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September 16th, 2013

Medical Interns – Not at the Bedside, but Not to Be Blamed

Paul Bergl, M.D.

If only all interns looked so happy on the job…

This past week in NEJM Journal Watch General Medicine, Abigail Zuger reviewed an article from the Journal of General Internal Medicine by Lauren Block et al. in which researchers examined how medical interns spend their time. The results from this time motion study might be concerning but are not unexpected. The investigators found that interns on inpatient rotations spend only 12% of their time in direct patient care and spend only 8 minutes daily with each patient on their inpatient services. Dr. Zuger notes this “distressing paucity” of direct patient care should cause leaders in graduate medical training to effect change in interns’ daily routines.

To those of us in training or just out of training, the reasons for less direct patient care are myriad and obvious:

  • A focus on multidisciplinary care and ever-increasing specialization results in each medical patient having a dozen or more physicians, consultants, nurses, pharmacists, case managers, social workers, and therapists directly involved in care. At this core of this legion of providers stands the intern. This novice physician must field messages, pages, and advice from all arms of the treatment team. As such, the intern spends as much time coordinating care as he or she spends relaying messages and answering “quick questions” — which are never quick and rarely are questions.
  • Patient acuity in academic centers also continues to rise. Patients on medical wards often are admitted with multiple comorbidities and in a state of disarray. Rare are the relatively straightforward admissions for uncomplicated pneumonia or CHF exacerbation. Thus, interns have to manage a number of active conditions, complex medication lists, and a barrage of patient data.
  • In addition, the Centers for Medicare and Medicaid pay us by DRGs and have also inculcated us to prevent 30-day readmissions. CMS will soon ask us to admit more patients to observation status. How do all of these shifts in payment affect a house officer? The intern has to spend all the more time ensuring safe and timely discharges. Tasks like medication reconciliations and communicating with outpatient providers suck up even more of the intern’s day at the expense of face time with the patient.
  • Finally, documentation steals many a precious minute from the day. The considerations of patient acuity and reimbursement add to the burden of documentation leading to bloated notes that take far too much time to construct.

I am probably too young to be so cynical, but I do not see a shift in these routines occurring any time soon. And without be excessively cantankerous, I feel obligated to ask, “Does the percentage of interns’ time spent in direct patient care matter?”

An smaller percentage of interns’ time spent directly interfacing with patients may not mean that patients get worse care. We don’t have any direct data that the distressing paucity of direct patient care is resulting in poor outcomes. Moreover, the very “non-patient” tasks outlined above are entirely necessary in today’s inpatient environment. For example, if a patient is started on a LMWH bridge to warfarin in the hospital, figuring out how the LMWH will be paid for and who will follow the INR post-hospitalization is as important as time spent at the patient’s bedside.

Of course, I am not suggesting that intern work is inherently rewarding or educational. Most of us embark on this career path because we value interaction with actual human beings, not because we like electronic note templates. I myself romance about the days when internists actually took the time to perform thorough histories and physicals. But if we don’t encumber the interns with all of this work, who will do it?

September 11th, 2013

Oral Anticoagulation, Part I: Direct Thrombin Inhibitors

Akhil Narang, M.D.

When I started residency 4 years ago, warfarin was really the only choice of anticoagulation widely used for prevention of stroke in patients with atrial fibrillation (AF) and in patients with venous thromboembolism (VTE). Despite knowing about the coagulation cascade for decades, only recently have viable alternatives to warfarin become available. In this post, I hope to break down (at a macroscopic level) use of oral direct thrombin inhibitors (DTI). In my next post, I will review Factor Xa inhibitors.

