Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you present the trade off between a small chance of a sustained response for a new drug at the expense of potential worsening quality of life?
Since we now have an increasing number of treatments at our disposal, this becomes an ever more frequent conversation in oncology. This question gets at several Shared Decision Making (SDM) model steps. Usually in this scenario, there are not routine standard of care options and highlighting the pat...
What interventions do you find helpful for the initial management of functional GI disorders in primary care?
TCAs seem to help modulate pain, particularly at low doses.
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
I developed a structured, objective approach centered on PAWSS risk stratification and standardized mMINDS plus RASS monitoring rather than relying solely on symptom-driven tools like CIWA. At intake, patients with suspected alcohol use disorder undergo PAWSS assessment, baseline mMINDS scoring, RAS...
How do you incorporate positive respiratory viral testing and/or low procalcitonin into antibiotic de-escalation when chest imaging still suggests pneumonia in a hospitalized patient?
De-escalation of antibiotic use is a key part of antimicrobial stewardship. Respiratory illnesses are one of the most common reasons for hospitalization, and bacterial pneumonia is frequently the major concern in these patients. However, there is evidence that we overdiagnose and treat bacterial pne...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
Do you have a preference between an ACEI and ARB when initiating therapy for a patient with diabetic kidney disease, albuminuria, and hypertension?
Why would you use an ACEi over an ARB these days? Cough is a LOT more common than stated. I see patients all the time who have a ticket, an annoyance that goes away on an ARB. Also, I don't see a $ argument, nor am I aware that ACEi have even been shown to be superior to ARB for reno protection. Als...
What advice would you give a hospitalist in their first few years of practice who wants to develop a focused area of expertise, such as perioperative medicine, quality improvement, or medical education, while maintaining a full clinical load?
I think my two big pieces of advice are: Pick one thing; you don't have to stay with it your entire career, so whatever seems interesting right now is just fine. I have moved from education to QI to even some basic science work, which I would never have predicted. Part of the fun is figuring out wh...
What advice would you give a hospitalist in their first few years of practice who wants to develop a focused area of expertise, such as perioperative medicine, quality improvement, or medical education, while maintaining a full clinical load?
I think my two big pieces of advice are: Pick one thing; you don't have to stay with it your entire career, so whatever seems interesting right now is just fine. I have moved from education to QI to even some basic science work, which I would never have predicted. Part of the fun is figuring out wh...
What go-to resources do you recommend if patients would like to discuss voluntary stopping eating and drinking (VSED) as part of advance care planning, for example, for consideration should they develop advanced dementia in the future?
This will be very dependent on location, but traditionally, if this is becoming a topic, they should be referred to outpatient palliative care, and when the time is close, hospice, as most of these patients get significant symptoms. Lastly, depending on local laws, this might not be allowed for deme...
Would you advise mobility restrictions in a patient with Protein S deficiency and acute upper extremity DVTs but contraindications to anticoagulation (e.g., acute GI bleed) to reduce the risk of thrombus embolization?
This question is an interesting one and an incredibly specific scenario. I'll try to broaden the answer to cover a few more scenarios. So, the question gets at three elements: 1) Patient has an acute VTE, 2) Patient has a hypercoagulable state, 3) Patient has a contraindication to anticoagulation. S...