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 to generate a differential diagnosis of thrombocytosis. How might ET present? Is it often an “incidental finding” in asymptomatic patients?
Ask your learners to list the myeloproliferative disorders. How does ET differ from polycythemia vera? Use the information in DynaMed Plus: Essential thrombocythemia, a benefit of your ACP membership.
What are the major complications of ET? What is the justification for antiplatelet therapy in ET? The editorialist notes that the benefit of antiplatelet therapy in a randomized trial of patients with polycythemia vera makes “the temptation…almost irresistible” to start antiplatelet therapy in patients with ET. What are the potential pitfalls of such an approach?
What do the results of this systematic review tell us about the use of antiplatelet therapy? How might a systematic review that concludes that the current state of evidence is insufficient to guide therapy still be useful to clinicians and the research community?
What advice would your learners give to a patient with ET with regard to the balance of risks and benefits of antiplatelet therapy? How would they explain these in light of the results of this systematic review?
Would the presence of a JAK2 mutation be helpful in deciding what to do? Invite a hematologist to join your discussion.
Ask your learners what the risks of long-term opioid use are. What are the barriers to discontinuation? Is dose reduction useful?
What are the challenges to dose reduction, and what are the potential unintended consequences (both medical and to the physician–patient relationship)? Use the accompanying editorial to help frame your discussion.
Do the barriers lie only with the patient? Are we sufficiently motivated to take the time required to assist patients in this process? How was dose reduction accomplished in the studies included in this systematic review? Are we prepared to do what was done in these programs? The editorialist suggests identifying and starting with a few motivated patients in one's practice. Why?
The authors and editorialists note the importance of obtaining patient buy-in. How might motivational interview techniques help? What are they? Role-play with your learners to practice.
Explore the resources available from the Centers for Disease Control and Prevention (reference 9 of the editorial). Will these be helpful to your learners or your patients?
What other members of the health care team are important in helping patients to reduce the dose of long-term opioid therapy?
The editorialist disagrees with the attitude that, “In the realm of opioid therapy, patient safety and pain relief have often been framed as conflicting and mutually exclusive goals.” Do your learners agree?
Watch the patient interview video with your learners, then ask them what they would recommend to this patient. Are there other questions or topics they would want to discuss with the patient to help him decide what to do?
Review the evidence supporting the use of therapies for depression. You might watch the grand rounds presentation with your learners, download and use the prepared slides to help present the material yourself, or assign your learners to summarize the points made by the primary care physician and the psychiatrist.
The discussants note the potential use of nonpharmacologic approaches to treating depression. What are they? How does one refer a patient for cognitive behavioral therapy? What is involved?
Use the multiple-choice questions provided to help break up a teaching session, and be sure to log on and enter your answers to earn CME and MOC credit for yourself!
Ask your learners how often adults should be screened for osteoporosis. When should screening be stopped?
How much vitamin D is it appropriate for adults to take each day? In addition to adequate vitamin D, what else is recommended to prevent osteoporosis?
How are Z scores on dual-energy x-ray absorptiometry interpreted? In which patients should secondary causes of osteoporosis be evaluated, and which tests should be ordered? Is consultation with a specialist needed?
Which patients are candidates for pharmacologic treatment, and how does one choose among treatments? Use the table to review their adverse effects and risks. How long should therapy be continued?
Share the patient information sheet with your learners. Would this be helpful for their patients? Does your practice have such reading materials readily available for your patients? If not, should your learners suggest this one be made available? Where should it be kept, and whose job should it be to remember to provide it to patients with osteoporosis? Is there anything missing from this information that they would have included?
Use the prepared teaching slides to help with a teaching session. Use the multiple-choice questions to introduce topics, and be sure to log on to enter your answers and earn CME and MOC credit for yourself!
Listen to an audio recording with your learners, read by Dr. Michael LaCombe.
Dr. Karkowsky was busy and had fit this patient into his schedule when he noticed something more might be behind the visit than concern about hypertension. Do your learners think that in such a situation, perhaps short on time, they might have ignored such a signal and simply increased the patient's antihypertensive medications?
How comfortable would your learners be talking about such personal issues with their patients? How would it make your learners feel to know their patient looked to them for such counsel? Would they draw on personal experience when trying to provide advice? How comfortable (or uncomfortable) would they be doing so?
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Taichman DB. Annals for Educators - 1 August 2017. Ann Intern Med. ;167:ED3. doi: 10.7326/AFED201708010
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Published: Ann Intern Med. 2017;167(3):ED3.
Coagulopathies, Endocrine and Metabolism, Hematology/Oncology, Metabolic Bone Disorders, Platelet Disorders.
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