A Doctor's 100 Pet Peeves About Hospital Medicine (50-1)

A rundown of 100 behaviors, management approaches, or systems issues that frustrate me as a hospitalist (i.e. a doctor who specializes in the care of the hospitalized patient), ranked according to how frustrating they are, how dangerous they are, how common they are, and how easy they would be to fix.
#50: Contrast-induced nephropathy / Contrast-associated AKI; pubmed.ncbi.nlm.nih.gov/31141...
#40: Use of prealbumin to assess nutritional status; cdn.mdedge.com/files/s3fs-pub...
#33: Don't use atenolol; www.nature.com/articles/ncpca...
#32: Mentioning a patient's race in the chief complaint; www.nejm.org/doi/full/10.1056...
#24: A Strong Medicine video on an Approach to "Altered Mental Status"; • An Approach to Altered...
#19: Toxicities related to chronic PPI use; www.ncbi.nlm.nih.gov/pmc/arti....
#18: A Strong Medicine video on the variability in normal body temperature and challenges with defining a fever; • What is a Fever? And t...
#13: Shockingly little evidence in favor of using antipsychotics to treat delirium in hospitalized patients; www.acpjournals.org/doi/full/...
#11: Things We Do For No Reason on "routine" overnight vitals in stable patients; www.ncbi.nlm.nih.gov/pmc/arti...
#7: Things We Do For No Reason on fluid restriction in patients admitted with acute decompensated heart failure; pubmed.ncbi.nlm.nih.gov/34826...
The unbelievable awfulness of ABIM's MOC program:
www.tctmd.com/news/cardiologi...
sensiblemed.substack.com/p/ma...
www.change.org/p/eliminate-ab...

[@Plinktitioner]

I have to say, I’ve referenced your videos, dozens of times to students, new learners, new, PA, med, students, and literally anyone who will listen. Thanks for the comments

[@elizabethdean1209]

Cooling blankets! That are grossly uncomfortable for patients and there is little to poor evidence to support the use. With some evidence indicating patients temps go up more from shivering. Hopefully they are almost never used now! They were part of protocols coast to coast even though they were NOT evidence based. Thanks for making our minds stronger Strong! Strong work!!

[@mehmetvural3128]

Eric you are truly genuine, generous, kind, caring, outstandingly skeptical, gem of a person and very smart teacher. Kuddos to Strong Medicine. You became my idol for teaching medicine. I met with your channel when I was intern in Uptown, Chicago right before pandemic had started , now I am being academic hospitalist in Stockton, California hospital, I am still learning from your excellent courses and humbling hearing your stories. I hope I can meet with you and get to know you in person to chat on history of medicine, medical education or general medicine culture at Stanford Campus on day.

[@MrZigan4ik]

Yeah, thanks for important words about the board!

[@JonathanCirillo]

Could you please post a PDF of 100-1 for reference? I've been talking about these videos on the wards since they came out.

[@bethjaena]

Thank you Dr Strong, this was very helpful. Would you mind sharing a video about making good notes, whether it be in patient/out patient soap notes, discharge summary etc. Thank you again.

[@StrongMed]

I've thought about making a video on this topic for a while, but unfortunately, it's a really hard topic to give general advice on when different institutions have wildly different requirements for documentation. As I alluded to in my pet peeve #1, our notes in the US are full of copy & pasted and autopopulated garbage that people are extremely reluctant to remove. I can't even give constructive feedback to my own interns on their notes any more because 90% of what's wrong with them are caused by these templates of which the hospital *very strongly encourages* the use.

[@uEffects123]

Top 1 might lead me as a medical student to actually leave medicine all together, it's not even the fact that it's a mess, the heartbreaking thing is if you try to do it right and focus on what's important and true you're instantly forced to copy paste shit you don't have time to check and fill in boilerplate text no one needs - this takes up the time and mental capacity to actually learn, reflect and providing good care. The insanity becomes evident if you rotate through departments and see the confusion this leads to for the team trying to decipher all this mess, while doing the same with their documents.

