Paul Williams @PaulNWilliamz Twitter profile

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Paul Williams

4 years

*How to round with Paul Williams* Tips for medical students, interns, and the curious - a thread Just in case this might be helpful. Your mileage may vary with other attendings, who may violently disagree with these. (1/16)

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Paul Williams

@PaulNWilliamz

3 years

I texted a surgeon to tell them that I deeply appreciated their consistent follow-up and was always so grateful when they were involved in my patients' care, and they responded with "👍", which, I say with affection, is the most surgeon-y response possible.

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Paul Williams

@PaulNWilliamz

3 years

I completed a prior authorization for colchicine with the written justification being “because that’s how you treat gout.” It got approved. Great system.

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Paul Williams

@PaulNWilliamz

2 years

You will never write a title better than this.

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Paul Williams

@PaulNWilliamz

1 year

I just listened to an abdomen for no good reason and the bowel sounds were hyperactive. I don’t know what to do. Please send help.

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Paul Williams

@PaulNWilliamz

1 year

Not too long ago, a student I was working with asked me why patients with iron-deficiency anemia experience ice-craving AKA pagophagia. I had no idea. So I thought I’d look. Spoiler—we’re still not sure. But I did turn up some neat stuff. A 🧵about 🧊 (1/14)

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Paul Williams

@PaulNWilliamz

3 years

I see a lot of ibuprofen 800 mg given with wild abandon. I thought I remembered learning from @02Satz that analgesic efficacy didn't increase much over 400 mg, but bleeding risks did. So I decided to revisit this. 1/5

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Paul Williams

@PaulNWilliamz

3 years

How to not know stuff – a thread for new attendings by someone who doesn’t know stuff. Let's pretend there's a funny gif here. 1/18

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Paul Williams

@PaulNWilliamz

1 year

United Health Care is demanding a prior authorization to switch a patient from one generic SSRI to another, as the first has been ineffective. I have to complete paperwork and fax chart notes for a completely evidence-driven, inexpensive, guideline driven decision. Ghouls.

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Paul Williams

@PaulNWilliamz

1 year

Sure, I’ll jump into the weird physical exam discourse. If you ever got anxious over a set of vitals, or looked at a patient and thought “Yikes—they look sick,” you have performed an exam that guided your reasoning. It’s not all tuning forks and eponyms.

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Paul Williams

@PaulNWilliamz

1 year

Perhaps this will age poorly, but the reason I’m not worried about being replaced by AI is that patients are not actually a collection of physical exam findings and history keywords (which, incidentally, is how they are presented in the USMLE exam that AI aced).

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Paul Williams

@PaulNWilliamz

4 years

Anybody else have an Outlook folder labeled “COVID” that they’re just indiscriminately dumping emails into?

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Paul Williams

@PaulNWilliamz

4 years

*How to clinic with Paul Williams* Mostly for internal medicine residents, but also for anyone else who is curious. Others may do things differently or disagree, and that’s totally fine. (1/22)

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Paul Williams

@PaulNWilliamz

5 months

Fine. Much of the language we use in medicine is designed to be intentionally opaque and confusing in order to make our field seem more necessary and important.

Paul Wischmeyer MD,EDIC,FCCM⎪ #NutritionMatters 💪

@Paul_Wischmeyer

6 months

🙋‍♂️ What’s your unpopular opinion in medicine that will get you in this position? #MedTwitter

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Paul Williams

@PaulNWilliamz

3 years

I think we need to be very careful during residency training to not contextualize time spent in primary care as a respite from the "real work" of inpatient medicine - this ultimately devalues primary care and frames it as something not to be aspired to.

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Paul Williams

@PaulNWilliamz

2 years

Just stumbled across a progress note where I noted that the patient was accompanied by a service dog, “who is clearly a very good boy.”

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Paul Williams

@PaulNWilliamz

2 years

It is extraordinary to me that the prior authorization process requires us to take the time to reach out to insurers and defend our reasoning, rather than the insurers having to contact us to ask why we ordered something before denying it.

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Paul Williams

@PaulNWilliamz

2 years

Screening for SDOH without meaningful systemic changes to address them places an implied onus on the PCP to address a problem beyond their capacity to fix. What are we actually trying to accomplish here?

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Paul Williams

@PaulNWilliamz

3 years

Is there a window between the period of imposter syndrome of the new attending and the imposter syndrome of a more established attending who worries they're just coasting by on reputation, or do you just feel vaguely uneasy until you retire?

