How can I best answer my families medical questions? How can I give my loved ones the best care without providing it directly for them? What boundaries should I have in place?

Show notes, Transcript and References:   https://www.coreimpodcast.com/2021/01/13/treating-friends-family/

Time Stamps:

• 02:45 The tension, the push and pull
• 05:45 Prevalence
• 06:32 Stances of societies/professional organizations
• 08:18 Concerns
• 10:35 How to respond
• 17:52 Favors for physician/trainee colleagues, self-doctoring
• 22:26 Formal vs informal, documentation
• 23:55 Long-term care

Tags: patient care, advocate, advice, healthcare, Core IM, IM Core, medical ethics, medical humanities

How do you form an educational mission statement? What role do coaches and mentors play? Do you need formal training for a MedEd career? What are the challenges with careers in medical education?

Digital Education conference (virtual) on Jan 22, 2021: cmeregistration.hms.harvard.edu/digitaleducation

Show notes, Transcript and References: https://www.coreimpodcast.com/2020/12/27/medical-educatio…s-careers-series/

Time Stamps:

• 00:00 Introductions
• 05:44 General Tips
• 18:00 Challenges in Med Ed
• 24:54 Conclusion

Tags: CoreIM, IM Core, mission statement, clinician educator, mentors, coaching, training, feedback

Can you identify where along the clinical reasoning pathway the learner is struggling? What coaching exercises can be helpful? What feedback do you fall back on when working with learners? What are common challenges?

Show notes, Transcript and References: https://www.coreimpodcast.com/2020/12/09/hoofbeats-strugg…inical-reasoning/

ACP CME: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Time Stamps:

• 00:00 Introduction
• 03:33 Mental Health & Wellbeing
• 06:43 Case 1
• 11:48 Exercise 1
• 12:53 Exercise 2
• 14:35 Case 2
• 19:15 Exercise 3
• 21:22 Exercise 4
• 23:24 Case 3
• 27:29 Exercise 5
• 28:07 Exercise 6
• 29:24 Conclusion

Tags: CoreIM, IM Core, problem representation, coaching exercises, data gathering, hypothesis generation, clinical reasoning, faculty development

ACP CME: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Time Stamps:

• 00:43 Case presentation Part 1
• 04:55 Case presentation Part 2
• 06:50 Expert discussant
• 28:52 Framing bias
• 33:38 Concluding thoughts

Tags:  IM Core, CoreIM, schemata, mnemonics, eosinophilia, framing bias

What leads patients to search for alternative treatments than those offered in Western Medicine? How can we provide patients with safer complimentary interventions? How do we prioritize what is important in our patients health?

Show notes, Transcript and References: https://www.coreimpodcast.com/2020/10/15/approach-to-patients-with-cam-beliefs/

Time stamps:

• 01:49 Intro
• 04:54 What is CAM
• 06:29 Prevalence of CAM
• 08:01 Holistic approach to patient care
• 11:09 Patient empowerment
• 14:38 Integrating CAM
• 18:34 Risks and Benefits
• 19:50 Caution patients
• 22:29 Indirect Risk
• 23:45 Big Picture
• 26:04 Therapeutic Alliance
• 27:27 Conclusion

Tags: IM Core, CoreIM, supplements, homeopathic, naturopathic, Ayurvedic medicine, mind-body interventions, massage, acupuncture, and chiropractic manipulation, qi gong and Reiki

How can we feel more comfortable in treating these patients? What treatment options do we now have in our toolbox to fight COVID-19? How has the landscape changed in what we can offer patients?

Show notes, Transcript and References: https://www.coreimpodcast.com/2020/09/30/covid-management/

Get CME-MOC credit with ACP: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Time stamps

• 04:16 Supportive Care
• 07:48 Step-up approach to oxygenation
• 13:44 Data Points
• 15:30 Clots
• 19:13 Steroid use

Tags: IM Core, CoreIM, oxygenation, proning, anticoagulation

How do we respond to challenging times? Are you a driver of change? How can we forge ahead during times of adversity? What lessons can we learn from the stories of our peers and colleagues?

Show notes, Transcript and References: https://www.coreimpodcast.com/2020/09/16/transitions-episode/

Time Stamps:

• 02:48 Minneapolis 2020 with Dr. Uloko
• 06:44 Early HIV/AIDS with Dr. Kalet
• 12:07 Hurricane Sandy with Dr. Hwang
• 17:20 Aftermath of the Syrian Civil War
• 20:23 Transitions with Dr. Arora

Tags: Core IM, IM Core, change, inspiration, narrative medicine

What are common mistakes with protein on the UA? What questions should you ask while obtaining a history that could clue you into nephrotic syndrome? Are kidney biopsies risky business? Is there an associated clot risk in patients with nephrotic syndrome?

Get CME-MOC credit with ACP: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Show note, Transcript and References: https://www.coreimpodcast.com/2020/09/02/5-pearls-on-nephrotic-syndrome/

Amboss Article on Nephrotic Syndrome: https://www.amboss.com/us/knowledge/Nephrotic_syndrome?utm_source=affiliate&utm_medium=link&utm_campaign=coreim-01

Time Stamps:

• 03:22 Evaluating Proteinuria
• 09:37 Nephrotic Syndrome specifics
• 22:31 Who to biopsy
• 31:39 Diuretics
• 37:16 Thrombosis Risk

Tags - CoreIM, IM Core, edema, proteinuria, kidneys, thrombosis, urinalysis, diuresis 

How tough is it to forge your career in clinical research? What struggles do physicians face in finding protected time? Are there setbacks and frequent rejections? How can you follow your passion and find success?

Show note, Transcript and References: https://www.coreimpodcast.com/2020/08/19/research-careers…rs-in-gim-series/

Time Stamps:

1:28 Origins

6:57 Mentorship

14:30 Reality, Roadbumps, and Failures

18:17 The path of many fellowships

Tags - CoreIM, IM Core, clinical investigator, general internal medicine

Are fall prevention programs helping our patients? Should patients receive outpatient PT based on clinical diagnosis? How has the landscape changed because of insurance reimbursement?

