CCCF Academy

Shafiee, Mohammad Ali¹; Sharif, Umar²; TabaTaba-Vakili, Sahar²; Parastandechehr, Gilda²; Hakimfaal, Shirin²; Nazarian, Amir; Dastgheib, Bijan²;

¹Division of General Internal Medicine
 Assistant Professor, Department of Medicine, University of Toronto
 Royal College Mentor, Department of Medicine, University of Toronto
 Toronto General Hospital, 200 Elizabeth Street, 14 EN-208
 Toronto, ON, M5G 2C4 | Tel: 416-340-4800 ex 6244 | Fax: 416-595-5826

²Division of General Internal Medicine Toronto General Hospital
University Health Network
 Toronto General Hospital, 200 Elizabeth Street, 14 EN-209A
 Toronto, ON, M5G 2C4 | Tel: 416-340-4800 ex 2182 | Fax: 416-595-5826
 Division of Medicine, Toronto General Hospital, Toronto, Canada

Introduction:
Although many studies have been written on the management of hyponatremia and SIADH, clinician appraisal is often overlooked. The term SIADH has lead physicians to under appreciate the importance of the physiology of hyponatremia in these patients. The consequence of this is often under treatment, misdiagnosis and a lack of understanding of the mechanisms of the heterogeneous group of hyponatremic patients diagnosed as SIADH. Additionally, clinicians often do not appreciate the current therapeutic modalities for SIADH which include but are not limited to: water restriction, salt tablets, vaptans and many more. As treatment of SIADH can be challenging, clinicians can sometimes be limited in terms of the management options of hyponatremic patients who have been diagnosed with SIADH.
 
Objectives:
It is hypothesized that there is a knowledge gap in the underlying physiological factors of hyponatremia and SIADH as a common clinical dilemma among physicians. Furthermore, hyponatremic patients who are diagnosed as SIADH are not accurately assessed by clinicians leading to confusion in approach and therapeutics. 
 
Methods:
The total of 150 questionnaires with 25 multiple choice questions were distributed amongst Canadian undergraduates, post-graduate trainees in years 1 through 5, clinical fellows, general internal medicine staff and staff nephrologists at Toronto General Hospital (TGH). The research proposal was approved by Coordinated Approval Process for Clinical Research (CAPCR) at the University Health Network. The basic concept of questions was the physiological appraisal of hyponatremia and SIADH, clinicians’ diagnostic approach toward hyponatremia and SIADH, therapeutic approach and knowledge of modalities to treat hyponatremia, assessment of treatment in hospital setting, knowledge of significance of hyponatremia and participants level of training and a self-assessment.
 
Results:
119 out of 150 (79%) participated in the survey. Most participants (50%) had only undergraduate level of training. One quarter were in their first year of post graduate training followed by equal numbers being represented by fellows, senior post graduate trainees and staff. Self-appraisal questions showed that most physicians admitted to having deficiencies in diagnosis and treatment by rating their level of knowledge in diagnosis and treatment as either fair or good (40% and 30%, respectively). Diagnostic and treatment modalities consensus was mostly on water restriction (95%), stopping offending agent (50%) and treatment of underlying cause (60%). Significant variation was seen among physicians regarding diagnostic criteria for SIADH (10-25%) and majority failed to appreciate that most of the patients would be readmitted. Overwhelmingly, more than 50% of participants diagnosed SIADH regardless of the proposed criteria for SIADH other than clinical euvolemic hyponatremia.
 
Conclusion:
This survey signifies the evaluation of clinicians’ understanding of physiologic approach and management of hyponatremia in the hospital setting and contributes to filling the knowledge gap that could reduce length of hospital stay, readmission, cost of hospital stay as well as to reduce morbidity and mortality in hospitalized patients. Therefore, a holistic approach to teaching as well as to management is required to improve quality of care. 

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