To start, let’s review the basics of clotting (Figure below). Fibrin clots form after activation of the intrinsic and extrinsic pathways. Tissue injury initiates the intrinsic pathway and compromises the vast majority of the coagulation cascade. Warfarin inhibits vitamin-K dependent cofactors (II, VII, IV, X) in addition to protein C and protein S. Warfarin acts across both the extrinsic and intrinsic pathways to prevent thrombus formation. Direct thrombin inhibitors and Factor Xa inhibitors both work in the common pathway of coagulation.

coagulation cascade

Most DTIs are administered parenterally and used in patients with ACS and in treatment of patients with heparin-induced thrombocytopenia. Oral DTIs have been slower to reach the market. While several are under development, dabigatran received FDA approval in 2010 for prevention of stroke in patients with nonvalvular AF. The RE-LY trial, published in 2009,showed that low-dose dabigatran (110 mg twice daily) was noninferior to warfarin for preventing stroke in patients with intermediate risk nonvalvular AF (mean CHADS2 score 2.1). High-dose dabigatran (150 mg twice daily) was superior to warfarin in this population. The risk for major bleeding (compared with warfarin) was lower in the low-dose dabigatran group and similar in the high-dose dabigatran group. In 2013, the RELY-ABLE study, which extended the follow-up period (median of 4+ years) for patients in the RELY trial, showed similar rates of stroke and death in both groups of dabigatran. In another recent analysis of the RE-LY population, in which cardiovascular endpoints were weighted, researchers concluded that both doses of dabigatran have comparable benefits in prevention of stroke when taking into account safety and efficacy.

The bottom line is that dabigatran is efficacious for stroke prevention in nonvalvular AF patients. Not having to monitor one’s diet or monitor INR are practical advantages that dabigatran offers over warfarin. The inability to readily reverse bleeding associated with dabigatran should be a point of discussion with patients when choosing the appropriate anti-coagulation strategy (especially in elders or patients with histories of bleeding), however a dabigatran antidote will likely be available in the future.

Turning towards venous thromboembolism, dabigatran has been investigated for treatment of acute VTE and also for prevention of recurrent VTE. In both scenarios, dabigatran has shown positive results. In the RE-COVER study, published in 2009, patients with acute VTE were bridged with either warfarin or dabigatran (150 mg twice daily). No significant difference was found in the rates of recurrent VTE or major bleeding. Further trials (RE-MEDY and RE-SONATE) evaluated dabigatran versus warfarin or placebo in patients who completed at least 3 months of treatment for acute VTE. The results showed dabigatran treated patients had similar rates of recurrent VTE (and lower rates of major bleeding) than those on warfarin. Interestingly, a higher incidence of ACS was seen in the dabigatran-treated group. Less surprisingly, when compared with placebo, dabigatran treated patients had a lower rate of recurrent VTE (and higher rates of bleeding).  As of now, dabigatran has not been FDA approved for treatment or prophylaxis of acute venous thromboembolism but is being used off-label for these indications by some clinicians.

To date, dabigatran is the sole oral DTI available in the U.S. and, as such, controls the majority market share in this class of medications. I anticipate newer generations of DTIs in the coming years. Stay tuned for the next post that will address Factor Xa inhibitors and their role in the treatment of atrial fibrillation and venous thromboembolism.

September 3rd, 2013

Benefits and Perils of Following the Literature Too Closely

Paul Bergl, M.D.

Don’t fall too far behind in the medical literature, but perhaps a little less vigilance is better for you.

As a resident, probably the most common piece of feedback one receives is, “Read more and expand your clinical knowledge base.” This critique is a standard and generic piece of feedback to encourage the younger generation to never quit in the endless pursuit of knowledge. As our erudite attendings know, medical knowledge always evolves and often reverses course. Thus, the trainee is reminded to establish the habit of keeping up on the literature early in his or her career.

Indeed there is merit to following the literature vigilantly. This past month, Vinay Prasad et al. published on “medical reversals” in the Mayo Clinic Proceedings journal. In their analysis, Prasad et al. reviewed a decade’s worth of original articles in the New England Journal of Medicine. The authors found that more than 100 original articles had overturned previous guidelines or accepted practices. Notable examples — some of which are now old news — included the following:

  • The standard teaching of CPR with rescue breaths was reversed by well-designed trials showing that adequate compressions were the main objective in CPR.
  • KDOQI guidelines in 2000 were updated to reflect a target hemoglobin between 11 and 13 g/dL in patients with CKD. These recommendations were subsequently refuted on the basis of randomized control trial of epoetin alfa that demonstrated no major benefits and increased risk.
  • Rosiglitazone was introduced in 1999 as a treatment for type 2 diabetes mellitus based on its ability to lower hemoglobin A1c. However, a meta-analysis in the New England Journal of Medicine later concluded this drug was associated significantly with cardiovascular death.