[@deepdark795]

Hi Dr. Strong, What a wonderful list of things that you’ve shared. If I may, I had a question about #17, the Pet Peeve about hemoglobin transfusion thresholds in CAD vs ACS. In your opinion, what are the recommended thresholds? I understand that somebody with ACS should probably get a higher threshold but I also vaguely recall reading that CAD patients (stable ischemic disease/chronic coronary syndrome) would also benefit from a slightly higher threshold than 7. Would appreciate it greatly if you could share your thoughts on this. Thank you!

[@Fastfingers322]

4:34 if the patient is not in severe dyspnea, does the exact respiratory rate (say ranging from 16-20 bpm) become significant enough to warrant a “7” on the detrimental score?

[@StrongMed]

- Not all patients are capable of reporting dyspnea - A patient can present with pneumonia and dyspnea and have a RR of 20; then it worsens with a RR rate now going to high 20s but because acute dyspnea doesn't routinely get given a score like pain, it's not always obvious that its worsened from remote chart review. While a documented RR increase from 20 to 30 would (hopefully) get your attention from across the hospital. - Charting 16-20 bpm for a patient with an acute respiratory illness when their RR is actually 30 implies that the patient is not being assessed as routinely as charted - There's also the issue of patients breathing too slowly from excessive sedation

[@hvymtal8566]

One of the best clinical lessons i ever learned was during rides for my first job, a wisened sage of a paramedic gave me this: If they're symptomatic, they're symptomatic, and if they're not, they're not, unless there is a related problem. (Usually with "related" repeated for emphasis) And yes, number 1 is a huge problem prehospital, too, at least among ET3 participants. Once treat-in-place becomes law, it will almost certainly get worse 😰

[@fevre_dream8542]

I'm not a doc, so correct me if I'm wrong: don't you start running into problems with antibiotic resistant organisms at some point with #28? Like, you may be only 10% sure of a particular infection, but if they _do_ end up having the infection and you don't give them the full course of Abx it's an issue, right? So wouldn't it end up being an all-or-nothing sort of thing?

[@StrongMed]

That's a great question! Shorter courses of antibiotics do not contribute to antibiotic resistance - it's just a pervasive and stubborn myth likely related to the early days of anti-tuberculosis treatment (when it might have been a thing). If anything, longer courses might contribute more to the general problem of resistance by exposing the "normal bacteria" that colonize people's skin and respiratory tract to selective pressures, such that when those bacteria find a route deeper into the body, they are more likely to be resistant to whatever antibiotic the person was on previously. www.health.harvard.edu/blog/is-the-full-course-of-antibiotics-full-of-baloney-2017081712253

[@fevre_dream8542]

@@StrongMed Holy cow, thank you for the prompt reply! That's a great resource, I really appreciate it. I've really only dealt with the short course antibiotics (like for strep) so thanks for dispelling the myth. Keep on what you're doing, Love your videos :)

[@khaleda5161]

The patient notes are somewhat like a message for the next physician I think it should be; -a brief note with the relevant facts with a reasonable amount of background info; followed by an appendix with the long details for those who wants them; What i see is that some people like making --- a "mystery novel" note with so so many details and 0 10% impression on what they are looking for + 0% guide for the next guy who will see the notes on the future Or --a long note with so little HPI info; but is rather filled with lap results, pathology/radiology reports etc... Thank you

[@rajgonsai1304]

Awesome Topic 😂 thank you for what you do Dr Strong 🙏 You are Inspiration for younger doctors 😊

[@AliDarawshe]

Thanks doc! Interesting insight. Timestamp 21:33 i think you meant dopamine and metoclopramide and not metoprolol :).

