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April 16, 2013 Issue

Clinical Practice Points

Patient-Centered Decision Making and Health Care Outcomes. An Observational Study

In surreptitiously recorded visits of real patients with their internal medicine residents, encounters where the physician took into account important patient-specific contextual information (e.g., a recent change in work schedule) were associated with better outcomes (e.g., improved blood pressure control following an adjustment in medication regimen).

Use this study to:

  • Ask what “patient-centered decision making" really means (the authors tell you on pages 573 and 578).
  • Review the “red flag” topics listed in Table 2 (e.g., missed appointments, declined recommended screening tests) to discuss the kinds of probing questions that might reveal important patient-specific contextual information that might help illuminate a means of improving a patient’s outcome.
  • Ask if patient-centered decision making could be incorporated into pay-for-performance measures.

Opportunistic Screening for Osteoporosis by Using Abdominal Computed Tomography Scans Obtained for Other Indications

This study found that computed tomography (CT) scans obtained for other clinical indications can be used for detecting vertebral osteoporosis by comparing them with dual-energy x-ray absorptiometry scans performed within the previous 6 months. Approximately half of patients with CT-identified osteoporotic vertebral compression fractures had nonosteoporotic T-scores.

Use this study to:

  • Structure a teaching session around multiple choice questions. We’ve provided one below. Four more may be found at the end of In The Clinic: Osteoporosis. By the way, you can get 1.5 Category 1 CME credits for yourself at the same time as you prepare this teaching session using the In The Clinic questions.
  • Use In The Clinic: Osteoporosis as a concise review to answer key questions in the screening, evaluation and treatment of osteoporosis (e.g., who should be screened for osteoporosis? What lifestyle measures are recommended for prevention? When should pharmacological treatments be used?) You also can download already prepared teaching slides!
  • Ask what your residents would do if osteoporosis were noted on an abdominal CT scan obtained for some other reason.
  • Teach about High Value Screening & Prevention– see below.

Update in General Internal Medicine: Evidence Published in 2012 and ACP Journal Club

These 2 sections provide concise synopses of recently published clinically important studies that are relevant to the practice of internal medicine.

Use these sections to:

  • Choose highly influential articles for a journal club session– and use the commentaries to help plan discussion points regarding the studies’ strengths and limitations.
  • Assign your medical students, interns and residents papers to present on rounds each day next week. Tell each they must present the KEY finding in less than five minutes, but be ready to answer questions about the study.

Humanism and Professionalism

Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards

This position paper discusses the influence of social media on the patient–physician relationship, their influence on public perception of physician behaviors, and strategies for communication that preserve confidentiality while best using these technologies.

Use this article to:

  • Discuss the potential dangers of social media to the patient-physician relationship (e.g., use for nonclinical purposes, threats to patient and physician confidentiality, effect on a patient’s trust of a physician, or on her/his reputation).
  • Discuss whether there are potential beneficial uses of social media in clinical practice (e.g., patient education, disease advocacy).
  • Ask if your residents think it would be OK for their patients to “check out” their physicians’ personal information at social websites? Would it be appropriate for a physician to do the same in trying to find out clinically important information about a patient’s behavior? When should email be used with a patient?
  • Ask if your residents agree with the positions of ACP and the Federation of State Medical Boards.

On Being a Doctor: The Racist Patient

Play an audio recording of this issue’s On Being a Doctor in which our colleague, Dr. Sachin Jain, describes his reaction to a patient’s racial slur against him. Ask your residents how they would have reacted? Have any of them faced similar comments from patients? How should we react? Are we obligated to put our own feelings and rights aside for the sake of maintaining the “doctor-physician relationship"?


Other Teaching Resources from ACP

High Value Screening & Prevention from the ACP High Value Care Curriculum for Educators, Residents, and Students

This focused and practical curriculum provides you with ready-to-use teaching materials including slides, cases, and facilitators’ guides to help you teach residents to provide better care, as well as thoughtful and responsible members of the healthcare system. Download these materials for free.

Use these materials to:

  • Discuss the required elements of a useful screening test.
  • Ask what the potential harms of a screening test might be.

mksap16

A 58-year-old man is evaluated for possible osteoporosis. He recently underwent removal of a 1.6-cm nonfunctioning pituitary adenoma and was placed on levothyroxine therapy.

On physical examination, vital signs are normal. Examination of the neck reveals no palpable goiter. The testes are small and soft. Laboratory studies showed the following: follicle-stimulating hormone, <1.0 mU/mL (1.0 U/L), luteinizing hormone, <1.0 mU/mL (1.0 U/L), testosterone, 50 ng/dL (1.7 nmol/L), thyroxine (t4), free , 1.2 ng/dL (15.5 pmol/L). A dual-energy x-ray absorptiometry scan shows T-scores of –2.5 in the left hip and –2.6 in the lumbar spine.

In addition to calcium and vitamin D supplementation, which of the following is the most appropriate initial treatment for this patient?

A. Bromocriptine
B. Calcitonin
C. Decreased dosage of levothyroxine
D. Testosterone

Answer: D. Testosterone

This patient had a clinically nonfunctioning pituitary adenoma with secondary hypogonadism and osteoporosis. He should be treated with testosterone replacement therapy. Hypogonadism is a prevalent secondary cause of male osteoporosis. Hypogonadism increases the skeletal sensitivity to parathyroid hormone and decreases intestinal calcium absorption. Because testosterone is aromatized to estradiol, it can be regarded as a prohormone for estradiol in the bone. Low bone mass in men with hypogonadism can be improved with androgen replacement, and bisphosphonates are effective in men regardless of their gonadal status. Anabolic therapy with teriparatide can likewise increase bone mineral density. Supplementation with calcium and vitamin D is also advisable.

Bromocriptine is useful for therapy of prolactinomas but has little utility for treatment of clinically nonfunctioning pituitary adenomas and will not treat this patient's osteoporosis.

Calcitonin can increase bone mass and is associated with a reduction in vertebral but not nonvertebral fracture rate. It is not as effective as bisphosphonate therapy and will not treat this patient's extraskeletal hypogonadal symptoms. Furthermore, calcitonin is not approved by the U.S. Food and Drug Administration as therapy of male osteoporosis.

Subclinical thyrotoxicosis can accelerate osteoclastic resorption of bone. Because this patient's free thyroxine (T4) level falls in the normal range, there is no need to decrease the levothyroxine dosage.

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

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