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Paul Williams

@PaulNWilliamz

3 years

Early in my career, I most admired the physicians I thought were cool. This eventually evolved into idolizing the ones I thought were the smartest. Now I gravitate to those I find the most decent. Is this the usual progression? (Yes, I know you can be all 3)

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Paul Williams

@PaulNWilliamz

1 year

@BenWashburn75 @WebMD Exactly what I told the patient.

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Paul Williams

@PaulNWilliamz

3 years

Primary care is kind of like if someone dumped out a bathtub full of marbles from the top of a nine story building, and your job isn’t just to catch the marbles, but also to juggle them.

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Paul Williams

@PaulNWilliamz

8 months

Why medicine? Because I’ve always loved science, but I also like helping people. But mostly, I love typing the same password over and over again until nothing else occupies my time.

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Paul Williams

@PaulNWilliamz

1 year

@medrants If I start smiling now, they’ll expect it at every visit.

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Paul Williams

@PaulNWilliamz

1 year

Just included a PubMed link in a progress note. Felt weird.

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Paul Williams

@PaulNWilliamz

4 years

Shorter, more up-to-date notes are preferred over the metastatic monsters I see with every imaging study ordered since conception and a plan for chronic gout that has been quiescent since 1973. (9/16)

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Paul Williams

@PaulNWilliamz

4 years

This is basic stuff, but please report vitals, and please address trends. Please tell our night floats that PRN antihypertensives will result in great anger and furious vengeance. (6/16)

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Paul Williams

@PaulNWilliamz

1 year

And, as God as my witness, if AI is able to figure out “dizziness” or “fatigue,” I will welcome our robot overlords with open arms.

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Paul Williams

@PaulNWilliamz

2 years

Just had a consultant call me directly to ensure I understood the reasoning in their note, and "because coordination is so important" -- I feel kind of bad that no one warned them they just self-selected to be my new best friend and confidant.

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Paul Williams

@PaulNWilliamz

4 years

I was not expecting this thread to get quite so much traction. Thanks for the nice comments. Since the HTN thing generated the most conversation, here's an excellent review:

Acute Treatment of Hypertensive Urgency

The “Things We Do for No Reason” (TWDFNR) series reviews practices which have become common parts of hospital care but provide little value to our patients. Practices reviewed in the TWDFNR series...

shmpublications.onlinelibrary.wiley.com

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Paul Williams

@PaulNWilliamz

8 months

Have they tried just having the existing primary care doctors simply see more patients and increasing administrative burden while continuing to structure training so that the end result is specialization? Might be worth a shot.

Vinny Arora MD MAPP

@FutureDocs

8 months

The primary care shortage actually made national news tonight in NBC because people cannot find a doctor accepting patients. Increasing residency spots is vital, but without reducing debt and valuing the work, we aren’t gonna fix it fast enough.

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Paul Williams

@PaulNWilliamz

1 month

Whoever invented non-skippable videos as part of required training modules should be launched into space

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Paul Williams

@PaulNWilliamz

3 years

My takeaways from this? 1) ER doctors are smart and I should talk to them more often 2) No reason to prescribe the higher "anti-inflammatory" doses of ibuprofen when 400 mg seems to do the trick 3) Especially when there is a signal for increased bleeding the higher the dose 4/5

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Paul Williams

@PaulNWilliamz

3 years

This tweet goes out to anyone who has tried to scroll through someone else’s document on a shared Zoom screen.

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Paul Williams

@PaulNWilliamz

3 years

In summary, it’s okay to not know stuff, but have a plan to address it. Talk to your colleagues-they will appreciate it! Role-model not knowing stuff for your trainees, but also use it as an opportunity to teach how to learn, and to learn together. 18/18

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Paul Williams

@PaulNWilliamz

2 years

I wonder if we shouldn't re-frame the conversation about burnout from being a passive process that results from ambient conditions ("he is burning out") to a process that is actively being inflicted on people ("this [system] is burning out its employees").

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Paul Williams

@PaulNWilliamz

5 years

Your doctor is being crushed beneath the burden of unrealistic expectations, systematized inefficiency, and repetitive moral injury. The solution? Morning visits.

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Paul Williams

@PaulNWilliamz

4 years

Despite all of this proscriptive and prescriptive stuff, we should be having fun. I tend to give feedback on the fly, both positive and negative. Please give me feedback as well. I would like to be good at my job. (16/16)

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Paul Williams

@PaulNWilliamz

2 years

I was thinking about nicotine replacement therapy (NRT), as one does. Varenicline works better (and varenicline + NRT works better still), but I think we often reach for NRT first because it seems more intuitive and maybe more accepted by patients. 🧵1/14

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Paul Williams

@PaulNWilliamz

3 years

Thinking about updating my email sign off from “Best,” to “Doing my Best”

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Paul Williams

@PaulNWilliamz

2 years

The vet heard a heart murmur on my geriatric cat, and I am genuinely furious at myself for acquiescing to a pro-BNP.

