Featured Post

Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Wednesday, February 01, 2023

Can internists keep up with medicine

 I have sampled four internists , two in active practice two retired more than 10 years earlier.Perhaps we can excuse the ignorance in the retirees.

All were woefully ignorant about the basics of the most common cause of anemia in the world,Iron deficiency anemia (IDA).

Case in point. A 78 year old man is noted to have a decrease of more than one gram in his hemoglobin from the previous annual "wellness meeting" which should not be confused with the annual physical exam which at least for some perhaps many Medicare patients is a thing of the past.Medicare will pay for an  annual wellness visit but not a real hands on physical exam.  The internist who  practiced in a practice group associated with a large "not for profit" hospital system recommend he take ferrous sulfate three times a day,

Note- there was not at the time a recommendation for the patient to have a GI tract evaluation, not even a stool Guiac was mentioned. In 2019 a influential often quoted article by Ganz and Weiss included a flow sheet indicating that older patients ( over fifty) undergo a upper and lower endoscopy to rule out a source of bleeding if their initial blood tests has a pattern consistent  with ( but not necessarily diagnostic of ) iron deficiency anemiaThe patient 's blood test fit that pattern. This  pattern was low serum iron and percent saturation and a ferritin less than 100. Possible iron defeciency anemia in a man over fifty certainty warrants an evaluation for GI tract bleeding.

As the case evolved the GI doc's ignorance re IDA was revealed when he commented that a subsequent increase in the patient's ferritin reflected increasing iron stores. These two internists apparently knew little or  nothing about the iron regulating hormone,hepcidin,   If they did they would know how to administer oral iron and how to use the ferritin  ( and other tests suh as the Ferritin index )to help differentiate between IDA and anemia of chronic inflammation and their combination.

No comments: