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The Curbsiders Internal Medicine Podcast

Supercharge your learning as these board-certified Internists interview the experts to bring you clinical pearls, practice changing knowledge, and a healthy dose of humor. 

Aug 20, 2018

Things We Do For No Reason #TWDFNR highlights some widespread practices that are difficult to justify based on lack of proven health benefits, but significant cost (both financial and non-financial harms). Avoid these low value practices and inflated medical bills with tips from expert, Dr Lenny Feldman, MD, FACP, Associate Professor of Medicine Johns Hopkins. Topics include: renal ultrasound and urine electrolytes in acute kidney injury (AKI), folate deficiency and anemia work-up, prealbumin and malnutrition, blood transfusions, shellfish and contrast allergies, monitoring after switch from IV or oral antibiotics, and “against medical advice” discharges.

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  • Written and produced by: Justin Berk MD, MPH, MBA
  • Editor: Matthew Watto, MD
  • Hosts: Justin Berk MD, MPH, MBA; Matthew Watto MD; Paul Williams MD, FACP
  • Guest: Lenny Feldman MD, FACP

Goal: Listeners will recognize things we do for now reason aka low value practices with an unfavorable ratio of benefits to cost and/or harm.

Learning objectives:

After listening to this episode listeners will…

  1. Determine if renal ultrasound is indicated in acute kidney injury
  2. Recognize the limitations of urine electrolytes in AKI.
  3. Identify the shortcomings of folate testing.
  4. Explain the significance of low albumin and prealbumin.
  5. Identify patients at risk for serious allergic reactions from IV contrast administration
  6. Explain the futility in discharge Against Medical Advice (AMA) paperwork
  7. Counsel patients on harm reduction in “AMA” discharges
  8. Rationalize discharging patients immediately after switching from IV to  oral (PO) antibiotics.

Time Stamps

  • 00:00 Announcements
  • 00:38 Disclaimer, intro, and guest bio
  • 03:53 Guest one liner, some recommendations, and advice
  • 08:35 Defining high value care and things we do for no reason (TWDFNR)
  • 12:40 Why do clinicians order useless testing?
  • 14:58 Urine electrolytes for acute kidney injury
  • 20:30 Renal ultrasound for acute kidney injury
  • 25:54 Stop ordering folate for anemia workup
  • 31:47 How many units should I transfuse?
  • 34:40 Prealbumin and albumin for malnourishment.
  • 43:24 Iodine, shellfish and contrast allergy
  • 50:28 Patient leaving against medical advice
  • 56:45 Switching from IV to oral antibiotics
  • 63:27 Dr Feldman’s plugs
  • 65:36 Outro 

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