Grand rounds continued today with our guest speaker, Dr. Mark Berelowitz from Royal Free Hospital, London, who spoke to us about resilience and well-being, through the metaphor of the experience from the trapped Thai soccer team (Wild Boars) in 2018. We started with an overview of the rescue itself and a brief discussion of the attitudes of the boys from the soccer team about their experience within the cave.
Dr. Berelowitz then shifted to a discussion of resilience itself. He highlighted several concepts of resilience – inoculation theory, exercise theory, intrinsic toughness theory, family relationships theory, situational vs lifetime resilience – all of which he feels are insufficient to actually capture the meaning and mechanism of resilience. Instead, he again brought up the metaphor of the Thai soccer team to establish points necessary for resilience, including optimism and gratitude.
We then discussed the challenges of building resilience, both as individuals and as a society. He highlighted the need for us as a society – similar to the soccer team in the cave – to promote a value based culture. As stated by the political philosopher Michael Sandell, “[We] must find a way to lean against purely privatized notions of the good life, and instead cultivate civic virtue.” In addition, he discussed the importance of cultivating this notion both in a top-down (e.g. our hospital administrators) and bottom-up (e.g. our small clinical teams) approach. Dr. Berelowitz finally discussed the need to make such concepts habitual and highlighted the need for both societal and individual mindfulness in our approach to a value based culture.
Today we discussed a middle age woman who was brought in by family for confusion that seemed to start after changes in her medication regimen. With the help of our excellent psychiatry expert discussants, Dr. Kanwar Kaleka and Dr. Aaron Meyer, we reminded ourselves of how to take a thorough psych history and mental status exam.
We also discussed the importance of looking through a med list and thinking of the indications for your patient’s psychiatric medication regimen and the biggest side effects. We determined this patient likely had delirium due to her unusual drug regimen.
Please check out the following worksheet below and above tables (adapted from UpToDate) to remind yourselves of the side effects of common psychiatric medications.
We also discussed pharmcogenomic testing and its purported beneficial use in psychiatry to tailor patient medication regimens. Our patient got one done and had her medications adjusted based on this. Like her case demonstrated, it has not been shown to have utility for this purpose, only in determining drug metabolism for select drugs.
Lastly we touched on the topic of abuse and in which instances we need to be mandated reporters. Remember in California: we are mandated reporters for Suspicious injuries, it is in UCSD’s policy to do so. However, reporting without a patient’s consent (as opposed to child abuse and elder/dependent adult abuse cases), is controversial. See this attached article for more on this topic: https://journalofethics.ama-assn.org/article/mandatory-reporting-injuries-inflicted-intimate-partner-violence/2007-12.
- Remember to take a careful history for patients with history of possible bipolar disorder, specifically about depressive and manic episodes as it will guide medication choices
- Pharmocogenomic testing has utility for determining drug metabolism but should not be utilized in isolation for determining psychiatric drug regimens
- Domestic violence should be reported if suspected in your patients, though consent should be discussed with your patient as well as risk of retaliation. Consult social work for additional resources as needed.
Thank you again Dr. Meyer and Dr. Kaleka for your expertise!
The California Society of Addiction Medicine’s annual conference will be held in San Diego from August 26-29th, 2020. Scholarships are offered to cover the entire cost of registration. Please contact Stacy Charat (firstname.lastname@example.org) if you are interested in attending with local faculty members. The scholarship application requires very little preparation but the deadline is April 24th so please express interest ASAP!
Who: Residents can take this course prior to obtaining their own DEA – your completion will be recorded for use later.
What: AAAP Buprenorphine Half and Half Course (1/2 online and ½ in person)
Where: UCSD Medical School Campus, Basic Sciences Building, Garren Auditorium
When: November 5th, 2019; 8:30 am -12:45 pm (you must attend the entire time for the waiver)
Why: To be qualified to get a DEA waiver to prescribe buprenorphine AND to feel confident managing this growing patient population
This course is designed to equip prescribers with the information necessary to understand and prescribe buprenorphine in a safe and effective manner. It also meets the 8-hour requirement (1/2 in person; ½ on line) for MD’s and DO’s to apply for the DEA waiver to prescribe buprenorphine.
The in person portion is ½ of the 8 hour requirement. The remaining ½ must be done on line, and you must pass a self-study exam to apply for the waiver. Contact Stacy Charat (email@example.com) if you are interested in attending.