The list goes on and can be found in the article’s supplementary materials. If you’re inspired by Prasad’s findings, you ought to make every effort to “read more” and “keep current.”

Then again, maybe better advice for trainees would be, “Read when you can, but don’t worry if you end up falling a few years behind in the literature.” Sure, a revolutionary medical practice might arise, but even residents are unlikely to be so tuned out to the world that they won’t hear about the latest breakthrough somewhere. New treatments will surface; new drugs will be manufactured. The trainee may want to see a novel therapy survive a few years of validation in real clinical practice before stepping out onto a limb of uncertainty. If one aggressively tracks every advance in medicine, one also runs the risk of adopting a practice that later proves more harmful than anticipated.

At least one recently published article speaks in favor of this more lax approach toward the literature. As Paul Mueller highlighted in a NEJM Journal Watch article this past week, many meta-analyses add very little to the growing body of medical literature except growth of the body itself. If you haven’t read a meta-analysis on the pharmacotherapeutic options for fibromyalgia or supplements to prevent colon cancer in the last handful of years, don’t worry: The article you read in 2009 had most of the same studies. A more rational approach might be to pull meta-analyses on an as-needed basis rather trying to stay ahead of the barrage of articles published weekly.

So what’s the best strategy for a trainee? I personally favor a “headlines, tweets, and abstracts” approach — not only for the time-strapped resident but for myself too. Skim a few journals each month, and subscribe to essential Twitter and RSS feeds. You might hit the right balance of staying current and staying above the fray.

August 28th, 2013

Vaccination Against Pertussis – Is It Worth the Trouble?

Paul Bergl, M.D.

According to a study in the BMJ, the pertussis vaccine appears to be 53% effective against clinical infection in a “real world” setting.

 “Four out of four!” exclaimed a proud PGY1 as she handed me the billing sheet for her last patient in continuity clinic.

“Four out of four?” asked I.

“Yes, I gave all of my patients their updated Tdap today,” she boasted.

As her preceptor, I commended her for her commitment to routine health maintenance — you know, the supposedly routine tasks that, instead, routinely get pushed to the bottom of the patient’s problem list. I remarked that I had only administered a total of four Tdap vaccines in my 3 years in resident clinic.

Of course, I was exaggerating, but I admit that immunizations often got lost in the shuffle of resident continuity clinic. After an exasperating primary care encounter, the last thing I wanted to hear from my preceptor was, “Has she had her tetanus shot?” And I could imagine few things more defeating than quibbling with a patient over whether flu vaccines cause the flu, pneumococcal vaccines actually reduce the risk for pneumonia, and so on.

With so many competing priorities, so many new patients, and so many old dictations to scan — maybe someone had already vaccinated Mrs. Jones and actually documented it! — I often felt that the burden of vaccinations was too much to bear. But should I be chided for my negligence?

This week Paul Mueller of NEJM Journal Watch reported that the pertussis vaccine is only moderately effective in adults. The data derive from a large case-control study of patients under the care of the Kaiser Permanente group in northern California. The vaccine was reported as “53% effective” against clinical pertussis infection.

I actually pulled the BMJ article, and a few things stuck out:

  • While the vaccine indeed reduced the odds of contracting pertussis, the majority of cases that did occur were not terribly severe. Only a total of 1.2% of patients with PCR-positive tests actually needed to be hospitalized; rates of hospitalization were not reported for PCR-negative controls.

  • Most patients in the study had been vaccinated in the past 2 years. If immunity wanes over time, then 53% effective may be about as good as we will see in clinical practice.

  • Effectiveness, the statistic of interest, is a measure of 1 minus the odds ratio. If one looks at the odds ratio, the statistics are a little less impressive.

I now feel a little more justified in my previous approach toward vaccines but am left torn over what to teach residents that I precept. If a patient has a short agenda and a clean bill of health, then the primary care provider has no excuses. However, if one spends 30 minutes counseling on smoking cessation, working toward better glycemic control, or advising colonoscopies, why worry about the Tdap?