Time Stamps:

• 01:47 Functional Assessment
• 07:47 Documentation
• 14:35 Outpatient PT
• 18:14 Durable Medical Equipment
• 22:55 Reimbursement

Tags: Core IM, IM Core, physical therapy, durable medical equipment, IPE, multidisciplinary team, interdisciplinary

What goes into decision making? What are the invisible tugs that may keep patients from acting in line with their values? Why isn't it part of the formal capacity assessment?

Show notes, Transcript and References: https://www.coreimpodcast.com/2020/07/22/capacity-2-0-and-voluntarism/

Get CME-MOC credit with ACP: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Time Stamps:

• 2:57 Defining voluntarism
• 5:36 Four elements that influence voluntarism
• 10:26 How do you incorporate voluntarism into the capacity assessment?
• 16:11 Discussions with uncooperative patients
• 19:14 Protecting unrepresented patients
• 21:30 Clinician perspective
• 25:06 Moral distress

Tags: medical humanities, ethics, psychiatry, IM Core, CoreIM

Unpack a famous historical legend's medical dilemma on a special "Historical CPC" episode!

Show notes, transcript and references: https://www.coreimpodcast.com/2020/07/08/22729/

Time Stamps:

• 02:55 HPI
• 07:33 Past Medical History
• 04:25 Physician Exam findings
• 24:22 Historical Figure Revealed
• 26:30 Reflections on top 3 diagnosis

Tags: cognitive and neuropsychiatric disturbances, rabies, mercury poisoning, cholera, delirium, COREIM, IMCORE, clinical reasoning case

Packed with so many clinically relevant points taking care of a patient with decompensated heart failure on general medicine floors!

Time Stamps:

• 03:17 What are the key initial clinical variables in evaluating heart failure admissions?
• 10:09 What are key lab findings for patients with heart failure exacerbation?
• 17:14 Which guideline-directed medical therapy, and in what circumstances?
• 22:12 What are diuretics dosing strategies and monitoring tips to help guide initial volume removal?
• 28:43 What role do thiazides and ultrafiltration play in diuresis, why does diuretic-induced metabolic alkalosis happen and what should you do about it?
• 38:09 Expert Recap

Show notes, transcript and references: https://www.coreimpodcast.com/2020/06/24/5-pearls-on-inpatient-heart-failure/

ACP CME: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Tag: Cardiology, BNP, cardiorenal syndrome, beta-blockers, CoreIM, IMCore

SNF vs. NH? SAR vs. SNF? What are the differences in resources, nursing and clinician oversight and who pays for what?!

Show notes, transcript and references: https://www.coreimpodcast.com/2020/06/10/snf-sar-nh-alf-and-more-discharge-options-interprofessional-education-series/

ACP CME: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Time stamps:

• 04:07 SAR vs SNF
• 13:35 Long term Nursing Home Care
• 18:30 Assisted Living Facility
• 24:40 Acute rehab
• 26:11 LTACH
• 27:49 Home

Tags: Subacute rehab, skilled nursing facility, long-term acute care hospital, CoreIM, Core_IM, hospital medicine, family medicine, emergency medicine, physician assistant, nurse practitioner, interprofessional education

• 01:37 Sodium restriction guidelines
• 07:13 Current data in outpatient data
• 11:32 Do inpatient studies show signal?
• 13:44 Physiology behind sodium balance
• 16:27 Take away and clinical applicability

Show Notes, Transcript, References: https://www.coreimpodcast.com/2020/05/06/outpatient-advanced-care-planning-during-covid-19/

• 01:32 COVID Crisis as an Outpatient and Advance Care Planning (ACP)
• 08:06 The virtual visit
• 12:44 Vital Talk Mnemonic:  “CALMER”
• 22:03 Challenges to Outpatient COVID Care
• 26:03 Parting Thoughts

1. Disconnection/connection: Patients
2. Disconnection/connection: Family/friends
3. Disconnection: Security, Certainty
4. Connection: Other clinicians
   • Sharing fears, supporting each other)
   • Shared ethos in healthcare (one workforce, no division of specialty or hierarchy)
5. Conclusion: Post-traumatic growth / Peri-Traumatic Growth

Thank you to everyone we interviewed, particularly to the voices you heard:

Dr. Kimberly Manning (@gradydoctor)

Dr. John Hwang (Hoofbeats segment)

Dr. Steve Liu (Mind the Gap segment)

Dr Katherine Arthur

Dr. Maria Garcia-Jimenez

Dr. Kelsey Luoma

Hosts:

Dr. Margot Hedlin (@MargotHedlin) - Introduction and Ending

Dr. Tamar Schiff

Dr. Michael Shen (also audio editing)

Dr. Jafar Al-Mondhiry (@mondhiry)

tags: COVID19, COVID-19, CoreIM, coronavirus, narrative medicine

What is your approach to goals of care conversations, particularly during COVID-19? How do you navigate some of the new challenges with COVID19?

Show notes, transcript and references: https://www.coreimpodcast.com/2020/04/22/goc-on-inpatient-service-during-covid-19/

Time stamps:

• 05:54 Laying the groundwork
• 08:56 Asking permission, eliciting values and making a recommendation
• 15:55 When a patient is dying
• 16:42 Sharing the prognosis first
• 20:28 Functional status post-CPR
• 21:52 Headline statement
• 23:40 Virtual and PPE Communication Challenges
• 25:28 Separate process from outcome

Tag: coronavirus, COVID, CoreIM, Sars-cov-2, medicine floors, wards, advanced care planning

How do you organize your day? How do you minimize exposure of yourself and your colleagues? What are the new things to keep in mind with discharging patients?

Show notes, transcripts and references:

CME Credit with ACP: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Time Stamps

• 02:37 Entrance and Exit strategy
• 04:25 Prioritizing patient acuity
• 08:14 PPE uses
• 11:11 Respiratory concerns in COVID-19 patients
• 16:35 Patient examination
• 18:49 Family updates
• 20:56 Oxygen requirements
• 23:12 Medications
• 24:08 Discharging patients
• 31:00 What we mean by isolation

tag: coronavirus, COVID, CoreIM, sars-cov-2, medicine wards

Practical tips on starting estrogen or testosterone on patients who are transgender and approach to primary care with cancer screening.

