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.
Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners what effects hyperglycemia has on outcomes among hospitalized patients.
How do your learners choose a glycemic target range for a hospitalized patient? What variables might alter their goals?
What medications do you use, and in what manner? Do you use a basal–bolus approach? Why?
What variables pose particular challenges to ideal glucose control in the hospital (e.g., changes in the timing of meals, concurrent metabolic derangements, fasting for procedures)? Use the accompanying editorial to help frame your discussion.
Present serial glucose measurements together with recent medication administration and nutritional intake information on a few theoretical patients to prompt discussion of what, if any, alteration in therapy might be appropriate for each. You might show the flow sheet in Appendix Figure 2 of the article as an example for discussion. What would your learners have done in response to the blood glucose reading of 310 mg/dL?
Review the diabetic flow sheets of patients on your service. Is there adequate glycemic control? Are there regularly occurring problems that your team can identify? How might they be remedied?
Ask your learners what the possible symptoms of polymyalgia rheumatica are. Use the box on page ITC67.
What physical examination findings should be considered? What is seronegative symmetrical synovitis with pitting edema?
What is the differential diagnosis of polymyalgia rheumatica? Why is it important to differentiate it from giant cell arteritis, for example? How does the specific diagnosis alter short- and long-term management?
In whom should an ultrasound be considered? Should other tests be considered? Which ones?
How is therapy approached? When should steroids be started, and when should they be tapered? When should other agents be considered? When is consultation with a rheumatologist appropriate?
Use the teaching slides to help prepare for a teaching session. Break up the teaching session with the multiple-choice questions, and be sure to log on to enter your answers to earn CME credit for yourself!
Ask your learners to define bias as it relates to the results of a study aiming to assess whether a treatment improves an outcome. How does randomization in a trial help to minimize bias?
What does (or should) it mean when one reads “intention to treat” in the report of a randomized clinical trial? Why might crossover from one assigned treatment group to another or some participants' failure to adhere to their assigned treatment protocols bias the results? Does an intention-to-treat analysis ensure that such bias does not affect the reported results and conclusions? The authors explain why it does not.
Ask your learners what the authors mean when they write that an “as-treated” analysis would not be “protected by the randomization.” What bias would be introduced with a “per protocol” analysis? Why do these details matter when assessing how the analysis was performed and reported in a paper?
Show the Annals Graphic Medicine piece to your learners. Ask them if they can relate to how the author feels. Does it make them laugh? Feel angry? Feel sad? All three?
Do your learners understand the “donut hole”? To whom should they turn for help in figuring out such issues? Is there adequate support for patients and clinicians at your center with “administrative tasks”?
What are the benefits of preauthorizations and approvals for treatments? What are the harms? Use the editorial to help frame your discussion.
How would your learners design a system that might better balance necessary and helpful administrative controls and their potential harms? Do your learners think a model such as Australia's is better? Do they think the framework proposed by the ACP to evaluate the value of an administrative task is a good one?
Do your learners worry that administrative hassles might drive them away from practicing medicine? How can they deal with them? Can they help bring about change?
Make a list of the administrative tasks in clinical care specific to your hospital only (e.g., a form to place an order). What is the purpose of each? Can your learners identify tasks that might be safely eliminated without causing a problem? Can they propose a more efficient alternative approach? To whom should they take their ideas within your health system?
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Taichman DB. Annals for Educators - 2 May 2017. Ann Intern Med. ;166:ED9. doi: 10.7326/AFED201705020
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Published: Ann Intern Med. 2017;166(9):ED9.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Giant Cell Arteritis/Polymyalgia Rheumatica.
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