Then again, perhaps the proud intern knew best. After all, this study confirms that pertussis vaccinations indeed are effective. If clinicians take perspective of our public health colleagues, then we ought to work to preserve herd immunity and protect the most vulnerable populations.

August 23rd, 2013

Teaching Ultrasound to Internal Medicine Residents

Akhil Narang, M.D.

Welcome, everyone! I am thrilled at the prospect of sharing with you my thoughts on issues that pertain to residency training during the current academic year.

I recently attended the Fundamentals of Critical Care Ultrasound course hosted by the Society for Critical Care Medicine (SCCM). It was well attended by a mix of intensivits, anesthesiologists, and emergency medicine physicians all looking to further their practices with ultrasound skills that can be utilized on a daily basis. In two days, we gained a working ability to evaluate basic cardiac function, identify significant pericardial and pleural effusions, recognize ultrasound signs associated with a pneumothorax, perform a DVT screening exam, assess volume status, and obtain vascular access.  

Informally, I polled a handful of the faculty on whether they teach their residents these skill sets. While the emergency medicine and anesthesiology faculty generally incorporated routine use of ultrasound in their teaching, few internal medicine faculty said that they do. Increasingly, internal medicine programs integrate technology in the form of iPads and smart phones into their curriculums, yet few programs teach ultrasound.

During the evenings/nights when attendings and fellows are typically away from the hospital, resident interpretations of chest radiographs, CT scans, and EKGs have are routine elements used to aid clinical decision-making. Similarly, ultrasound can and should be used in a variety of settings as an extension of the physical exam.

A needs assessment1 of medical students and internal medicine residents conducted in 2010 showed a clear desire to integrate ultrasound training into established curriculums. The natural question asked: is it feasible to teach internal medicine residents basic ultrasound skills that are readily applied to clinical care? Without hesitation, I would answer yes!

While a growing body of evidence in the emergency medicine and even medical school curriculum literature highlight successful implementation of an ultrasound curriculum, less has been published with respect to internal medicine residency programs. Several small studies have shown the effectiveness of ultrasound simulation modules2, resident-driven assessment of cardiovascular function using ultrasound3, and heightened procedural confidence with ultrasound4.

While our residents at the University of Chicago have been using ultrasound for years to aid in procedures, we have not utilized a consistent curriculum. The brainchild of a former Chief Resident, Dr. James Town, we are in the midst of creating a standardized ultrasound curriculum for the internal medicine residency program. The curriculum provides formalized instruction on easy-to-acquire skills: using ultrasound for central venous access, measurement of IVC and IJ diameters for volume assessment, and DVT screening. Planned elements for the next phase of education will include ultrasound use for thoracentesis/paracentesis, evaluation of cardiac function, and identification of a pneumothorax.

Starting this year, we conducted formal ultrasound training sessions for nearly all of our housestaff. Following a pre-test and introductory lecture, interns and residents practiced ultrasound skills in groups of three or four on live models with the aid of a faculty member.

We also plan to host weekly “office hours” whereby trained faculty members in pulmonary/critical care and cardiology will be available on the wards to review images/clips that residents save onto USB drives. In addition, we are developing an ultrasound library of collected images/clips that can be used for future teaching and training.

Ultimately our goal is to create a proficiency list of ultrasound skills each resident must accomplish by the time he or she graduates. While it might take years before the American Board of Internal Medicine mandates residents have competency in ultrasound use, there is no question that ultrasound will increasingly find its way into internal medicine graduate medical education. Better to start sooner rather than later!

  1. J Clin Ultrasound 2010 Oct; 38:401.
  2. BMC Med Educ 2011 Sep 28; 11:75.
  3. J Hosp Med 2012 Sep; 7:537.
  4. J Grad Med Educ 2012 Jun; 4:170.

August 19th, 2013

Managing Hypertension – Not as Easy as It Once Seemed

Paul Bergl, M.D.

Target a blood pressure < 140/90 mmHg in everyone, but be rational in the medications you choose to get there.

Hypertension…

As a medical student, I never really understood the fuss over it. Practicioners had an excellent and concise guide in the JNC-7 to handle all of the major aspects of this disease. The JNC-7 guidelines were algorithmic, and a helpful table of compelling indications for antihypertensive agents couldn’t make life any easier.