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Paul Williams

@PaulNWilliamz

4 years

Length of stay is important, but a good general rule of thumb is to not discharge patients who have been febrile in the past 24 hours, or who have a dropping hemoglobin or rising creatinine. (15/16)

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Paul Williams

@PaulNWilliamz

4 years

Nothing makes me happier than intellectual curiosity. If a patient is anemic, we should be asking why. If a creatinine bumps, we should wonder why. Same goes for VTEs, MIs in young patients, and so on and so on. (5/16)

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Paul Williams

@PaulNWilliamz

1 year

Logging on just to say that most primary care clinicians view the ER as a potentially toxic exposure for their patients, and the decision to advise ER evaluation is overwhelmingly the result of risk-benefit calculus and not laziness or ignorance.

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Paul Williams

@PaulNWilliamz

4 years

I seem to have picked up some followers based on my inpatient rounding thread. My terrible secret? I'm mostly a primary care doc, which is the thing I love best and am most proud of. I can try to do a thread on the clinic too, if anyone is interested.

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Paul Williams

@PaulNWilliamz

4 years

Please let our night floats/nighttime coverage know that I need to be called about deaths, premature discharges, elopements, and ICU transfers. I do not mind being called. I do mind finding out on rounds the next day. (14/16)

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Paul Williams

@PaulNWilliamz

4 years

We should know where the patient is coming from, and where they are going. Who do they live with? Are there stairs? Are they going back there? Do they need a physical therapy consult? These are questions I will be asking often. (11/16)

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Paul Williams

@PaulNWilliamz

10 months

Pro-tip for giving injections! Yesterday, after giving a patient a therapeutic injection, I turned around and accidentally smashed my head into a cabinet. The patient was so distracted by my pain they barely felt the shot! Feel free to use!

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Paul Williams

@PaulNWilliamz

1 year

Just read a progress note I wrote where I mentioned a patient “follows with Ophthalmology for their ophthalmology,” which is the kind of nuanced detail people have learned to expect from me.

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Paul Williams

@PaulNWilliamz

3 years

Role-model not knowing. Do it out loud. Role-model reasoning out loud, looking for answers, and asking hard questions. There is nothing embarrassing in any of this—it is literally the job you are getting paid to do. 16/18

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Paul Williams

@PaulNWilliamz

3 years

The misconception is that residency trains you to be a good attending. The fact is--residency gets you to the starting line. Being an attending is what trains you to be a good attending. And it takes years (full disclosure-I’m still not convinced I’m a good attending). 4/18

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Paul Williams

@PaulNWilliamz

1 year

I’m just a man, standing in front of a gastroenterologist, asking them to please stop adding “screening for colon cancer” to my patients’ problem lists.

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Paul Williams

@PaulNWilliamz

4 years

Five Medical Education Podcasts You Need to Know Always nice to be appreciated.

Five Medical Education Podcasts You Need to Know - PubMed

Podcasts have become increasingly popular tools for medical education in recent years. Only requiring a computer or smart phone, podcasts are readily accessible to healthcare professionals, helping...

pubmed.ncbi.nlm.nih.gov

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Paul Williams

@PaulNWilliamz

2 years

Heck yeah.

Paul Williams

@PaulNWilliamz

3 years

I am going to run a marathon. It will be terrible. My knees will revolt, and my right hip will never be the same. I will talk about nothing else while training for it. Apologies in advance. 6/10

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Paul Williams

@PaulNWilliamz

9 months

I have found that when the clinic gods taketh away patient volume, they usually giveth back patient complexity.

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Paul Williams

@PaulNWilliamz

10 months

@AshleyGWinter I don’t see the top half of the child. Someone should look into this.

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Paul Williams

@PaulNWilliamz

5 months

Here’s how to save primary care. Rebrand it as a subspecialty with a dumb name like “longevity medicine.” Make it a one year fellowship that pays like an entry-level attending. We can have a practice pathway too. Pay primary care like specialists. Flawless plan.

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Paul Williams

@PaulNWilliamz

2 years

Hello. Hi. Good morning. Copying the patient’s admission history and physical is not the same as actually writing a discharge summary.

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Paul Williams

@PaulNWilliamz

3 years

@DrPoorman That’s not unreasonable.

