Things making me happy this week

• Journaling: it’s so wonderful to indulge in your own mind. It’s like taking a walk after a long day of sitting at a desk. You forget you had such wonderful muscles/thoughts.
• Learning so much from my attendings (my old ICM preceptors…we go way back)…Dr. H and Dr. S have both taught me so much about not just diagnosis and management of specific disorders, but clinical thinking and management. Here are some examples -
• Be mindful of the labs & tests you order: Don’t order a set of labs just because some preceptor at some point taught you to do so, think about whether or not the results would actually change your treatment plan. For hyponatremia, if you have a clinical diagnosis of true hypovolemia causing a hypotonic hyponatremia, then just start a trial of IVF hydration, and see what happens…if they respond, then that confirms your diagnosis! If you actually got labs, and the results point more toward SIADH, then what are you going to do with that information? Give the patient a vaptan or demeclocycline when they’ve already responded to IVF hydration? No.
• Just because a patient’s outside PCP or previous physicians have decided that the patient is at her baseline but she’s clearly still hypertensive or hyperglycemic, don’t just assume this is just her normal. It’s not normal! Don’t give into clinical inertia!
• Anticipatory medicine: even though the bump in creatinine might not be technically acute renal failure (>0.3 increase in Cr, >50% increase in Cr, or UOP <0.5L/kg/hr over <48 hours), doesn’t mean it won’t be by the next AM labs.
• Look at everything in the patient’s clinical context! If the patient is floridly psychotic and/or unstable, you worry more about their mildly abnormal lab values and vitals than if they’re clinically normal and at baseline. You widen your differential to include more rare and scary diagnoses, and order more labs to rule them out.
• Even when I’m at my loneliest and most down-trodden moments, I’m so appreciative of the support and love I have from my friends. Remember that love. Remember all the moments we’ve shared together and will continue to have together and let that give you strength!
• Getting that 7-8 hours of sleep Wednesday night. It’s true. Your brain performs better on more rest than on more information.

“One of the things that I keep going back to over and over again is how do we sensitize clinicians to the patient’s cultural worlds so that we can better understand what’s normal for them and what’s abnormal for them, because only once we’ve done that can we then start to tailor our treatments plans to help our patients in the ways they need in order to lead the lives they want.”

 — Asian American Mental Health - YouTube project from 4th year psychiatry resident at Columbia

"Clinical Judgment"

So much of clinical judgment is subjective. It doesn't just encompass making difficult decisions based on evidence based medicine and undeniably correctly interpreted results/physical exam findings/history, it also encompasses the actual interpretation of the aforementioned… how much epigastric pain do you believe he’s really having if he’s eating so well? Did he really have a 40 lb weight loss over 1 month if you had to dig that info out from him, and even then you had to ask if his belt & clothing size changed to assess how much weight loss he had? This is why no amount of evidence based medicine and technology will ever replace physicians, and why we have to be so careful about who we give the privilege of becoming physicians to..