I soon realized a little more finesse was required of the internist-in-training. JNC-7 didn’t tell the whole story. My attendings all had slightly different opinions on the optimal strategies for control, and these approaches might contradict my antihypertensive gospel.

Hydrochlorothiazide was replaced by chlorthalidone after a preceptor noted, “All of the important studies on thiazides were done with chlorthalidone.” After adopting its use, I found another internist who advised, “Chlorthalidone just causes more hypokalemia. There’s no reason to believe HCTZ is inferior.” So, back to HCTZ. Soon after, I learned that calcium-channel blockers were a preferred option for isolated systolic hypertension in elders. “Diuretics just make older patients dizzy, dehydrated, and hyponatremic.” And the advice continued to accumulate in the form of these little pearls.

To complicate matters further, various societies and expert-written guidelines also had a slightly different take on the ideal systolic and diastolic pressures. I was becoming dizzy myself. Do I target a systolic blood pressure of 130 mm Hg in patients with diabetes? Or was that patients with CKD? Or is the diastolic blood pressure more important? And does it really matter?

Well, if JNC-8 looks anything like the Eurpoean Society of Hypertension/European Society of Cardiology joint guidelines that are so nicely summarized in Joanne Foody’s NEJM Journal Watch article, we can all breathe a sigh of relief. As Dr. Foody highlights, these guidelines emphasize a more universal blood pressure target of 140/90 mm Hg and a greater focus on global cardiovascular risk. I haven’t gotten through the whole document, but I was also glad that these guidelines allow for more lenient control in elders. And these guidelines are not at all prescriptive in the choice of antihypertensive medications.

A brief report in Physician’s First Watch on a common class of antihypertenisves also caught my eye this past week. Staff writer Amy Orciari Herman reported on the recent JAMA Internal Medicine article by Christopher Li et al showing an association between long-standing calcium channel blocker (CCB) use and risk for breast cancer.

The article gave me pause for one major reason: I really fell in love with CCB’s as a house officer. CCB’s struck me as an affordable, convenient, and efficacious antihypertensive class. Amlodipine in particular seemed to promise worry-free prescribing to this young physician. Patients liked the once-daily dosing and small pill size. Since amlodipine required no periodic electrolyte checks and side effects are uncommon, I would gladly discharge a patient from the hospital on it. If the patient was lost to follow-up, I probably wouldn’t be on the hook for an adverse drug effect.

Or maybe I will be. This population cohort study suggests an elevated risk of breast cancer with CCB’s. While this study doesn’t prove causality, it should make us all a little more circumspect about the antihypertensives we choose.

In the end, these articles gave me a chance to reflect on what we ought to teach residents about managing hypertension. I expect I will keep my teaching simple in the coming years:

  • Go for 140/90 in everyone; be a little more lax in those with advanced age.
  • Make sure your choice of an antihypertensive is rational.
  • Every drug has side effects and risk; make sure your choice to treat hypertension is rational.

August 13th, 2013

Broad Is Best? The Culture and Etiquette of Antibiotic Selection in the Training Environment

Paul Bergl, M.D.

Friends and colleagues, welcome to the new academic year! I am delighted to be a chief resident blogger for NEJM Journal Watch for the coming year. Without further ado, let’s discuss residents’ use of antibiotics.

Antibiotic selection can either be one of the most anguishing or most mindless decisions that an internal medicine resident makes. For some patients, defaulting to a broad spectrum makes sense. A patient with neutropenic fever who is in shock deserves stat delivery and subsequent administration of almost every antibiotic in the pharmacy — at least until culture data can guide more informed decisions.

Rational antibiotic selection might be compromised by a culture of professional etiquette.

On the other hand, some patients require a little more deliberation in nuance. Most residents have probably dealt with some degree of self-torment in choosing antibiotics.

