Darren B. Taichman, MD, PhD
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From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University.
Taichman DB. Annals for Educators - 5 April 2016. Ann Intern Med. 2016;164:ED7. doi: 10.7326/AFED201604050
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Published: Ann Intern Med. 2016;164(7):ED7.
Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners to describe the pathophysiology of gout. What are the causes of urate overproduction and decreased urate excretion? Use the information in DynaMed Plus: Gout (a benefit of your ACP membership) to help prepare.
What are the presentations of acute gout? What is the differential diagnosis, and how is a diagnosis made? How should it be treated? Review the results of this trial.
Ask your learners what a pragmatic clinical trial is. How does it differ from an explanatory trial? In which ways is each more (or less) useful in answering clinical questions? Use a brief perspective on this topic to help frame your discussion.
What made the enrollment and management of patients in this trial more “real world” (pragmatic)? Prompt your learners by asking if they think the results might have been affected by allowing gout to be defined by the clinician, rather than requiring confirmation of urate crystals in the synovial fluid? How might that have affected the results of the trial?
What can be done to prevent recurrent acute attacks of gout?
Ask your learners to list the potential causes of chronic anemia in a patient with CKD. How should each be managed?
What is the role of iron supplementation in patients with CKD? How should it be administered?
What are the potential benefits of ESAs in the treatment of patients with CKD? What are the potential harms? When should their use be considered? See what a current clinical guideline recommends.
This review concluded that using ESAs to obtain higher hemoglobin targets in patients with CKD does not result in important differences in HRQOL. Ask your learners to define HRQOL. What “domains” might be considered (e.g., physical health, mental health)? What variables affect each domain? How might they be measured?
Have your learners complete the SF-36, used in the studies included in this review and one of the most widely used “generic” HRQOL measures. You may get the form at this link. How might a “disease-specific” HRQOL tool differ? Do your learners think the questions addressed by such research tools ask what is important to a patient? Do they think HRQOL is an important outcome in trials of therapy?
Watch the interview of Mr. F with your learners. He worries that tests and the results of screening for CHD might make him nervous. As he puts it, “...candidly maybe a little knowledge is a dangerous thing. I think if I subjected myself to one of those tests and I was informed that there was a moderate possibility that I would have some symptoms of coronary artery disease, that would make me anxious.” Ask what your learners would recommend to Mr. F.
Now watch the video of the grand rounds debate regarding whether screening for CHD is beneficial. Or, download the already prepared slides to help summarize the key points made for your learners.
Has the discussion altered your learners' thoughts?
Given the prevalence of CHD, and the number of trials conducted each year in cardiology, are your learners surprised by the lack of a single, clear-cut answer to the questions posed in this debate? How would they design a study to assess whether screening is beneficial to patients like Mr. F? What outcomes would they want to study?
Download the teaching slides. Use the provided multiple-choice questions to introduce topics during a teaching session. Log on to enter your responses and claim CME for yourself.
Ask your learners what the most common substance use disorders are. How common are they?
Can substance use disorders be prevented? Ask how.
How is unhealthy alcohol use defined? How is it diagnosed? Review the questions that may be useful in the Diagnosis section of this review.
Ask how withdrawal from alcohol should be approached in the outpatient setting. What about withdrawal from opioids? Benzodiazepines? What interventions are available for each?
What is the role of the primary care physician (versus an addiction specialist) in the care of a patient with a substance use disorder?
Is it funny? Is it disturbing? Is it ever OK to make jokes about our patients?
If we are honest with ourselves, might we be guilty of ever dehumanizing our patients? When and why? What should we do?
Listen to an audio recording, read by On Being a Doctor associate editor Dr. Michael LaCombe.
Ask your learners if there are situations that would make it difficult to continue to provide care to a patient. Is there a limit to our duty to treat all patients?
When might it be appropriate to stop being a patient's doctor? How should this be done? Should you arrange for another physician to take over? If so, what should you tell the patient's new physician? How might his or her knowledge of the reasons you need to stop influence care?
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Cardiology, Coronary Heart Disease, Endocrine and Metabolism, Gout, Hematology/Oncology.
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