CME Credit with ACP; https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Show notes, transcripts, and references: https://www.coreimpodcast.com/2020/04/01/5-pearls-on-transgender-health-hormone-therapy-and-preventive-screening/

Time Stamps:

• 02:54 Hormone therapy contraindications
• 07:09 Time course for hormone changes
• 10:21 Hormone risks
• 19:09 Hormone treatment options
• 25:22 Preventative Care Screening

Tags: CoreIM, gender affirming care

Practical tips on Gender Affirming Care!

Show notes, transcript and references

Time Stamps:

• 02:43 The Gender Unicorn and how it helps us better understand gender identity,  expression, and sex assigned at birth
• 11:15 Gender dysphoria
• 14:16 The organ or anatomical inventory
• 16:46 The inevitability of mistakes
• 18:39 Ways to ensure gender-affirming care in clinic

What goes into a capacity assessments? Is it just reciting risks, benefits and alternatives? Explore this and more on this At the Bedside Episode!

Show notes, Transcript and References: https://www.coreimpodcast.com/?p=22310

Time Stamps:

• 2:04 Introduction to decision making
• 4:12 Choice
• 8:24 Understanding
• 11:22 Appreciation
• 13:58 Reasoning
• 21:55 Common myths and misconceptions
• 25:11 When and how to call a psychiatry consult for capacity assessment
• 27:47 Conclusion

Tags: CoreIM, AMA Discharges, Psych, Competency, medical ethics, medical humanties

• 03:10 The art of diagnosing the flu
• 05:17 Bayesian statistics and the diagnostic odds ratio
• 07:09 The ins and outs of diagnostic testing for the flu
• 08:44 Changes in influenza guidelines - testing and treatment
• 11:17 The not-so-rosy origin story of neuraminidase inhibitors (NAIs)
• 13:47 Neuraminidase inhibitors (NAIs), mortality benefit and limitations of studies
• 15:49Take aways

What is the difference between a case manager and social worker? What are the limitations that social workers and case managers face? How do you create a safe space for the interdisciplinary team?

Show Notes and References

Get CME-MOC credit with ACP!

Time Stamps:

• 03:54 What are the various roles within a multidisciplinary teams?
• 10:42 Understanding limitations of social workers and case managers
• 15:55 The “behind the scenes” paperwork
• 18:42 Insurance and medications
• 22:17 Insurance and disposition options
• 25:08 The importance of creating a safe space for better communication

What are the symptoms? What distinguishes coronavirus from other influenza-like illness? When coronavirus is suspected, what should you do?

Show notes and references

CME credit: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Time Stamps

• 01:30 Novel parts of coronavirus

• 03:00 What symptoms do patients present with for the novel coronavirus?

• 04:22 What distinguishes coronavirus from other influenza-like illness?

• 05:31 When coronavirus is suspected, what should you do?

• 07:13 What does testing for coronavirus entail?

• 09:06 What kind of isolation is required?

• 10:13 Do patients need to be isolated in biocontainment units?

• 10:42 What is treatment for the novel coronavirus?

• 12:30 Potential for vaccines

• 15:23 What is R0?

• 17:12 Animal reservoirs with 2019-nCoV, SARS, and MERS

• 19:18 What should we tell patients for prevention?

How do you learn from diagnostic errors? Walk through a case that the host had initially gotten wrong and uncover possible reasons as why from data gathering to hypothesis generation to the interplay between hypothesis generation and evaluation. Learn interesting tidbits on prior work in medical education around how we think, particularly around diagnostic failures.

CME Credit: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im

Time Stamps

• 02:39 Case Introduction
• 04:46 Yes/No questions with our first two discussants
• 18:43 The diagnosis is revealed
• 21:14 Why did I miss the diagnosis?
• 27:44 Using diagnostic problem solving to break down the case and understand our errors
• 30:20 The importance of data gathering
• 30:49 Introducing our third clinician
• 34:17 Hypothesis generation
• 37:11 The interplay between hypothesis generation and evaluation
• 38:34 The win-stay, lose-shift heuristic
• 41:33 Cognitive forcing strategies
• 49:32 Knowledge vs. experience

Tags: Dermatology, rash, DRESS, AGEP, varicella

Why is prognostication hard? How do we improve at communicating prognosis? How should we approach uncertainty? Explore this and more on this At the Bedside episode!

Prognosis Calculators, Transcript and References

Time Stamps

• 02:48 What is prognosis?
• 04:00 Why offer prognostication?
• 08:32 Why is prognostication hard?
• 16:41 How do we improve at communicating prognosis?
• 21:56 How should we approach uncertainty?
• 31:06 Take Aways

Tag: life expectancy, CoreIM

• 02:59 The history of the influenza virus
• 08:18 What does the influenza vaccine target?
• 13:20 Chickens, and bugs, and mammalian cells, oh my! How the vaccine is made.
• 14:00 What to do about egg allergies.
• 15:53 Vaccine effectiveness and herd immunity.
• 17:43 Waning immunity and other debates

Show Notes, Transcript and References

Get CME-MOC credit with ACP!

Explore gaps in your knowledge about the home health world, particularly on home health aides!

• Get CME-MOC credit with ACP !
• Full transcript, show notes, references

Time Stamps:

02:33 What support do our patients have at home and how does those people play a role in their care?

06:00 Are there various types of home care workers?

07:25 What role do home attendants play in caring for a patient?

08:31 What tasks do home health aides do?

10:11 What are the types of "skilled carez'?

13:17 What can Medicare cover for older adults in terms of home health aides?

15:17 How does Medicare define homebound?

16:03 How does having Medicaid impact access to home care?

19:10 What if a patient isn’t eligible for Medicare or Medicaid?

19:43 What is the cost to use a private agency for home health services?

24:02 What are some challenges that home health aides face?

25:42 What are “plans of care”?

30:01 Who makes up the home care workforce?

31:52 When patients get discharged from the hospital, do they go home to the same home care assistance?

