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.

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.

https://twitter.com/andrewolsonmd/status/1515503749367836676

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.

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 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

#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

https://twitter.com/medrants/status/1500451577726849024

"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.

1/ Here is the story - hopefully instructive. Patient (ESRD w/ dialysis) admitted 3 weeks previously for dyspnea. Portable CXR shows small pleural effusion & some haziness - pneumonia or atelectasis. No fever, no increased WBC, no productive cough. Discussed now w/ radiology

https://twitter.com/medrants/status/1493005774691389441

2/ Radiologist teaches our team - pneumonia is a CLINICAL DIAGNOSIS - cannot make the diagnosis by CXR/CT scan.

Patient discharged - readmitted for more dyspnea - now with moderate pericardial effusion and large left pleural effusion. Receive furosemide & then thoracentesis

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 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

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 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

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… 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.

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. 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

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 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.

#UncleBob - eGFR Tweetorial

eGFR - estimated GFR
mGFR - measured GFR

@UnremarkableLab 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

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. 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.

#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

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.

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 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.

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 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.

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: 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.

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 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.

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. 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.

/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".

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.