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July 15, 2014 Issue


Clinical Practice Points


Interpersonal and Communication Skills
Systems-based Practice
Medical Knowledge
Patient Care

Burden of Changes in Pill Appearance for Patients Receiving Generic Cardiovascular Medications After Myocardial Infarction: Cohort and Nested Case–Control Studies

Generic drugs produced by different manufacturers may vary in shape and color. This study found that variation in pill color and shape is associated with lower adherence rates of essential drugs in patients after myocardial infarction.

Use this study to:

  • Ask your learners what “health literacy” means. Ask how they assess whether their patients understand what has been explained regarding their illness and treatment.
  • Watch a short video on health literacy.
  • How do your learners know that their patients can read and understand written instructions?
  • Practice the “teach back” method in which the patient explains to you what you just explained. Ask your learners to do this with all their patients in their next outpatient session. What did they discover? Discuss ways to improve patient adherence to medication regimens.
  • Review which therapies have been shown to improve outcomes following myocardial infarction. Use the “therapy” section of Acute Coronary Syndromes in ACP Smart Medicine.

Medical Knowledge
Patient Care
Interpersonal and Communication Skills
Professionalism

Personalizing Age of Cancer Screening Cessation Based on Comorbid Conditions: Model Estimates of Harms and Benefits

This study predicted the harms and benefits of mammography, PSA, and fecal immunochemical testing among patients of various ages and comorbid conditions. It found that screening cessation discussions may be informed by considering comorbid conditions to estimate the benefits and harms of a screening test.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Use a recent In the Clinic on Colorectal Cancer Screening and research article evaluating its value according to age and comorbidity.
  • Review recent guidelines for prostate cancer screening from the ACP and the U.S. Preventive Services Task Force.
  • Ask your learners how they consider comorbidities when counseling their patients about the value of a screening test.
  • Discuss with your learners how they would initiate a discussion about cessation of screening with a patient who has come to expect it. When appropriate, do they tell a patient that he or she is more likely to die of other causes sooner than from the cancer that a screening test might identify? Does such a conversation make your learners uncomfortable?

Patient Care
Medical Knowledge
High Value Care

Update in Hospital Medicine: Evidence Published in 2013

This concise update selects articles published in 2013 that the authors consider highly relevant to the practice of hospital medicine. Topics covered include studies of fecal microbiota transplant and probiotics for Clostridium difficile infection, blood transfusion triggers for acute gastrointestinal bleeding, aspirin for prevention of venous thromboembolism following hip replacement, and more.

Use these updates to:

  • Have your learners select the updates that have the greatest potential to impact cost, as well as outcomes of care. Do they plan to alter any of their practices on account of these papers?
  • Discuss whether the outcomes evaluated in each study are strong enough to impact current practice. Read the essay "Faded Promises" in this issue to help frame a discussion on changing practice habits.

Ideas and Opinions


Medical Knowledge
Patient Care

Ready or Not: Responding to Measles in the Postelimination Era

Dr. Sammons provides an overview of the epidemiology and clinical presentation of measles and makes suggestions for managing suspected cases. She encourages physicians to maintain vigilance in considering this disease in the differential of a febrile illness with rash and continue to educate and encourage patients to adhere to recommended vaccine schedules.

Use this article to:

  • Review the epidemiology and clinical presentation of measles. Download the figures as teaching slides to help your learners recognize the manifestations of measles.
  • Invite an infection control officer from your hospital to review your institution’s levels of isolation for hospitalized patients (airborne, droplet, contact, enteric). What does each entail? Which illnesses, or clinical presentations prior to diagnosis, require isolation precautions?

Video Learning


Medical Knowledge
Patient Care

Consult Guys logo

The Consult Guys: Spinal or General Anesthesia?

Watch this episode of the medical consultation talk show, in which Drs. Weitz and Merli debunk myths regarding general versus spinal anesthesia, and make you laugh along the way.

Use this video to:

  • Ask your learners whether they comment on the approach to anesthesia when performing a preoperative consultation.
  • Answer the multiple-choice questions as a team. You can log on and get CME credit for yourself as well.

Humanism and Professionalism


On Being a Doctor: Remembering Johnnie

In her essay, Dr. Chretien describes her memories of Johnnie, a friend who worked in Environmental Services at her hospital, and how his death has affected her.

Use this essay to:

  • Play an audio recording of the essay, read by Michael LaCombe, MD.
  • Ask your learners how many of their nonphysician hospital colleagues have they gotten to know. Do they find the time to get to know other members of the hospital staff?
  • Ask how many have attended a funeral. Of a friend? Of a patient? Did attending the funeral alter how they dealt with the death?

mksap16

A 52-year-old man is evaluated during a periodic health examination. He has benign prostatic hyperplasia, and his father died of prostate cancer at the age of 74 years. His only current medication is tamsulosin. He has no urinary symptoms. Vital signs are normal, as is the remainder of the physical examination.

Which of the following is the most appropriate management?

A. Discuss the risks and benefits of prostate cancer screening
B. Obtain a prostate-specific antigen level
C. Perform a digital rectal examination
D. Perform a digital rectal examination and obtain a prostate-specific antigen level

Correct Answer
A. Discuss the risks and benefits of prostate cancer screening

Key Point
The decision of whether or not to screen for prostate cancer in an individual man should begin with an informed discussion regarding the risks and benefits of screening and the limitations of the methods used to screen.

Educational Objective
Manage prostate cancer screening.

The most appropriate management is to have an informed discussion with the patient regarding the risks and benefits of prostate cancer screening. The European Randomized Study of Screening for Prostate Cancer included 162,243 men aged 55 to 69 years. During a median of 9 years, the rate of diagnosis of prostate cancer was higher in the prostate-specific antigen (PSA)-screened group (8.2%) compared with the control (non-screened) group (4.8%) and there was an absolute, albeit small, mortality benefit (1410 men would need to be screened and an additional 48 men would need to be treated for prostate cancer to prevent one death from prostate cancer). In contrast, the Prostate, Lung, Colorectal, and Prostate Cancer Screening Trial found no benefit for annual concurrent PSA and digital rectal examination (DRE) after 7 to 10 years of follow-up. Given the conflicting evidence regarding the benefit of prostate cancer screening, the decision of whether or not to screen an individual patient should begin with the clinician having an informed discussion with the patient regarding the risks and benefits of screening and the limitations of the methods used to screen. Based on the conflicting results of these trials, it is not surprising that there is little consensus in terms of screening recommendations. The American Cancer Society supports the need for men to be involved in the decision of whether or not to be screened. In 2012, the U.S. Preventive Services Task Force (USPSTF) published a formal recommendation statement based on a review of existing evidence advising against PSA testing for prostate cancer screening in all men.

Performing a DRE alone is not recommended for screening owing to the poor test characteristics (positive likelihood ratio, 0.53-1.33; negative likelihood ratio, 0.65-14.9).

Although obtaining a PSA level alone and performing a DRE in combination with obtaining a PSA level are frequently employed in screening for prostate cancer, neither approach should be performed without first having an informed discussion with the patient.

Bibliography
Chou R, Croswell JM, Dana T, et al. Screening for prostate cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(11):762-771. Epub 2011 Oct 7. PMID: 21984740

This question is derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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