Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
How do you follow patients after SBRT for NSCLC?
When we started our lung SBRT practice almost 13 years ago, the follow up schedule was based on trying to measure the benefits and impact of the therapy in a fairly structured fashion so that we could develop expertise in understanding outcomes, radiographic changes, patient experience, and treatmen...
How do you approach the choice of basal-bolus insulin vs correctional insulin alone to manage hyperglycemia in a hospitalized older adult with type 2 diabetes and significant frailty?
Frail older adults with type 2 diabetes, compared to their less-frail counterparts, may have less predictable oral intake, and you may have more difficulty obtaining an accurate medication reconciliation. You may need to review facility records or speak to multiple collateral historians to find out ...
How do you approach the choice of basal-bolus insulin vs correctional insulin alone to manage hyperglycemia in a hospitalized older adult with type 2 diabetes and significant frailty?
Frail older adults with type 2 diabetes, compared to their less-frail counterparts, may have less predictable oral intake, and you may have more difficulty obtaining an accurate medication reconciliation. You may need to review facility records or speak to multiple collateral historians to find out ...
What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?
The benefit for SGLT-2 inhibitors at slowing the progression of kidney disease or death from cardiovascular causes had been well established in patients with diabetic nephropathy. Further studies continued to demonstrate benefit in non-diabetic, proteinuric kidney disease (HR, 0.72 (95% CI, 0.64-0.8...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.