one is watching" and “no one seems to care."

Should you call it sepsis?

TWO definitions. ONE big problem.

Understand the problem and a solution in 1.5 minutes. The problem?

🔶 There are two definitions of Sepsis
🔶 Neither definition is perfect
🔶 One is arguably better for patient survival...
🔶 But hospitals lose money if they use that definition

Let's dive in.

(Check out my previous thread for more info)

https://twitter.com/2284420200/status/1555909336391639042

You’re told to “add as many CC and MCC diagnoses as possible.”

But what do they mean. And why?

Finally understand why in 1.5 minutes👇 First, what do they mean?

• CC = Comorbid Condition
• MCC = Major Comorbid Condition.

I know, still meaningless.

Here’s why they matter…

What should you call that elevated Creatinine?

That's the easy question.

But what is their baseline?! That's tougher.

A thread 🧵 The problem?

🔶 People don't know criteria for AKI
🔶 Determining baseline Cr is unclear
🔶 ATN is underdiagnosed
🔶 Poor documentation sabotages your AKI diagnosis

Let's dig in ⤵️

What should you call that elevated troponin?

This is NOT taught well and impacts more than you think.

Understand it in 2 minutes: The problem?

💙 Most don't understand how to interpret troponins
💙 Most don't understand the actual definition of an infarction
💙 Proper diagnosis (& documentation) ➡️ impacts clinical decisions and quality metrics

Let's dig in ⤵️