  • Is this really a community-acquired infection? A true community dweller is hard to find these days, and didn’t I just read something about infections like MRSA and C. difficile making their way out into the community?
  • Is this antibiotic regimen really the correct spectrum? I know my Sanford guide says so, but this patient just looks too sick to use a narrower spectrum. Maybe I’ll broaden just so I don’t miss something, and I’ll let my attending decide when to narrow.
  • I know not all fevers are from infection, but how can I justify withholding antibiotics on rounds tomorrow? What if my patient ends up in the ICU because I didn’t start antibiotics?
  • The pharmacy says the antibiotic I want to use is restricted for use by the Infectious Disease consultants only. But my patient needs this antibiotic… Besides, the most critical thing I can do for a septic patient is give them broad-spectrum antibiotics as quickly as humanly possible, right?

A recent NEJM Journal Watch article broaches these topics and offers a little solace to the conscientious and excessively deliberative house officer.

Abigail Zuger reviewed an article by Charani et al in Clinical Infectious Diseases that evaluated prescribing practices in four London hospitals. The authors interviewed nurses, pharmacists, and physicians and identified that a “prescribing etiquette” is woven into the culture of medicine.  There were several aspects to this culture that we’ve all likely experienced:

  • Colleagues do not want to question another’s autonomy. For example, a pharmacist might defer to a senior attending’s antibiotic selection even if the pharmacist perceives it as irrational.
  • Everyone tolerates noncompliance with policies. Thus, even though a stewardship plan is in place, stewards might be lenient with policies and might not offer much of a hindrance to poor prescribing practices.
  • Even though trainees write most of the orders for antibiotics, the approach to antibiotic therapy is gleaned from attendings and consultants. A hospital might have prescribing policies, but trainees are more likely to be influenced by the patterns of other prescribers instead.

This culture probably makes the resident more vulnerable as well. If the antimicrobial stewards are unable to regularly enforce their policies, then the resident has even less leverage. Given this culture and the uncertainty in our own knowledge and skills, who can blame a house officer for the “broad is best” and “more antibiotics are better than less” approaches?

I look forward to your comments.

August 2nd, 2013

A Time of Transition

Jonathan Schwartz

August-2013-CalendarAugust is here, and we are deep in the throes of a new academic year.  With this annual cycle, we deal with transitions in the academic medical world – many of which seem somewhat painful at first glance but, on closer inspection,  actually can be quite fun.  Many of you in medical training undoubtedly have moved into new roles: be it matriculation from student to intern, or adjusting to the care manager and team leader simultaneous roles with the switch from intern to resident.  The transition from junior resident to senior resident typically is less dramatic, but generally means more time for self-directed learning and a focus on the next steps in your career.  Arguably, the most unnerving transition is that from senior resident to independent practitioner.  That said, a great number of NEJM Journal Watch readers have likely opted to continue training and begin fellowship (the category to which I belong!).

A few researchers have looked into whether this abrupt transition each academic year has an effect on patient care.  Dubbed the “July effect,” studies have shown some evidence of decreased quality of healthcare in July (with careful attention to how quality is defined).  A meta-analysis of such studies was published in the Annals of Internal Medicine in 2011 (see the NEJM Journal Watch summary here), which reported higher patient mortality, as well as lower hospital efficiency during this trainee transition period.  However, the evidence is not strong, and further inspection with high-quality studies is needed.  I would argue that, in fact, new trainees have an intense focus and are highly motivated to do an excellent job – particularly when starting at a new position.  Combining this with attending physicians who take a more hands-on approach to guiding their trainees so early in their careers, I believe a strong argument can be made that patients receive better, if not equal, care in July as in other months.  Regardless, attentiveness to detail and a low threshold for seeking help when needed is prudent, particularly during these first few months.

The new academic year has also brought my own transition to fellowship training; it has been an incredibly exciting progression (and sometimes scary!) to now call myself a cardiology fellow.  This transition has provided me with new motivation to understand and master new skills, this time not only to increase my knowledge base with specific focus on cardiovascular medicine, but also to prepare for eventual independent practice as a cardiologist.  The transition from chief resident to first-year fellow has been quite humbling at times, but I clearly remember the transition from medical student to intern just a few years ago – it’s not significantly different!

As you might have guessed, this new role for me also means the time has come to pass the baton of the Journal Watch Chief Resident Blog to a new pair of authors, to whom you’ll be introduced shortly (stay tuned for a new post soon…).  I wish each of you the best of luck in your new positions, whatever and wherever they may be!

