HIV and ID Observations

Acronyms on the medicine service remain mystifying.

Here are five things that occurred to me after a stint on General Medicine this year, where (per our department’s wise policy), I was paired with an experienced and excellent hospitalist to oversee two medical residents, three interns, and two medical students.

#1:  Energy. Medical house officers radiate positive energy. Yes, it was summertime, and motivations were high to tackle their new responsibilities (leading teams for the PGY-2s, being a real doctor for the PGY-1s).

But at any time of year, this energy is a wonderful thing to experience. You can’t help but be caught up in the spirit — their desires to help their patients, to learn, and to teach influence us all. The positive effect it had on our medical students was especially notable. Makes a person hopeful for the future of medicine in this country. Yay!

#2:  Acronyms rule. One of the hardest things for me as a trainee was deciphering the blizzard of letters sprayed around during morning rounds and in patients’ charts. I get flashbacks to this mystification each time I attend on medicine, and am not shy about asking for a glossary.

This year’s most prominent newcomer was GDMT — guideline-directed medical therapy — in which patients with heart failure receive a quartet of medications, each of which improved outcomes in comparative clinical trials. While I knew about these drugs and their favorable studies, the acronym for all of them as a group was new to me.

But now that I know about GDMT, label me as skeptical as this general internist. Sure, it could work for some eventually to get started on an angiotensin receptor inhibitor, a beta blocker, a mineralocorticoid receptor antagonist, and a SGLT2 inhibitor. But during the first few days of hospitalization? It seems like too much too soon.

#3:  Fear of quinolones is now mainstream medical knowledge. I totally get it — these are drugs that have unexpected and sometimes severe toxicities. Permit me to bring out this incredible graphic, kindly shared with me years ago, highlighting the various problems:

But the FDA warning to avoid these drugs in outpatients has so permeated clinical practice that they are now frequently overlooked even when a quinolone is the best treatment option. So here’s a reminder that they are highly effective, have excellent oral bioavailability, and are usually quite safe.

Hey, I get the irony. Here I am, an ID doctor pitching for quinolones in 2024, while if we go back a couple of decades we could easily have called them the most overused antibiotic drug class by medical services — so much so that I used to use this slide as a joke!

That is a completely made-up rule.

Still funny? You be the judge.

#4:  We ID doctors offer something special when we attend on general medicine. Well, what do you expect me to say? I’ve argued for self-selected subspecialists to do inpatient general medicine before, but now there’s something new that occurred to me this time about ID in particular. Namely, we’re among the remaining few doctors who can see a problem in a hospitalized patient on the general medical service, act as the primary attending of record, and then arrange to see that patient after discharge in our clinic for follow-up.

Not all of us, of course — some ID doctors don’t do outpatient care — and yes, there are other subspecialists who do this as well. But at least at our institution, we seem to be the leaders in this particular flexibility, one that is especially important since the number of general internists who do both outpatient and inpatient care seems to shrink yearly.

#5:  Hyponatremia continues to perplex. Way back in the early days of UpToDate, the visionary founder Dr. Burton (Bud) Rose shared with me that hyponatremia was the most common single topic looked up on his nascent clinical information resource. I wouldn’t be surprised if this is still the case — causes, evaluation, management, all still a challenge! So many discussions on rounds focused on the results of the daily sodium, the volume assessment, the urine electrolytes, the best approach to correct the low sodium, and how fast to do so.

Here’s a “big picture” view from one ID doc (me):

1. People sick enough to be hospitalized often have low sodium.
2. There are many possible causes, and they’re not mutually exclusive. Often more than one is in play.
3. If the underlying process (pneumonia, CNS disease, CHF, GI bleeding, whatever) is treated, and/or the offending drug stopped, in most cases a small degree of volume restriction (if volume replete) or hydration (if volume deplete) will lead to a slow correction.
4. In more severe cases, get help from your friendly nephrologist.

That’s my five! And thanks again to the terrific medical team for making the experience so rewarding.