Today, we learned about dementia, how to disclose the diagnosis, and the challenges around this disease. This is HIGH YIELD stuff. Dementia is like the last frontier, where clinical acumen is necessary. We do not have one test that gives a slam dunk diagnosis. To start if you are thinking about dementia, you need to consider depression and delirium. According to Dr. Sladek, these are the three a”D”go’s! You also should think about the reversible causes. Reversible causes make up <1% of dementia but you can save someone’s life. Alzheimer’s disease is the most common, but there are other types of dementia you need to know. Check out this list:
Friday school this week was the last session of our ultrasound curriculum for the academic year! HUGE shout-out to our amazing chief residents, Dr. Kevin Eng and Dr. Jack Temple, for putting together a phenomenal curriculum! Also thank you to Dr. Dan Sweeney and all of the other faculty and fellows for helping to facilitate all the sessions! The residents also had another journal fight club today. This week’s topic was the use of antipsychotics for the treatment of ICU delirium. We had great article presentations by Drs. Justin Chen, Jeremy Kong, Carlos Lago-Hernandez, and Karen Yun, followed by a lively debate between Drs. Jeremy Hirst and Bob Owens (co-author of the Mind-USA trial)!! Here are the articles we discussed: Quetiapine ICU Delirium CritCareMed 2010 Quetiapine vs Haloperidol Drug Design 2013 HOPE-ICU JAMA 2013 MIND-USA NEJM 2018 Our winner this time was Dr. Bob Owens – his award is that he gets to be Brad Pitt on the Journal Fight
read more Friday School: Ultrasound and Journal Fight Club
We continued our geriatrics/general internal medicine Friday school block this week! We started with back-to-back sessions by our AMAZING geriatrician and associate program director, Dr. EB Sladek about healthcare maintenance in the geriatric population and a polypharmacy game. Remember “Bed-to-Bacon” for the activities of daily living! If you can get out of bed (transferring), wash up ( bathing/showering and personal hygiene), get dressed (dressing), and get to the kitchen (functional mobility) to eat bacon (self-feeding, you don’t have to cook it!), you’re able to complete your basic ADL’s! An important geriatric mantra is “fix the can’ts” (ie: can’t read, afford, open, remember, or swallow medications). Even if a patient wants to take the medications they are supposed to, they aren’t able to if they can’t! The interns joined us for sessions about dementia with Dr. Ellen Lee (amazing geriatric psychiatrist) and advanced communication with Chris Onderdonk (invaluable palliative care clinical social worker). Get excited to put these communication skills to
read more Friday School: Geriatrics Galore!
In the midst of an epidemic of opioid misuse and overdose deaths, it’s valuable for all clinical staff to be aware of an effective treatment for this large public health problem. Who: Any MD’s, DO’s, PA’s or NP’s. Residents can take this course prior to obtaining their own DEA – your completion will be recorded for use later. What: AAAP Buprenorphine Half and Half Course (1/2 online and 1/2 in person) Where: MET Building, Room 223 When: May 29th, 12:30-4:45 pm Why: To be qualified to get a DEA waiver to prescribe buprenorphine AND to feel confident managing this growing patient population Interested? Block your calendars and RSVP to Carla Marienfeld at firstname.lastname@example.org Details: The in person portion is ½ of the 8 hour requirement. The remaining ½ must be done on line, and you must pass a self-study exam to apply for the waiver.
Today at the VA, we reviewed cognitive impairment and some of its causes with Dr. Huege, UCSD psychiatrist! We started with a case of a 74 yo man presenting with memory complaints (names, dates, directions) and a MOCA of 27/30. His IADLs and ADLs were unaffected. At this point, he was diagnosed with mild cognitive impairment; however, he was referred to neuro-psych testing for full evaluation. The patient never had this completed. A year later he was hospitalized after a suicide attempt with recent history of depression, agitation, and delusions about his neighbor and guns. He was started on risperidone and zoloft. At this time, his memory impairment was “stable.” He was diagnosed with MCI with depression with psychosis. On follow up, he was noted to have improved depression but worsening cognition with a MOCA now of 20/30. Physical exam revealed bradykinesia and cogwheel rigidity. He was sent back for neuro-psych testing, which reveled a diagnosis of dementia, suspected to
read more VA AM Report: Lewy Body Dementia