Kindest regards,

Jonathan Schwartz, MD

May 24th, 2013

The MICU Rotation — Oh, no!

Jonathan Schwartz

ICU MonitorAfter a well-received post last week that focused on a commonly asked question I have fielded this year, I thought another common question would make for an excellent topic this week.  We’ll focus on the MICU rotation from the resident (and, potentially, the medical student) perspective.

The MICU can be one of, if not the most, daunting rotations of residency.  However, I believe that many students, interns, and residents would agree with this statement: “After I completed that rotation, it ended up being one of the best months in my entire residency.”  I say this from a learning perspective, but the MICU rotation can also be a confidence boost.  Realizing you can save simultaneous “crashing” patients with entirely separate disease processes can be quite rewarding – even in the unfortunate situations with poor clinical outcomes.

I am of the opinion that the worst part of the MICU rotation is dealing with the unexpected.  Not knowing how many admissions will be called during your shift, the uncertainty of just how sick these patients will be, and the insecurities you might have about your own clinical knowledge and/or skills can make for quite an intimidating call day – and potentially an intimidating month.

What can we do to calm these fears?  Good solutions are hard to come by (aside from simply diving in head first, and proving to yourself that you are capable).  However, before starting your rotation, reviewing a few clinical concepts and manuscripts will likely pay great dividends.  Additionally, I have a few pieces of advice that will also make for a much smoother, enjoyable experience in the MICU.

I had a few discussions with my colleagues to identify some of the most important manuscripts to review while working in the intensive care unit.  This list is by no means exhaustive, but it serves as a good starting point and a reasonable inventory to at least briefly reconsider (or sometimes consider for the first time, if this is your first ICU experience!) before starting your rotation.  With that caveat, here is my list of 7 landmark articles:

  1. Sepsis – Early Goal Directed Therapy (or read the Journal Watch summary for a capsule view of this landmark paper)
  2. Therpeutic hypothermia after cardiac arrest and Treating Comatose Survivors of Cardiac Arrest (read the Journal Watch summary)
  3. Transfusions in the ICU – TRICC trial (read the Journal Watch summary)
  4. Respiratory failure – ARDSnet and low tidal volume ventilation
  5. Corticosteroids in septic shock – CORTICUS (read the Journal Watch summary) and a French corticosteroid trial (read the Journal Watch summary)
  6. Fluid management – FACTT (read the Journal Watch summary)
  7. Blood glucose control and insulin therapy in the critically ill – NICE-SUGAR trial (read the Journal Watch summary)

Obviously many other topics and manuscripts are as important as those I’ve listed above.  But, I’ve found these are very commonly referenced papers, and they’ll serve as an excellent starting point for keeping the doubts and apprehension at bay in the days leading up to the start of your MICU rotation.

How about a few general tips for the MICU month?

  • Decipher the schedule and plan for fun activities to do on your days off.  You’ll likely be working very hard while at work; recharging while away from the hospital is vital.  Also, plan ahead to prevent any scheduling surprises mid-month.
  • Do not hesitate to seek help when you are starting to feel uncomfortable.  Almost certainly, you will have multiple resources for help if you need it — a co-intern or resident, the patient’s nurse, the pulmonology/critical care fellow, your attending, a pharmacist…  You simply have to ask for help!
  •  Focus on details. You might be able to skip over some pieces of data, vital signs, parts of the physical exam, and other aspects when you are on other rotations, but this practice is both dangerous and sloppy when you are caring for critically ill patients.

Finally, enjoy yourself!  Even if you hate critical care, smiling and making the best of a potentially bad situation will take you quite far.  Who knows, maybe you’ll even find a new interest you never realized you had — only because you never gave it a chance!

I would love to hear your own ideas on important papers, topics, and general tips for the MICU.  Post a comment below!