• 4:30 What is the daily risk of thrombosis if HIT Is left untreated?
• 5:40 What happens during platelet activation?
• 07:11 How long does it take for patients to develop for IgG antibodies to Heparin to form?
• 09:52 Is HIT common?
• 10:28 Who is at higher risk for HIT?
• 11:48 Why does low molecular weight heparin have a lower risk for HIT than unfractionated heparin?
• 15:30 Approach to thrombocytopenia
• 17:44 How do medications cause thrombocytopenia?
• 18:38 With medications, what is the time course between medication initiation and thrombocytopenia?
• 22:20 What is the sensitivity and specificity of anti-PF4 antibody?
• 23:58 How does the serotonin-release assay (SRA) work?
• 29:10 What type of anticoagulant do you choose for treating HIT?
• 31:58 Why is it important to not use warfarin in patients with platelet counts <150,000?
• 33:32 What is the treatment duration for a patient has confirmed HIT?
• 36:29 Dr. Cuker’s story and the "Scarlet H"
• 39:07 Dr. Linkin’s Recap
• 42:25 Dr. Linkin’s story
• 44:37 Pearl 5: Throwback to coronary calcium scores

• 02:33 Episode preview and Guest Introductions
• 04:20 Definition of Gallows Humor
• 07:25 Gallows Humor by Comedians vs Patients vs Physicians

The Good

• 08:15 Benefits/Functions of Humor in General
• 11:10  Connection
• 13:07 Coping/Catharsis
• 16:22 Resistance Against Oppression
• 19:03 Humor as our Authenticity/Humanity

The Bad, The Ugly

• 21:01 Unintended Audiences (e.g., patients, families)
• 25:30 “Corporeal” Joking
• 28:00 Toxic Role Modeling
• 31:10 Desensitization/Losing Empathy
• Tips, Takeaways & Conclusion33:48 Challenging Inappropriate Jokes
• 35:45 Excessive Gallows Humor:  Signal of Distress?
• 37:17 Using Gallows Humor: Questions to Ask Yourself
• 38:40 Keeping the Faith!

• 41:11 Excerpt from Man’s 4th Best Hospital by Samuel Shem

Transcript and References

Tag: medical humanities, medical ethics, CoreIM, IMCore

1st outpatient clinical reasoning case on Core IM Hoofbeats!

Get CME-MOC Credit (live at 9AM EST on 10/16)

Time Stamps

• 01:18 Case introduction
• 11:40 The Casablanca strategy
• 23:17 The diagnosis revealed
• 25:30 Logical fallacy: Denying the antecedent
• 33:22 Components of illness scripts
• 41:37 Conclusion

Show notes, transcripts and references!

Do you have a good case or an expert you would like to suggest for an episode? Send it our way at hello@coreimpodcast.com

Tag: normocytic anemia, splenomegaly, CoreIM, endocarditis, clinic case

Go deeper into the world of blood cultures!

Time stamps

• 04:10 Review of Choosing Wisely Guidelines
• 05:55 What are estimated incidences of positive blood cultures?
• 06:17 Which clinical signs or patient history is more likely to have positive blood cultures?
• 09:48 What is the estimated incidence of false positive blood cultures?
• 11:01 What infections more likely to have bacteremia?
• 13:50 How do positive blood cultures impact patient outcomes and the use of resources?

Show notes, transcript, and references

Tags: Infectious disease, CoreIM, pyelonephritis, cellulitis, community acquired pneumonia

Practical tips on smoking cessation! Get CME Credit with ACP!

Full Transcript with References and Show Notes

Time Stamps

• 04:50 What questions are important to ask after a patient who contemplative about quitting tobacco?
• 07:00 Is quitting abruptly on a quit date or gradual cessation to a quit date better?
• 08:10 How can technology help support patients who are trying to quit?
• 08:49 How should we prepare patients who quit smoking and are worried about weight gain?
• 11:06 How can we try to convince patients to use medication as assistance to quit smoking?
• 11:50 What is the most effective nicotine replacement approach?
• 13:54 What are the potential side effects of the nicotine patch?
• 15:00 What should we prescribe for patients who smoke <5 cigarettes a day?
• 16:28 How can we determine how severe a patient’s nicotine dependence is?
• 18:26 When is the ideal frequency of nicotine gum or lozenge?
• 21:45 How does varenicline work?
• 25:05 Can you start varenicline in patients who have had psychiatric history?
• 27:15 What major side effect is seen in patients taking bupropion?
• 29:15 How do e-cigarettes work?
• 31:18 How should we approach adding e-cigarettes into a patient’s plan for quitting?
• 31:42 How should we discuss e-cigarette use with our patients?
• 33:47 Recap
• 39:54 Screening for Barrett’s Esophagus

Show Notes, Full Transcript and References

• 3:03 Demographics of AMA discharges
• 5:59 Clinician/System related factors of AMA discharges
• 10:30 Strategies for mitigating AMA Discharges
• 15:59 Do we have to make patients sign the AMA form?
• 18:27 Do insurances deny payment for patients who leave AMA?
• 23:09 Take Away Points

Tags: shared-decision making, harm reduction

We hope these stories can make us more introspective and open minded on how these concepts can affect each one of us differently.

Let's continue the discussion on the Women in Medicine Twitter chat on 8/25 at 9pm EST !

Full Transcript and Show Notes

• 2:07 Introduction to one woman’s journey
• 3:00  Stereotype Threat
• 6:15 Not all Anger is Created Equal
• 10:17 Asking and Writing Your Own Job Description
• 13:08 Imposter Syndrome
• 15:50 Breaking Points to Self Care
• 18:50 Work Life Integration
• 21:40 Support Networks

20 Qs with Core IM Team vs. Expert Discussant !

Full Transcript and Show notes

Get CME-MOC Credit for listening to this episode (live at 09:00 am EST on 8/7)

Time Stamps

• 00:20 The game of medical Twenty Questions
• 04:37 Case introduction
• 05:50 The CoreIM team attempts to solve the case
• 15:36 The discussant’s diagnostic schema for abnormal bleeding
• 23:37 Primary versus secondary hemostasis
• 30:33 The pathology report !
• 37:38 Criteria for the final diagnosis
• 38:46 Dissecting a diagnostic coup
• 49:42 Conclusion

Do you have a good case or an expert you would like to suggest for an episode? Send it our way at hello@coreimpodcast.com

Tags: Coagulopathy, Bleeding Disorder, Diagnostic Schema, Von Willebrand's Disease, Clinical Reasoning

Night and Day… join us for part II of our exploration into why we prescribe medications in the morning vs. at night, featuring statins!

