You know how you get to that point in medicine rather early in your career where after about

15 minutes with a certain person, you know that the only dose of opioid that's going to get

them out of 10 out of 10 pain is a dose 2 milligrams short of the fatal dose?

And that intuition is kind of how I am with hyponetremia for the majority of my patients,

and it took me a while to get there, meaning I am pretty darn accurate just by a good

history and physical and often chart review for figuring out what is causing the problem

without doing a bunch of labs. That's not to say there aren't times where I do

need to check a bunch of labs other than the basic ones that have already been completed, but subjectively,

I feel that's less than 20% of the time I need to do that. And I think the reason there is such a

failure for people to understand hyponatremia, even after they feel like they spend a lot of time trying to learn it, is that often the way it is taught academically doesn't build any intuition. So I think we got to move away from that kind of algorithmic teaching and thinking in this specific topic. There are times where I still

access some algorithms on this, but usually don't need to and still get it right. And my residents

tell me this all the time that they just feel like this is one of the harder topics for them

to comprehend and learn. And just like I think

it's time to congratulate drugs for winning the war on drugs, I do think it's time to move away from

a purely numbers thought process of hyponatremia. Not that's ever been purely numbers, but you get

what I mean. It's a lot of serum osmality and urine sodiums and all these things.

I'm going to talk about just a little bit, but often just the basic labs you have not only get you started,

but ultimately you don't have a lot of time to make a decision to wait on people to urinate and the nurse to collect it and the lab to run it.

And particularly you to remember to look at all those things in between your next 10 patients.

And if you learn hyponetremia intuitively, one, I think you'll feel very comfortable rarely using a nephrologist to consult on hyponetremia intuitively one, I think you'll feel very comfortable rarely using a

nephrologist to consult on hyponetremia.

It's definitely happened where I do need a nephrologist, but usually that's because

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