May 15th, 2013

The Next Step: Fellowship Applications

Jonathan Schwartz

toxicology fellows at UMassThe end of the academic year is fast-approaching, which means many changes and exciting transitions lie ahead – for all levels of trainees: medical students and new interns, brand-new attending physicians, and seasoned diagnosticians alike.  One of the more stressful tasks facing many of the senior residents in the coming months is the fellowship application process.  We recently held a program-wide gathering here at the University of Colorado to discuss tips that potentially can ease the process – and possibly even calm the nerves of anxious soon-to-be fellowship applicants.  I completed the fellowship match process this past year, and identified a few pointers that would have been helpful to know prior to applying. Here’s my list of 8 tips to get the perfect fellowship:

  1. Create or update your curriculum vitae.  The ERAS fellowship application mirrors the ERAS residency application, so, if you happen to have saved yours from a few years ago, you can use it to speed the data entry.  Additionally, investing a substantial amount of time and effort in producing a high-quality personal statement will likely reap great benefits in the form of interview invitations.  These two tasks will get your foot in the door… the interview is your time to shine, and stand out from the pack.
  2. Request letters of recommendation — early!  Clearly, you’ll want a letter from your residency program director, as well as your research mentor (if you have completed research).  Additionally, I would recommend at least two other letters, ideally from faculty members with whom you have worked closely and who agree to write a strong letter on your behalf.  Having letters from faculty in the field to which you are applying is probably best, but not an absolute must – particularly if you have worked a significant amount of time with another mentor that can write a very strong letter.  A letter that details your clinical skills as well as personal attributes (and potentially research aptitude) will take you far in the application process, regardless of whether or not the author is in your selected field. It is a fantastic idea to have your letter writers begin working on the letters very soon.  When the application officially opens (EFDO tokens will be available on June 12th, 2013),  you have approximately 2-4 weeks to complete it before having the option to send it to programs (and I strongly recommend submitting your application to programs as early as possible).  Most residency programs have a process that will keep the letters confidential until the application opens; investigate this now, so you will be ready.  You also might want to contact your program director to discuss the details of the letter they will be writing on your behalf.
  3. Focus on creating a list of programs that pique your interest.  Many factors must be considered during this process – and these are highly individual. Ideally, you’ll find a handful of programs that:  a) are strong in the subspecialty to which you’re applying, b) have mentors and/or research that aligns with your interests, and c) are feasible matches for you.
  4. Closely review websites for specific programs before submitting your application.  Some programs have special requests with regard to your application – topics you need to address in your personal statement, specific requests with regard to letters of recommendation, or other tasks.  These guidelines are often used by programs as a first-pass filter (anyone who does not follow the instructions might be quickly rejected; the “shotgun” approach to applications – applying broadly without any knowledge about the program in particular, is not ideal nor recommended).  Also, each website provides a wonderful way to learn more about the program.  If you have a specific research interest, try to identify a few faculty members whose research potentially align with your interests, and who conceivably could serve as a mentor should you match into their program.  Most programs will ask if you would like to meet a particular faculty member during your interview.  Having someone in mind demonstrates strong interest.
  5. Meet with the program director of the subspecialty to which you are applying at your home institution.  He or she can help you create your list of programs, and also also might know faculty at programs across the nation to which you are applying.  Program directors are potentially a fantastic resource that many applicants do not take advantage of, but definitely should!
  6. Submit a professional photo with your application if possible, but I do not think this is a requirement.  That said, many programs receive countless applications each year (many in excess of 100 times the number of positions available), and if the program is able to put a face with an application, it can help to distinguish you from the rest of the field.  A good first impression is a lasting impression – this is not the time for humor!
  7. Talk to the current fellows in your selected subspecialty at your institution.  Not only can they provide specific tips about the application process for your chosen field (each one seems to have a few quirks), but also they are the best resource for overall tips – considering that they just completed the process last year.
  8. Finally, start saving money (a small fortune might be necessary in some cases!) for the whole process… expenses mount rapidly , especially if you apply to many programs and accept many interviews.  Application to 10 programs is included in your the initial fee; beyond this, extra fees will apply (the amount varies depending upon how many programs you ultimately choose).

I hope you have found this list helpful, rather than stress-inducing!  I am happy to answer questions – leave a comment below and I will try to reply.  Deep breaths, and good luck!

Resident Bloggers Bergl and Narang

Akhil Narang, M.D.
Paul Bergl, M.D.

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