03:28 How do statins and cholesterol synthesis work again, anyway?

04:00 Power in numbers - what do the meta-analyses say about timing of statins?

04:40 The long and short of it - how half-life may dictate when to take your statin.

07:35 Effect magnitude - does medication timing actually really impact patient outcomes?

10:30 Practical matters - so what should we tell patients?

11:05 Review of teaching points

Show notes, transcripts and references

Solidify your knowledge on Coronary calcium scores and Coronary CTAs!

ACP members can claim CME-MOC Credit !

Quiz yourself on the 5 pearls we will be covering below:

• 3:10 What are the big picture differences of functional stress tests and anatomical cardiac tests?

• 7:48 What is the role of coronary artery calcium scores in managing coronary artery disease (CAD)?

• 16:20 How do coronary CTAs compare to stress tests?

• 24:28 When should we avoid CTA?

• 29:33 How do we communicate coronary CTA results with patients?

• 36:02 Recap

Full transcript, infographics and show notes !

• 01:13      Introduction
• 05:27      Question 1: What makes a patient difficult for you?
• 13:22      Question 2: What is a “good outcome” when working with difficult patients?
• 23:05      Question 3: What have you learned from your difficult patients?
• 31:56      Conclusion

Show notes, Transcript, Further Reading

Transitions can be hard. Laugh, commiserate and be inspired by these July stories in medicine!

Very big thank you to everyone who told their stories !

Let's help each other feel a little less alone in the struggle, be more understanding and compassionate or laugh at ourselves. Please share this episode with colleagues.  Do you have a July story? Email us at hello@coreimpodcast.com.

Lets continue conversation over social media. Which stories moved you? Which July stories can you relate to? Tweet us, find us on instagram at coreimpodcast or Facebook. Good luck this coming July !

Dissect clinical reasoning and dive deeper into an interesting case!

• 02:04     Initial Presentation
• 03:03     The Core IM team tackles the case
• 09:30     Social History
• 16:05     Physical Exam
• 22:47     An exercise in Bayesian inference
• 36:35     Pre-mortem
• 43:37     Revealing the diagnosis
• 48:57     How do we define diagnostic success?

Full transcript with references and show notes

• Why do we dose warfarin at night? (2:45)
• Back to the basics - what are the pharmacodynamics of warfarin and how does vitamin K intake matter? (4:28)
• Practical matters - so what should we tell patients (6:14)
• Dippers and non-dippers - what happens to blood pressure (BP) at night? (9:32)
• The surprising link between dipping and cardiovascular outcomes (11:15)
• Timing is everything… or is it? The evidence behind taking BP meds at night (11:58)
• Review of teaching points (15:58)

What is your prescribing practice with blood pressure medications? Leave a comment, tweet us or share with us on instagram or facebook on how you dose BP meds?

Transcript with references and show notes

Solidify your knowledge on stress tests! Quiz yourself on the 5 pearls we will be covering:

• What are the indications for a stress test? (2:18)
• How to choose  stress protocol in a stress test? (8:29)
• How to choose diagnostic modality in a stress test? (14:46)
• How do we interpret results from stress tests, and how should this be communicated to patients? (24:08)
• Pearl Recap (31:13)
• Risk of contrast induced nephropathy between arterial and venous contrast load (36:02)

For full transcript, infographic and show notes: https://www.coreimpodcast.com/2019/04/24/stress-testing/

Tags: Internal Medicine, Internist, Primary Care Physician, Hospitalists, Emergency Medicine, Nurse Practitioner, Physician Assistant, Family Physician, Cardiology

• New features in this episode [0:30]
• Case one: 66M w RUQ pain [1:09]
• Case two: 41M w Afib in RVR [9:26]
• Case three: 50M w Syncope [14:33]
• Reveal [19:57]
• Retrieving illness scripts [22:29]
• Typical versus Atypical presentation of diseases [26:12]

For full transcript and show notes: https://www.coreimpodcast.com/?p=21028

Tag: medical education, clinical cases, expert clinicians, internal medicine podcast

Check out part 1: Acute Coronary Syndrome and TIMI Risk Score

Lets go deeper into

1) How the chest pain history correlates with pathophysiology? [2:40]

2) How has high-sensitivity troponin changed the way we think about unstable angina? [7:34]

For transcript, infographic and show notes: https://www.coreimpodcast.com/2019/03/27/unstable-angina/

• How effective are non-opioids? ( 3:17)
• Are NSAIDs contraindicated in patients with kidney, liver or heart disease? If not, how can we use them safely? (10:51)
• What are the best practices for patients who require opioid analgesia? (19:00)
• When prescribing opioids at discharge what can we do to minimize harm? (25:02)
• Throwback to mechanism of acetaminophen and NSAIDs (27:14)
• How do we believe tylenol works and how does that compare to NSAIDS? (28:27)

For full transcript of the audio and show notes: https://www.coreimpodcast.com/2019/03/13/5-pearls-on-pain-management/

• The basics – what is acute coronary syndrome? (4:08)
• Clinical context matters – angina pectoris, atypical chest pain, and troponins (5:22)
• You can’t just “cath” everyone – risk stratification to identify patients with high mortality risk (9:42)
• TIMI isn’t perfect – the issues with the score and MACE outcomes (14:00)
• Review of teaching points (17:58)

For full transcript and show notes: https://www.coreimpodcast.com/2019/02/27/acute-coronary-syndrome-acs-and-the-timi-score/

Dissect an interesting case and improve your clinical reasoning skills!

Time Stamps:

• New features in this episode [00:25]
• Data point 1: Early hypothesis generation? [03:20]
• Data point 2: Pertinent negatives? [11:18]
• Data point 3: Representativeness heuristic over-represented in medical education? [13:28]
• Data point 4: Economical hypothesis generation by expert clinicians [19:20]
• Data point 5: Diagnosing diagnostic error [22:10]
• Data point 6: Moving toward a final diagnosis [27:11]
• Case resolution [29:50]

Solidify your knowledge on Barrett's Esophagus and more! Quiz yourself on the 5 pearls we will be covering:

1. What is Barrett’s esophagus and why should we care? (4:12)
2. Who do we screen for Barrett’s, and why? (8:41)
3. How do we screen for Barrett’s and counsel? (13:50)
4. How do we treat and monitor Barrett’s esophagus? (18:21)
5. Take Aways (21:45)
6. Throwback to trending troponins (23:05)

For full transcript of the podcast, show notes and references: https://www.coreimpodcast.com/2019/01/30/5-pearls-on-barretts-esophagus/

Dissect an interesting case and improve your clinical reasoning skills!

