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 whether they discuss screening for lung cancer with their patients. If so, which ones?
In whom is screening for lung cancer with LDCT currently recommended? Review the statement of the U.S. Preventive Services Task Force.
Ask your learners why screening recommendations might be altered by a patient's risk for lung cancer. What factors influence the balance of risks and benefits? Use the editorials by Gould and Tammemägi to help frame your discussion.
The first paper assesses how patient preferences influence the likely risk–benefit ratio of lung cancer screening. How are patient preferences studied? What are utilities and disutilities? These are explained in the editorial.
The authors found that the benefit of lung cancer screening is influenced by a patient's disutility (“degree of dislike”) when there is either a low risk for lung cancer or a shorter life expectancy. Yet, the benefits of screening were not sensitive to patient preferences when there was a high risk for lung cancer and a longer life expectancy. Why do your learners think that might be?
How would your learners use this information to counsel patients? Review Table 2 for “rules of thumb” and the editorial to help jump-start a discussion.
Invite a colleague in your center's lung cancer screening program to join your discussion.
Ask your learners what the potential benefits and harms are from a cancer screening program.
What is overdiagnosis? How does it differ from a false-positive test result? What are the harms of overdiagnosis?
Review the definitions that are important to understanding overdiagnosis in Table 1.
Why does the public (and the medical profession) continue to have a difficult time envisioning how health care, and particularly testing, can be harmful?
Why are we unable to measure overdiagnosis directly? How is it estimated? What are the challenges and limitations of these estimates?
How would your learners explain overdiagnosis and its potential harms to a patient who believes screening and early detection must always be good?
Invite an expert in epidemiology—or screening specifically—to join your discussion.
Ask your learners whether they discuss the safety of driving with patients with cognitive impairment or their families. Have they ever considered whether similar discussions should occur about access to firearms?
What options exist for ensuring firearm safety?
How might the degree of cognitive impairment influence what should be done? Review the Table.
The authors propose discussing a “firearm retirement date,” similar to an “advance driving directive,” with patients with minimal cognitive impairment. Do your learners think this is a good idea?
Ask your learners who is at risk for concussion and which types of trauma are most likely to cause it. Can they be prevented?
What acute symptoms after head injury should prompt consideration of concussion, and how should the patient be evaluated? What symptoms may be present within minutes to hours, and which ones may appear within days or weeks? What should the examination include? What imaging or other testing is required, and when?
How is concussion diagnosed? How is severity assessed?
What restrictions on work, school, or other activities should be instituted, and in whom? How is the safety of returning to these activities determined?
What are the potential complications of concussion? Are specialists required for evaluation and treatment? When should rehabilitation be considered?
What is the prognosis of concussion?
Download the teaching slides to help with a teaching session, and use the CME/MOC questions to help introduce topics for discussion. Be sure to log on and enter your answers to earn CME/MOC credit for yourself!
Listen to an audio recording, read by Dr. Michael LaCombe.
Ask your learners what assumptions they made when they heard early in the essay that the autopsy was of a man in his 30s with a history of heroin abuse who died after an opioid overdose. If they are uncomfortable answering, ask them to at least think about it.
How did their image of the man who died change by the end of the essay?
Do your learners worry that they may contribute in some way to similar tragedies? What can we each do to avoid it?
Ask your learners whether they have seen the autopsy of a patient they had known well. Were they, like Dr. Zuckerman, “of two minds”?
How does the death of a patient, whose soul we have come to know, affect us as physicians? Do we talk about this enough? Do we allow ourselves to contemplate and grapple with the loss while learning from the death?
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Taichman DB. Annals for Educators - 3 July 2018. Ann Intern Med. ;169:ED1. doi: 10.7326/AFED201807030
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Published: Ann Intern Med. 2018;169(1):ED1.
Cancer Screening/Prevention, Cardiology, Coronary Risk Factors, Emergency Medicine, Hematology/Oncology.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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