[@jjd3039]

I think he meant metoprolol lol

[@hvymtal8566]

If I had to pick a couple, here are two from the weewoo realm, both with regards to interacting with hospital clinicians 1. When specialists are called to the ED for an ambulance arrival and completely ignore the EMTs/Paramedics after initial handoff. Bonus points if they ignore us completely. 8/8/5/10 on your scale. We may have information that we didn't convey in the handoff for whatever reason but can recall when asked, and it can often be significant enough to make the difference between starting with the correct course of treatment, or a longer-than-necessary stay with treatment plans being changed midway. It's certainly not an every day thing, but it happens enough that sometimes I wonder if doctors think there is some rule that means only intensivists and EPs can talk to EMS 2. Any time a medical professional refers to EMTs and especially Paramedics as "ambulance drivers," 10/3/4/10. This usually is more of a problem with non-emergency physicians than nurses or techs of any specialty, and kind of goes hand in hand with 1. This has much potential to be harmful, because it can lead to said person internalizing the idea that EMS is just a transport service, and thus unconsciously disregard our assessment, working Dx, and Tx out of hand. It also helps blind doctors to the utility of EMS in public health initiatives. If I were to die on a hill, it would be this one Me and my colleagues will be referred to by our proper titles, period.

[@mathib04]

The "ambulance driver" term might come from other languages. In french, they are commonly called "ambulanciers".

[@hvymtal8566]

@@mathib04 No, it definitely does not come from other languages. Before the 1960s, Ambulance Driver and Ambulance Attendant were actual job titles in most parts of the world. They are not anymore, at least where I work

[@mathib04]

@@hvymtal8566 what i mean is that since some languages do not really differenciate between the two, it migh5 influence the use of inappropriate terms in english

[@hvymtal8566]

@@mathib04 I am specifically referring to an english-speaking community where the vast majority of practitioners learned and speak english as their primary language, where the title "ambulance driver" is supposed to have been extinct for 50+ years except in edge cases, and where the most common alternative language also has a specific word for "paramedic" that is distinct from "ambulance driver" In my situation, which I am and have been speaking to specifically, this is not a matter of mistranslation or secondary language influences. I have not been referring to all situations

[@michaelhongng]

Unnecessary use of oxygen: very true- communicating with nursing staff is key. They might assume the patient accidentally took it off and replace it without checking their sat.

[@HealeRx21]

EMR's are now more or less, an accounting device. Sad.

[@StrongMed]

Very true. Many are hoping that the AI revolution will transform EMRs into becoming more functional and less burdensome in a relatively short time frame...we'll see...

[@piotr5349]

What a great unexpected ending. What have we become.

[@aconcretemoth9382]

the 99 theses of medicine

[@gutiersa]

I agree, MOC is a scam!

[@juliachambers725]

Charting “ rounded with the nurse” when in fact that didn’t happen or not happened at all. Passing the buck from specialty to specialty. Not updated notes. Cardiology saying pt in NSR when I’m fact they are in AFib.😊tons of other not so wonderful things. Nurses are backbone in my opinion.

[@hvymtal8566]

My "favorite" is medical professionals who refer to EMTs/Paramedics as "ambulance drivers." Bonus points if it's dismissively

[@Vazcov1609]

Getting paged by a nurse at 3AM because the patient does not have an unimportant order and... I don't know they are bored and checking the chart at 3AM. When at 5AM you get paged asking what's the plan and you are the nocturnist, not the primary team. Yeah, nurses are the backbone but they need to get a better understanding on when it's acceptable to page in the middle of the night and when they should not.

[@juliachambers725]

@@Vazcov1609 communication. Tell them or talk to their charge what’s acceptable. Being upset about is not going to change a thing. Im icu and we have docs on the floor with us.

[@StrongMed]

@vazcov1609, I kid you not, when I was a resident, our documentation department would page residents in the middle of the night to remind us to complete our outstanding discharge summaries when they were more than just a little late.

[@HealeRx21]

Patient presents with sickle cell crisis: do not mention race in HPI? Ok.Right.

[@StrongMed]

If you know they have sickle cell disease, then what's the point of mentioning race? And if they are presenting for the first time, diagnosing sickle cell disease is typically not a diagnostic challenge in which details like race will make or break the diagnosis.

[@yessi7961]

The only time mentioning race in the HPI is remotely helpful (maybe) is on standardized medical exams (ie STEP). Race has never helped myself or anyone I know on the wards otherwise.

[@dannyash3805]

In addition to what the channel replied, it's important to remember that sickle cell disease does not affect only one racial group.