Time stamps:

• Player three has entered the game! [0:15]
• Case presentation, part 1 [1:20]
• First impressions [3:24]
• Rethinking another provider’s diagnosis [4:36]
• Interpreting the test of treatment [8:48]
• Keeping your instincts on a leash? [10:58]
• Case presentation, part 2 [12:33]
• Diagnostic schemas [14:30]
• Our discussant’s differential and the final diagnosis [17:46]
• Shira’s cognitive autopsy [23:02]

For full transcript and show notes: https://www.coreimpodcast.com/2019/01/16/hoofbeats-34m-with-fever-headache-and-myalgias/

Solidify your knowledge on troponins and more! Quiz yourself on the 5 pearls we will be covering:

1. What aspects of the history are concerning in a patient with a positive troponin? (4:00)
2. What is the difference between the TIMI, GRACE, and HEART scores, and how should we use them in the evaluation of a patient with an elevated serum troponin? (8:42)
3. How does the change in troponin over time help with diagnosis, and what should we consider in a patient with uptrending troponins but an unremarkable ECG? (14:48)
4. What can a “negative but detectable” troponin tell you about any patient, not just those with suspected ACS? (21:31)
5. Pearls Recap (25:26)
6. Throwback – what are the first-line medications for alcohol use disorder? (28:36)

For full transcript of the podcast, show notes and references: https://www.coreimpodcast.com/2019/01/04/5-pearls-on-troponins/

Tags: chest pain, cardiology, myocardial infarction, acute coronary syndrome

Let's dive deeper into the world of acetaminophen and fever and how it may work and patient outcomes

Time Stamps:

1. What data is there to support the use of acetaminophen as a fever reducer? (2:08)

2. Does acetaminophen improve patient outcomes? (4:30)

3. How does acetaminophen compare to other medications like NSAIDs? (9:56)

4. What is the mechanism of acetaminophen action? (10:50)

5. Review of teaching points (16:02)

For full show notes and transcript of audio: https://www.coreimpodcast.com/2018/12/19/mind-the-gap-on-acetaminophen-fevers-pathophysiology-and-patient-outcomes/

Dissect an interesting case and think about the way clinicians think! Many clinical reasoning pearls here:

Time stamps:

1. Case [1:19]
2. Diagnostic weight [8:42]
3. Hypothesis driven reasoning [12:26]
4. Anomalous clinical data [19:30]
5. Final diagnosis [22:20]
6. Take away points [31:21]

Human Dx  Case link: https://www.humandx.org/o/co7yrer3dim2y59t5c0sbd370?s=FEED

For show notes: https://www.coreimpodcast.com/2018/12/05/hoofbeats-43m-with-diarrhea/

Women in medicine inspire us with what they would tell their younger selves. Some of the speakers with Shreya Trivedi MD @ShreyaTrivediMD at the Women in Medicine GirlMedLive Conference:

Qaali Hussein MD @QaaliHussein1 Clinical Pearl @ClinicalPearl Marguerite Duane MD @mduanemd Kate Prior MBBS @doctorwibble C. Nicole Swiner MD @docswiner Carmen Landrau MD @DrLandrau Jessica Willett MD @jkwillettmd Ilene Brenner MD @irb123 Joannie Yeh MD @BetaMomma Karen Davidson, Esq karend@kdavidsonlaw.com Suzanne Feigofsky MD @DrSuzyFeigofsky GirlMedLive: https://www.girlmedmedia.com/

Episode page: https://www.coreimpodcast.com/2018/11/21/what-would-you-tell-your-younger-self/

Tags: career development, professional development, lifelong learning, burnout, imposter syndrome, mentorship, worklife balance

1. Throwback: At what levels of drinking does unhealthy alcohol use start, and how do you screen for unhealthy alcohol use? (1:47)
2. What does the brief intervention and counseling part of SBIRT entail? (4:43)
3. What are the first line medications for AUD and contraindications to them? (11:11)
4. What are the  second-line medications for AUD and their limitations? (18:14)
5. What new therapies are being studied for for alcohol use disorder? (22:09)
6. Pearls Recap (25:06)

For full transcript of the podcast, show notes and references: https://www.coreimpodcast.com/2018/11/07/5-pearls-on-treatment-of-alcohol-use-disorder/

tag: naltrexone, acamprosate, gabapentin, topiramate, SBIRT, neuromodulation, nalmafene, psychaedelics, audit-c

Dissect a working diagnosis through a process of validation!

Time Stamps:

1. Your collective differential [0:40]
2. The test results (that you asked for) are in... [2:13]
3. The hospital course, and the diagnosis (or is it?) [7:10]
4. Validating a diagnosis: Base rate, adequacy, and coherence [8:30]
5. Revisiting the differential [14:44]
6. What to do when there is no final diagnosis? [17:39]

For full show notes: https://www.coreimpodcast.com/2018/10/24/hoofbeats-85f-with-acute-ams-part-2/

Tags: Clinical reasoning, Diagnostic Uncertainty

Submit your diagnosis or differential for this episode's case at HumanDx.org (free registration required): http://hdx.org/2VP ! Part 2 (releasing 10/24) will have the final diagnosis!

Time stamps:

1. A new challenge and the rules of the game (1:13)
2. Introduction to Human Dx (3:06)
3. The case: An 85 year-old woman with paranoid delusions (5:28)
4. What exactly is problem representation? (15:15)
5. Building the differential (19:53)

Join us in this episode with Doctors Who Create where we explore how Core IM was started and some things that happen behind the scenes!

Episode page: https://www.coreimpodcast.com/2018/09/27/meet-the-producers/

Let's go deeper into the world of UTIs and delirium!