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Paul Williams

@PaulNWilliamz

4 years

If you are thinking about calling an ICU consult, call the ICU consult. (13/16)

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Paul Williams

@PaulNWilliamz

4 years

You're in charge of coming up with the assessment and plan. I will do my best to agree with your plan, but please tell me why you’re thinking what you’re thinking. If I ever dictate the plan, it’s because I’m worried we are drifting into oncoming traffic. (3/16)

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Paul Williams

@PaulNWilliamz

2 years

Mohela: Your student loans have been transferred to us to allow for more organized and seamless handling. Me: Cool cool. What’s the status of my student loan forgiveness? Mohela: No idea. Check back in a few months or something.

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Paul Williams

@PaulNWilliamz

3 years

So it seems I slept on a nifty little 2019 ER study that randomized a convenience sample of patients presenting with acute pain to a 400 mg, 600 mg, or 800 mg dose of ibuprofen. Turns out, all 3 doses have similar analgesic efficacy. 2/5

Comparison of Oral Ibuprofen at Three Single-Dose Regimens for Treating Acute Pain in the Emergency...

Oral ibuprofen administered at doses of 400, 600, and 800 mg has similar analgesic efficacy for short-term pain relief in adult patients presenting to the ED with acute pain.

pubmed.ncbi.nlm.nih.gov

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Paul Williams

@PaulNWilliamz

4 years

For me, the history is the thing. There is nothing more important to me than the story. A brief history can be a marker for premature closure. (4/16)

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Paul Williams

@PaulNWilliamz

3 years

"Staycation" is an especially cute way to say "using paid time off to limit patient access so you can try to excavate yourself from your other administrative and life responsibilities in casual-wear."

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Paul Williams

@PaulNWilliamz

1 year

@h_pytori Still probably postnasal drip.

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Paul Williams

@PaulNWilliamz

4 years

Not now, weekly screen time report.

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Paul Williams

@PaulNWilliamz

2 years

Has anyone looked into if vitamin D might be good? May be worth studying.

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Paul Williams

@PaulNWilliamz

4 years

To those with outpatient panels, may I offer up two holy phrases for every visit: “Do you need any refills?” and “What pharmacy are you using?” Always trust the patient more than the EHR.

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Paul Williams

@PaulNWilliamz

4 years

Please revise and re-order your assessments and plans on a daily basis, with the most important problem listed first. I know that you know this, but it’s sometimes good to repeat it. For your daily progress notes-if there was an acute event overnight, please document it. (10/16)

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Paul Williams

@PaulNWilliamz

2 years

If you are not talking to your patients about their dogs, you are missing a huge window into their lives.

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Paul Williams

@PaulNWilliamz

1 year

I should not be the gatekeeper for diabetic shoes.

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Paul Williams

@PaulNWilliamz

3 years

I made homemade bagels, if you find that kind of thing interesting.

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Paul Williams

@PaulNWilliamz

2 years

Finally got around to watching RRR on Netflix last night. Absolutely bonkers good time. If you have 3 hours to burn, and want to see tigers and explosions and incredible dancing, I highly recommend.

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Paul Williams

@PaulNWilliamz

1 month

I’m going to design an EHR with 14 different “home” buttons, each of which takes you to a different screen. There will be 7 different “medications” tabs, each with a different list. Every click will result in a pop-up that asks if you’re sure. Charging $7 million—DMs are open.

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Paul Williams

@PaulNWilliamz

2 years

Ah, the sweet guilt-streaked anxiety of sending a clinic patient to the ER, where the outcomes are either a potentially unnecessary healthcare exposure during a pandemic, or a validation of something bad.

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Paul Williams

@PaulNWilliamz

1 year

To recap: -Pica is common in iron-deficiency anemia, and pagophagia is a common manifestation Ice-chewing may soothe the tongue, boost dopamine, or mitigate the brain fog of anemia. (14/14)

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Paul Williams

@PaulNWilliamz

1 year

Just two cool dudes wearing matching hoodies at a medical conference.

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Paul Williams

@PaulNWilliamz

2 years

ABIM: It's been an extraordinarily difficult year, and we hope you have found the space to take care of yourself. Thank you for all that you do to care for patients during this unprecedented time NOW GIVE US $220 IMMEDIATELY.

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Paul Williams

@PaulNWilliamz

7 months

Just wanted to share that I, a primary care physician, had my first primary care visit in years, and I was a very brave and good patient, except for when they tried to check a manual blood pressure with me sitting on the exam table.

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Paul Williams

@PaulNWilliamz

1 year

“Pagophagia” derives from the Greek “pagos” (ice) and “phagein” (to eat). It's a type of pica, the eating or chewing of non-food like clay, corn starch, and paper. Pica, delightfully, derives from the Latin word for magpie, for the bird’s indiscriminate eating habits. (2/14)

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Paul Williams

@PaulNWilliamz

2 years

I'm thinking about resolving to be more positive in the new year, so while there's still time: I hate Epic with the fiery passion of a thousand suns.

