5/5
To avoid becoming a "boutique" tool, VEXUS needs implementation science 🧪. We must ensure our competency standards are as implementable as they are precise.
Read the full piece here: link.springer.com/article/10.1... #MedSky #POCUS #VEXUS #MedEd #HospitalMedicine
4/5
Generalist adoption faces real hurdles 🚧:
🔹 Steep learning curves 🔹 15–20 min exam times 🔹 Handheld devices lacking ECG leads for temporal mapping Precision shouldn’t be a barrier to accessibility 🔓.
3/5
But here is the "Precision Paradox" ⚖️:
Experts have proposed a 35-item competency rubric. While essential for fidelity, do granular checklists survive the "task creep" of a high-acuity environment?
2/5
VEXUS is a physiologic evolution, moving our gaze from the surface to the entire systemic watershed 🌊. By integrating Doppler across 4 vascular beds, we can visualize the pathologic backpressure compromising organ perfusion.
1/5
For a century, the Method of Lewis has defined bedside assessment of congestion 🫀. But IJV height is a unidimensional surrogate for a multidimensional hemodynamic problem.
My new editorial in @jgim.bsky.social explores what comes next: VEXUS 🛰️. 🧵
New JAMA review attempts to equate pulmonary congestion with systemic congestion ("volume overload")
This is sloppy & often wrong
Pts w/ LV failure often have pulmonary congestion w/o systemic congestion
Pts w/ RV failure usually have systemic congestion w/ dry lungs
CVP isn't PCWP
#EMIMCC
5/5
Ultimately, uJVP needs to move from a "cool hobby" to formal credentialing (looking at you, SHM POCUS Cert).
It’s time to professionalize the probe so the next generation isn't left staring blankly at the neck.
#MedSky #POCUS #MedEd #HospitalMedicine
4/5
However, a checklist validates the measurement, not the doctor.
A resident might perfectly measure a uJVP of 12 cmH2O but fail to recognize the tamponade physiology driving it. We need to ensure we aren't just teaching image acquisition at the expense of clinical reasoning. 🧠
3/5
I dive into recent work by Franco et al., who used the Delphi & Angoff methods to create a standardized uJVP checklist.
This moves us from arbitrary metrics ("I did 50 scans!") to criterion-referenced safety ("Can a minimally competent resident do this without error?"). 📉✅
2/5
Think of the JVP like a river. 🌊
The physical exam only looks at surface ripples (pulsations). POCUS lets us measure the actual depth (vessel diameter + collapse).
But here’s the problem: A better tool is dangerous without better rules. We can’t keep using "vibes" to assess competency.
🧵 1/5. Raise your hand if you’ve ever stared at a patient’s neck with a penlight, pretending to see the JVP while your attending nodded enthusiastically. 🙋♂️🔦
We’ve all been there. But in the POCUS era, we can do better than "guessing at shadows."
My latest editorial in JGIM:
#MedSky #POCUS #MedEd
Today @TheNewYorker released our short documentary “Rovina’s Choice” online.
It traces the ongoing effects of the sudden shutdown of US foreign aid through the story of one mother in Kenya as she seeks to save her daughter from sickness and starvation. 🎥 1/ www.newyorker.com/culture/the-...
As medical advocate for the gut: ‘Anything’ is inadmissible—lacks nutrition and intent. Enter fruits/veg into evidence.
Indeed which has been fascinating to see. A great example of how broadly applied dichotomous thresholds (Hgb<7 =transfuse) miss nuances.
Certainly if risk profile is lower argument more could benefit is reasonable. Unfortunately donor supply is decreasing www.bbc.com/news/article...
Oh yeah, thanks for the reminder to get that done
It’s an odd term. There ref says it is “as an unanswerable question”… that is not what most docs are doing IME.
Clinical medicine is humbling. I try to preface my ? of trainers w/ these are ? I ask myself to probe thinking and understanding.
IMO, it’s instructive to ?
This is spicy indeed 🌶️ 🔥
Fantastic work here! Very much agree with accounting for pretest of bacteremia given heterogeneity of sepsis as a clinical entity and that quality sepsis metrics play a role in diagnostic testing over clinical judgement more than it likely should. Bravo!
Important to note, even with 3 findings, the LR tells you the test result is x7 more likely in those with cholecystitis versus those without. Reiterates the point we all know, the story of the patient going into scanner matters ALOT more
Such a great thread and clinical pearl!
Conceptually, sensitivity and specificity # s get confused. Retrospective case series illustrates why I prefer LR. With more findings of cholecystitis, LR+ 4.5→6→7 (more=⬆️ prob of sure Dx) but at same time LR– 0.1→0.4→0.7 (more=⬆️ prob of missing some)
I prefer to think in terms of interval likelihood ratios, and account for pretest prob. Agree that the above language anchors to broadly in description & highlights how “test-centric” decision making has become.
A common pearl is the story/history is (probably) the best performing test we have
Definitely applies to HFrEF, but I haven’t seen reimbursement tied to HFpEF-specific GDMT. Here’s a summary of current therapies. With cost/access issues around GLP-1 RAs and SGLT2is, curious how implementation will go—most patients unlikely to get both.
I really worry about this use of AI/LLMs in peer review, specifically for methods review. The brakes analogy is apt. All for pursuing progress, but how this does not spin out of control seems unlikely in the current climate #pumpthebrakes
Efficiencies?! 🤦
Providing public health through a lens of scalable business is short sighted and, well, counter to the mission.
Much worse in 🇺🇸. the pulling back of public safety net in larger society (housing, education, etc) coincides with move to align care models based on ROI
🙋🏻♂️I have seen the same. it has been a common teaching of mine to correct with learners on service. Unfortunately I am seeing it in cardiologist notes now too.🤦
data does not support outcomes beyond improvement in NT-pro BNP and HF hosp. we need docs to push back against this
Prevalence statistics inform pre-test probability. These numbers are staggering and reflect my anecdotal experience. When considering interventions, Kaiser's PHASE program implements an effective intervention but prevention efforts will be key. www.amjmed.com/article/S000...
Anecdotal, though hypothesize the correlation coefficient for a patient who asks to start testosterone for low energy despite normal levels who will subsequently ask me to empirically treat for parasites/cancer unspecified with ivermectin is 0.84
The Bible of Medicine. Spreading the gospel of Longo, Fauci, et al.