1. The basics – what are the official (IDSA) definitions for bacteriuria, pyuria, and UTI? (02:07)
2. The lay of the land – how common are bacteriuria and delirium? (07:09)
3. The big money question – do UTIs really cause delirium and what does the evidence tell us? (10:50)
4. Review of teaching points (15:59)

Full show notes: https://www.coreimpodcast.com/2018/09/12/mind-the-gap-uti-delirium/

Solidify your knowledge on Proton-Pump Inhibitors (PPIs) and more! Quiz yourself on the 5 pearls we will be covering:

1. What are associated adverse effects for patients are on long-term PPIs? (2:02)
2. What are strategies to get your patient off PPIs?  (10:57)
3. How do histamine-2 (H2) receptor antagonists blockers work and how can it explain why H2 blockers might not be as effective as PPIs? (13:30)
4. How should you educate patients to take PPIs to get the maximize benefit? (16:48)
5. How do you manage ongoing symptoms in patients on PPIs? (21:41)

For full transcript of the podcast and references: https://www.coreimpodcast.com/2018/08/29/5-pearls-on-ppis/

Dissect an interesting case and think about the way clinicians think! Many clinical reasoning pearls here:

1. Case history and exam 00:40
2. Causal models 11:24
3. Facets versus diagnoses 13:25
4. Problem representation 16:37
5. Part two of the case 17:10
6. Occam’s razor, Hickam’s dictum, and Crabtree’s bludgeon 23:00
7. Diagnostic uncertainty 27:10
8. Learning points 34:24

For show notes: https://www.coreimpodcast.com/2018/08/15/hoofbeats-57f-with-confusion/

Lets go deeper into the misunderstood side of Vancomycin!

1. Where did vancomycin come from, and why is it so controversial? (0:28)
2. What is vancomycin-induced nephrotoxicity and how common is it? (4:37)
3. Vancomycin trough monitoring – what is it good for?  (7:28)
4. AUC to MIC ratio – the real math behind vancomycin dosing (7:53)
5. Review of teaching points (10:27)

Full show notes: https://www.coreimpodcast.com/2018/08/01/mind-the-gap-vancomycin/

Solidy your understanding of unhealthy alcohol use! Quiz yourself of the 5 Pearls we will be covering:

1. What is alcohol use disorder (AUD), and how is it different from unhealthy alcohol use?
2. Who should we screen for unhealthy alcohol use, and which screening tools are preferred?
3. What are the consequences of unhealthy alcohol use?
4. Can moderate alcohol be good for patients, and if so, how much is “moderate”?
5. Who, how and how often should patients with chronic hepatitis B infection be screened for hepatocellular carcinoma?

For full show notes: https://www.coreimpodcast.com/2018/07/11/5-pearls-unhealthy-alcohol-use/

Dissect an interesting case and think about the way clinicians think! Many clinical reasoning pearls here:

1. Part one of case (0:56)
2. Cognitive ease and strain (03:51)
3. Metacognition and routine diagnostic timeout (08:15)
4. Think outside the box of organ systems (11:19)
5. Illness behavior (12:30)
6. Part two of case (14:06)
7. Algorithms (17:57)
8. Fast thinking & pattern recognition (19:30)
9. Slow thinking & analytical reasoning (21:31)
10. Diagnosis (25:15)
11. Takeaways (26:52)

Be inspired by why so many are proud to be in General Internal Medicine (GIM)!

Episode page: https://www.coreimpodcast.com/2018/06/23/celebrating-proudtobegim/

Let’s take your breath away… with a review on steroids in treating COPD exacerbations!

Time Stamps

1. How does GOLD (Global Initiative for Chronic Obstructive Lung Disease) define a COPD exacerbation? (2:44)
2. What outcomes do steroids actually improve in treating a COPD exacerbation? (5:08)
3. What is the evidence behind a 5 day steroid “burst”? (7:20)
4. Are IV steroids more powerful than PO? (9:00)

For full show notes: https://www.coreimpodcast.com/2018/05/30/mind-the-gap-steriods-in-copd/

Solidify your understanding of contrast-induced nephropathy (CIN)! Quiz yourself on the 5 pearls we will be covering:

1. Are there diagnostic criteria for CIN? (2:11)
2. Is there a difference between exposure to intra-arterial vs. intra-venous contrast in terms of risk of CIN? (6:28)
3. What are the biggest risk factors for CIN? (14:48)
4. What preventive measures have been shown to best reduce the risk of CIN? (19:41)
5. Can ESRD patients on hemodialysis still suffer from CIN? (23:32)
6. Recap (25:49)

For full show notes: https://www.coreimpodcast.com/2018/05/16/5-pearls-contrast-induced-nephropathy/

Dissect an interesting case and think about the way clinicians think! So many clinical reasoning pearls here:

1. Part 1 Case (2:05)
2. Framing bias (7:07)
3. Data-driving reasoning  (11:48)
4. Hypothesis-driven approach (12:38)
5. Periodic paralysis syndromes (16:08)
6. Representativeness heuristic (17:26)
7. Part 2 Case (20:51)
8. Pivot Points (31:36)
9. Diagnosis (35:55)
10. Take aways (37:20)

Solidify your knowledge on adrenal insufficiency! Quiz yourself on the 5 pearls we will be covering:

1. What are signs and symptoms of chronic adrenal insufficiency (AI)? What is the most sensitive? (2:02)
2. How do we diagnose and differentiate types of adrenal insufficiency? (6:05)
3. How sensitive and specific are the diagnostic tests for AI & at what cutoffs? (12:06)
4. Can we both test and treat adrenal insufficiency at the same time? (16:40)
5. Throwback: How do hypokalemia and hepatic encephalopathy connected? (24:55)
6. Dr. Nidhi Agrawal Recap (19:20)

For full show notes: https://www.coreimpodcast.com/2018/04/18/5-pearls-chronic-adrenal-insufficiency/

1. Who should be screened for latent tuberculosis infection (LTBI)? (1:45)
2. What screening tests are available and how do they differ? (6:30)
3. What are the LTBI treatment options available? (10:24)
4. What are the major adverse drug effects to consider? (13:28)
5. How frequently should you check liver function tests in a patient being treated for LTBI? What do you do with the results? 17:43
6. Dr. Caplan-Shaw Recap (21:29)

For full show notes: https://www.coreimpodcast.com/2018/03/28/5-pearls-latent-tuberculosis-infection/

Solidify your knowledge on albuminuria! Quiz yourself on the 5 Pearls we will be covering:

1. How good is a dipstick, urinalysis and UACR in detecting albuminuria? (1:42)
2. What conditions that lead to transient proteinuria? What is the appropriate interval to recheck and how should be it be repeated? (5:14)
3. Who should be screened for albuminuria and can it prognosticate risk for cardiovascular mortality? (7:47)
4. Does increasing RAAS inhibition improve renal outcomes? (10:57)
5. Throwback Question: How do you prescribe oral iron and what tips do you tell your patients? (13:11)

For full show notes: https://www.coreimpodcast.com/2018/02/28/5-pearls-albuminuria/

Let’s go deeper into to why we think about diseases the way we do: COPD Classifications through the years!