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Paul Williams

@PaulNWilliamz

4 years

If there is a leukocytosis, please be prepared with a differential. If there is an anemia, please be prepared to tell me the morphology (microcytic, normocytic, macrocytic) and what the hemoglobin trend has been; please follow the bouncing creatinine. (7/16)

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Paul Williams

@PaulNWilliamz

3 years

Suspenseful news-just got an email that my password will expire in 19 days, and am looking forward to the next 18 emails. Brace yourselves for the world’s most boring game of chicken.

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Paul Williams

@PaulNWilliamz

4 years

I am not advocating for intellectual laziness, but patients are owed the standard of care, and the best care we can give them. As long as we have a concrete, reasonable question that we have been unable to safely or promptly answer, we should be thinking about a consult. (12/16)

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Paul Williams

@PaulNWilliamz

1 year

Oh great, now my tax dollars are being wasted on feeding children.

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Paul Williams

@PaulNWilliamz

1 year

Excited and nervous for this first day of work at @PennStHershey ! I am truly looking forward to learning and growing as a clinician and educator in this next stage of my career.

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Paul Williams

@PaulNWilliamz

2 years

@laxswamy It is not helpful to compare yourself to others, since everyone in medicine covers their internal panic with a thin veneer of false confidence. We’re all freaking out, for what it’s worth.

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Paul Williams

@PaulNWilliamz

3 years

A really fantastic student I worked with gave me feedback that they learned a lot about "the art of medicine" from me, which in retrospect may mean I didn't teach anything that would be remotely useful on a test.

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Paul Williams

@PaulNWilliamz

4 years

I've learned a lot over the past few days, but the most important things: 1) I could not hack doing residency again. 2) The sheer volume and quality of the work our residents do is astonishing, and we should never, ever lose sight of that. @TempleIM is amazing.

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Paul Williams

@PaulNWilliamz

4 years

Is anyone else wrestling with the hideous elasticity of time lately, where days and weeks last forever, and yet hours slip quickly by without the least sense of accomplishment? Anyway, happy Friday!

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Paul Williams

@PaulNWilliamz

3 years

Repeat after me—it is literally impossible to know everything you need to know to take care of patients. There—doesn’t that feel better? No? Okay, read on. 5/18

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Paul Williams

@PaulNWilliamz

1 year

The first documented case of pagophagia was the Byzantine emperor Theophilus (829-842 AD), who ate snow to calm down stomach irritation (although it’s also possible that the stomach irritation came from dysentery from the snow, which he was eating for some other reason). (3/14)

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Paul Williams

@PaulNWilliamz

3 years

If you learn something from a consultant, say out loud, in front of your team: “I didn’t know that. Thank you! That’s great!” Same for when you learn something from a resident or student, which happens all the time. We are supposed to continue to learn. That’s the point. 17/18

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Paul Williams

@PaulNWilliamz

1 year

Pica has long been known to be associated with blood disorders. Hippocrates wrote that “a craving to eat earth” was associated with “corruption of the blood.” de Cervantes even describes pica in Don Quixote. (4/14)

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Paul Williams

@PaulNWilliamz

4 years

If we ordered an EKG, I will want to see it, and will ask someone to interpret it. If there is a student with us, it will probably be them. Same goes for imaging. (8/16)

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Paul Williams

@PaulNWilliamz

2 years

I think what I'm saying here is that the prior authorization process is stupid and evil and everyone whose job it is to deny patients care should not be able to sleep at night. Sorry for the controversial opinion.

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Paul Williams

@PaulNWilliamz

1 year

Some have hypothesized that addiction centers of the brain may be selectively affected by iron deficiency given the powerful cravings associated with pica, but there has not been evidence for this. Worth noting that iron is an enzymatic co-factor in dopamine synthesis. (9/14)

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Paul Williams

@PaulNWilliamz

1 year

I love this thread so much. Yes, my notes take forever, but that’s because when I’m writing them, I’m reflecting and reconsidering. I’m not built for snap decisions—I’m a ruminant.

Robert Oubre, MD | The Doctor of Documentation

@Dr_Oubre

1 year

It was 8 PM. Late. My attending called me. "Hey, Robert. I was writing my note and realized something..."

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Paul Williams

@PaulNWilliamz

1 year

So much of this job is spent thinking about what horrible thing could be happening or is about to happen, and I have to wonder if that's maybe not so good for your brain.

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