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Friday, April 6, 2012

Still studying for the American Board of Internal Medicine Maintenance of Certification Exam: what's wrong with this picture?

Really nothing is wrong with still studying. I'm still enjoying it and absorbing some non-negligible percentage of what I'm reading. There is just a tremendous amount of stuff that has become commonly held truth since I last took this exam.

But as I study, which is still following the general form of reading a multiple choice question from the MKSAP (American College of Physicians Medical Knowledge Self Assessment Program) then reviewing various sources on anything that I don't feel totally confident about, some of the patient vignettes demonstrate a lack of attention to the big picture.

The multiple choice questions are all case presentations, which is good since it keeps me engaged. Here are a few of the more disturbing ones out of the hematology/oncology section which I am working on now, reworded, simplified beyond recognition.

1. A 70 year old severely demented man, living at home with his wife, very thin, presents in bad shape with respiratory failure and pneumonia. He is admitted to the intensive care unit, given antibiotics and IV fluids and supported on a ventilator. He is able to breathe on his own, ventilator is removed, wife decides he should go to a nursing home, he develops bruising and bleeding. The diagnosis? Vitamin K deficiency, not too hard to guess given the lab values and setting. But...pneumonia is "the old man's friend." Why didn't they have a discussion with their primary care doctor before he was put on the ventilator about the prognosis of severe dementia with malnutrition, and then maybe he wouldn't have had to die in a nursing home?

2. A 60 year old woman with a history of a smoldering bone marrow disease has 2 weeks of fatigue and bruising, presents to the emergency room. Her white count is high, platelets low, she has a fever. Her blood smear is shown, myeloblasts with Auer rods, diagnosis is acute myeloid leukemia. She also has some infection, as yet unidentified. But...why is she in the emergency room? She would have to wait hours, probably, surrounded with sick people from whom she could get even more infections, feeling lousy, and then see an ER doctor who didn't take the internal medicine board preparation course, and might potentially even miss the diagnosis. Certainly she has a primary care doctor and an oncologist somewhere who could coordinate her care. ER care is way more expensive than office care but is becoming sort of a standard for dealing with unplanned medical needs.

3. A healthy 59 year old woman without risk factors for a deep venous thrombosis (blood clot in the leg) presents the the ER with a swollen leg, but not terribly swollen and in a pattern that is more suggestive of an injury than a clot. Clearly the big worry is whether she has a blood clot. She could have any of a number of expensive imaging procedures, they suggest, or a relatively simple blood test called the D dimer which, if negative, effectively removes worry that she has a clot in the leg. But...D dimers are often false positive for various reasons, and doing a simple bedside ultrasound, which the ER doctor could do if the ultrasound tech wasn't right there, and could really do it for free since it takes 10 minutes or less, could get her reassured and out of there in next to no time. Most ER doctors don't know how to do this, but it would take them about an hour to learn. It wasn't one of the multiple choice options.

4. A 48 year old man presents with a swollen leg after a long trip somewhere. His ultrasound did show a blood clot, requiring anticoagulation. How long does he need to stay on expensive, injectible anticoagulation before he can transition to pills for 3-6 months? 5 days, of course. That's the way it has been forever, still is, related to how quickly the pills (warfarin is standard) take to actually work to prevent further clotting. But...in the last 6 months there have been 2 articles demonstrating that rivaroxaban (Xarelto), a new oral anticoagulant which works within minutes or hours rather than days, can effectively replace the injectible anticoagulant and the warfarin, which would mean that any but the most disabled or unstable patient could get a prescription and go home. Probably even go back to work, depending on what work was. This drug is expensive, but absolutely nothing compared to a day in the hospital. Plus rivaroxaban requires no blood test monitoring. How long will it take us to change? It will probably be pretty quick since the new drug has powerful Janssen pharmaceuticals as its champion. Maybe a year. Maybe longer.

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