1. How did prior understanding of COPD pathophysiology lead to COPD classifications in the past? (3:25)
2. How is COPD diagnosed? (6:13)
3. How has COPD been classified and why? (6:42)

For full show notes: https://www.coreimpodcast.com/2018/02/14/mind-the-gap-copd-classifications/

Quiz yourself on the following 5 Pearls on Chronic Hepatitis B (HBV) Management!

1. What is the focused history, physical and lab workup in a patient with chronic HBV? (1:40)
2. What is the best imaging to evaluate for intermediate stages of liver fibrosis? (4:06)
   • What scoring tools can you use to estimate fibrosis and what are their limitations?
3. What factors do you use to assess which patients get treatment? (7:41)
4. What drugs are available for HBV treatment and how do you choose? (11:18)
5. Which chronic HBV patient should be screened for HCC, and how often? (14:45)

For full show notes: https://www.coreimpodcast.com/2018/01/31/5-pearls-on-chronic-hepatitis-b-2/

Solidify your knowledge on Chronic Hepatitis B (HBV) screening and vaccinations! Quiz yourself on the 5 Pearls we will be covering:

1. Who do you screen for HBV? (3:37)
   • How is HBV transmitted and who is at risk for HBV reactivation?
2. What tests do you order when screening for HBV?   (10:48)
   • In which populations is HBV vaccination recommended?
3. What are the four possible meanings of an isolated positive total anti-HBc? (13:55)
4. In an asymptomatic adult, is it necessary to send an anti-HBc IgM to distinguish acute from chronic HBV infection? (15:01)
5. What are the implications of seroconversion of HBeAg from positive to negative? (16:19)

For full show notes: https://www.coreimpodcast.com/2018/01/17/5-pearls-on-chronic-hepatitis-b/

1. What are other causes of altered mental status in cirrhotics? (1:45)
   • What are common precipitants for an acute episode of HE?
2. What is asterixis? (6:10)
   • What is the diagnostic utility of a cirrhotic with asterixis?
3. How do lactulose & rifaximin reduce symptoms of HE? (11:00)
   • What are their indications?
4. What is the connection between hypokalemia and HE? (14:10)
5. What is the discriminatory power of an ammonia level in HE? (16:40)
   • In what situation does the NH3 has stronger predictive value?

For full shownotes: https://www.coreimpodcast.com/2017/12/13/5-pearls-on-hepatic-encephalopathy/

Part 2 on Abdominal Paracentesis ! Let's go deeper

Time Stamps

Should a cirrhotic’s INR and platelets deter you from doing a paracentesis? (3:15)

Do generalist have worse procedure complications than specialists?  (5:40)

Do you need to send ascites fluid in blood culture bottles? (6:10)

For full shownotes: https://www.coreimpodcast.com/2017/11/29/mind-the-gap-abdominal-paracentesis-2/

1. Should patients be screened for iron deficiency? If so, who and how often? (1:40)
2. What are the indications for diagnostic endoscopy in iron deficient patients? (3:23)
3. How should you advice patients to take oral iron? (5:53)
   • What is optimal dosing for oral iron?
4. In which patients would you consider IV iron? What are the risks? (11:41)
5. Throwback Question: What is a medication-overuse HA? (14:44)

You have always been told to do a diagnostic paracentesis on admission in cirrhotics with ascites, but why? Can you just get away with clinical judgement to rule out SBP? Is faculty judgement any better? And if you’re going to do a paracentesis on admission, do you need to do it right away? Go deeper with Dr. Steve Liu and Dr. Janine Knudsen!

Click the link for the full show notes: https://www.coreimpodcast.com/2017/11/01/mind-the-gap-admission-paracentesis/

Time Stamps

1. What do guidelines say about diagnostic paracentesis in cirrhotics with ascites? (1:51)
2. Can we just use clinical judgement to decide if paracentesis is warranted? (3:13)
   • Do attendings have better clinical judgement than residents to rule out SBP?
3. Does timing of paracentesis on admission matter for mortality? (6:33)

Cement your knowledge on headaches with 5 Pearls on when imaging is indicated, approach to abortive medications, medication overuse headaches, when to use migraine prophylaxis and effective non-pharmacological treatment for migraines!

For full shownotes: https://www.coreimpodcast.com/2017/10/18/5-pearls-on-headaches/

Time Stamps

1. What are the indications for imaging for HA? (1:36)
2. What is your approach to abortive therapy for migraines? (4:45)
3. How do you diagnose medication overuse HA? (6:41)
4. What is your approach to migraine prophylaxis? (8:29)
5. What are some evidence based nonpharmacological therapies for migraines?  (10:42)

CORE IM is an independent consortium of educators aligned to create internal medicine-specific portable learning tools in the form of podcasts, corresponding show notes and illustrations. Segments include 5 Pearls and Mind The Gap.

For more information: https://www.coreimpodcast.com/2017/10/13/introducing-the-core-im-podcasts-5-pearls-mind-the-gap/

Sincerely,

CORE IM team:

Executive Producer: Shreya P. Trivedi, MD (@ShreyaTrivediMD)

Five Pearls Producer: Marty Fried, MD (@Marty_Fried)

Mind the Gap Producer: Steve Liu, MD

Advisors: Neil Shapiro MD, John Hwang MD, Vincent Santillo MD

Podcast editing and technical set-up: Harit Shah and Steven Liu MD

Director of Sound Design, Theme song: Shaun Finnegan

Artistic director: Dr. Mike Natter (@mike_natter)