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.
Ask your learners if any of their patients have pursued direct-to-consumer genomic testing.
Look at the reports promised by one company. Do your learners feel prepared to review the results of such testing with their patients? If a patient provides a list of such results, what obligation do your learners feel to review and understand them? How long would it take to fully understand them? Is it different from any other test result that a patient may have had elsewhere?
Should your learners try to counsel a patient about the meaning of the presence of a gene variant? Do all such questions require evaluation by a geneticist? How will your learners decide? Invite a geneticist to join your conversation.
What do patients who have such testing anticipate? Look at the Web sites of some companies offering these services. Do your learners feel such testing is of value? Use the accompanying editorial to help frame your discussion.
Start a teaching session with a multiple-choice question. We've provided one below.
Review when to consider and how to diagnose RA. Use the information in DynaMed Plus: Rheumatoid Arthritis to help prepare to teach (a benefit of your ACP membership).
Teach at the bedside! Examine the joints of patients with and without RA with your team. Ask a radiologist to review with your team the radiologic changes found in patients with RA.
Review the results of this randomized trial. What targets are used in a treat-to-target strategy? Ask your learners what the goals of therapy for RA are. How are they monitored? What should they ask their patients about, and how often? Is any testing routinely required?
List the variables noted in Table 1, and ask your learners if they know the ranges used to diagnose pre-diabetes and diabetes. Ask your learners if they know how to order an oral glucose tolerance test.
How frequently should hemoglobin A1c be measured? What are the limitations of hemoglobin A1c testing?
Ask what advice your learners would provide to a patient with hypoglycemia unawareness. How should treatment be adjusted in such patients?
How should glycemic targets be selected? Use Appendix Figure 2 to visualize the interplay among important variables to consider (e.g., life expectancy, the presence of vascular complications)
How do your learners select antihyperglycemic therapy for type 2 diabetes? Review the information in Figure 1. How and when do they select second and third agents?
Review succinctly the experiments performed in Tuskegee and Willowbrook, the lobotomies performed on patients with mental illness, and the other events described by the authors. Ask what breach of ethics occurred in each.
The authors stress that it is essential to understand the context in which the physicians who participated in these events found themselves. Ask your learners why. Might such contextualization be used to justify what happened? Instead, might it help us understand why it happened when it did?
The authors state that by understanding the context, “… we are forced to question whether the ethos and rationales of that era could resurface.” What motivations present at the time of these unethical practices are still present today? How have things changed?
The authors argue that such an emphasis is too often missing when these events are presented as though they merely involved monsters from an alien past. Read the quote above from Susan Reverby. Do your learners believe that the evil of the past could not surface in our more modern, ethically “enlightened” era?
Ask if written informed consent protects against abuse? How might a patient be coerced into participation? Are participants truly “informed” when signing an informed consent agreement?
Prompt your trainees to discuss their own responsibilities as role models. But first, use it to ask yourself what language you use on rounds (body and words), and how it might shape the experience of your patients and the future practice of your trainees.
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Darren B. Taichman. Annals for Educators - 19 April 2016. Ann Intern Med. 2016;164:ED8. doi: 10.7326/AFED201604190
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Published: Ann Intern Med. 2016;164(8):ED8.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Ethics.
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