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August 18, 2015 Issue


Professionalism in Medicine

Professionalism

Our Family Secrets

On Being a Doctor: Shining a Light on the Dark Side

Although all other Annals for Educators alerts have started with suggestions for the use of research articles in your teaching, we considered this On Being a Doctor essay and the accompanying editorial a “must” for all training programs, indeed for all of us involved in medical care. The essay describes the disrespectful, and repugnant, behavior of some physicians toward patients. Moreover, it challenges us to ask ourselves to consider truthfully whether we have ever silently observed inappropriate behavior or even joined in.

Use these papers to:

  • Read the essay with your learners. You might ask each to quietly read it on her or his own.
  • Ask your learners if they have ever been in situations where they felt they should stop colleagues from behaving inappropriately. Did they? Was it easy? What is the right thing to do? These are lessons we've all heard since childhood. Are they different here?
  • Why do physicians sometimes behave badly? How can we prevent it? How can we stop it when it happens? What should be done after such an event has been stopped?
  • Ask your learners to imagine they are the editors of a medical journal. Would they have published this essay? Why or why not? Do they object, or agree, with the decision to publish this piece anonymously? Why?
  • Why did the editors make the decisions they did? The editorial shares their thoughts. Play an audio recording of it, read by Dr. Michael LaCombe.


Clinical Practice Points

Medical Knowledge
Patient Care

Mortality Associated With Medical Therapy Versus Elective Colectomy in Ulcerative Colitis. A Cohort Study

The authors analyzed Medicare and Medicaid data from 2000 to 2011 to compare the survival of patients who either had elective colectomy or had received medical therapy for advanced ulcerative colitis.

Use this study to:

  • Start a teaching session with multiple-choice questions. We've provided two below.
  • Review the medical therapies used for the treatment of ulcerative colitis. Use the information in DynaMed Plus: Ulcerative Colitis (a benefit of your ACP membership).
  • Ask your learners what the indications are for colectomy. How would they weigh the risks and benefits of escalating immunosuppressive therapies, or their prolonged use, versus those of colectomy when advising their patients?
  • Read the accompanying editorial. your learners how they would define “success” in the management of ulcerative colitis. Is it the same as in other chronic diseases that are not “curable?” How does one assess quality of life?


Patient Care
Interpersonal / Communication Skills
Systems-based Practice
Professionalism

Personalizing Death in the Intensive Care Unit: The 3 Wishes Project. A Mixed-Methods Study

The busy, technologic setting of the intensive care unit may interfere with the ability of dying patients, their families, and their clinicians to personalize and humanize care at the end of life. This study describes how the staff of an academic intensive care unit helped to dignify the dying process by eliciting and implementing simple wishes of patients or their families.

Use this study to:

  • Ask your learners what they talk about with their patients who are dying. What do they ask the families? Have they ever asked what they wish for? Must these conversations be “uncomfortable”? Might they find them rewarding?
  • Ask if their patients have ever requested things that cannot be accomplished. How do your learners respond?
  • Do they think the approach taken in this study could be implemented at your hospital? Do they think it could be maintained? Will you try it? Use the accompanying editorial to help frame your discussion.
  • Look at the “word cloud” depicted in the Figure. How might making a word cloud help family members of patients who are dying? How might it help the clinicians caring for a dying patient?
  • Watch the author insight video in which the clinicians and family members in this study discuss their experiences.


Beyond the Guidelines

Medical Knowledge
Patient Care
Interpersonal / Communication Skills

Treatment of Blood Cholesterol to Reduce Risk for Atherosclerotic Cardiovascular Disease. Grand Rounds Discussion From the Beth Israel Deaconess Medical Center

This feature includes an interview with a patient for whom treatment with a statin is being considered, as well as the discussion among experienced clinicians regarding what is “best.” Also included are slides, a paper summarizing the key points, and a video of the grand rounds discussion. The program may help your learners become accustomed to considering the many issues involved in choosing an approach to care when there is no single, best answer.

Use this feature to:

  • Watch the patient interview. Ask your learners how they would treat her.
  • Then, watch the grand rounds presentation. Have your learners changed their minds?
  • Is the risk calculator helpful? Are your learners disturbed to hear that the evidence used to support national recommendations is debated?
  • Complete the CME and MOC activities that accompany this feature to claim credit for yourself!


The Business of Medicine

Systems-based Practice

The 8 Basic Payment Methods in Health Care

This article divides the different ways that providers can be paid for administering medical care into 8 methods. Understanding this distribution helps explain trends in payment reform, conflicts that occur between providers and payers, and the reasons for some professional norms and business practices.

Use this paper to:

  • Watch the brief video in which the author summarizes key teaching points.
  • Review the “units” of payment (e.g., time, episode, service) that the author describes, and how the financial risk to providers and payers differ among them.
  • Invite an expert in health care economics (perhaps a member of your hospital's administration) to discuss how changes toward “value-based” reimbursement are altering the way your system does business.
  • Ask your learners why understanding these concepts might be important to them in their careers.


Video Learning

Medical Knowledge
Consult Guys logo

The Consult Guys: Shoot From the Hip? Surgery With Aortic Stenosis

Watch and enjoy this brief, engaging video with your learners as Geno and Howard (The Consult Guys) take on the tough question of whether and when to proceed to surgery in a patient with aortic stenosis. Answer the short multiple-choice questions to claim CME.




mksap16

A 37-year-old woman is evaluated in the emergency department for the acute onset of pain after 2 weeks of bloody diarrhea. The diarrhea has escalated to 15 times per day. She has ulcerative colitis that was diagnosed 2 years ago. She currently takes azathioprine.

On physical examination, she appears ill. Following aggressive fluid resuscitation, temperature is 38.9 °C (102.0 °F), blood pressure is 70/40 mm Hg, pulse rate is 148/min, and respiration rate is 35/min. Abdominal examination discloses absent bowel sounds, distention, and diffuse marked tenderness with mild palpation.

Laboratory studies reveal a leukocyte count of 16,800/µL (16.8 × 109/L). Abdominal radiograph is shown:

http://www.acponline.org/graphics/email/afe081815.jpg

Which of the following is the most appropriate management?

A. CT scan
B. Immediate surgery
C. Start infliximab
D. Start intravenous hydrocortisone

Correct Answer
B. Immediate surgery

Key Point
Toxic megacolon is the most severe complication associated with ulcerative colitis; progressive abdominal distention and tenderness with hemodynamic instability are indications for immediate surgery.

Educational Objective
Manage toxic megacolon in a patient with ulcerative colitis.

The most appropriate management is immediate surgery. Most patients with toxic megacolon related to ulcerative colitis have at least 1 week of bloody diarrhea symptoms that are unresponsive to medical therapy. On examination, patients have tachycardia, fever, hypotension, decreased or absent bowel sounds, and lower abdominal distention and tenderness, often with peritoneal signs. On plain film radiography, the transverse colon is most affected, with dilatation exceeding 6 cm. This patient has toxic megacolon based on the clinical history, examination findings, and imaging studies. Toxic megacolon is the most severe complication associated with ulcerative colitis; it is associated with a 40% mortality rate in patients undergoing emergency colectomy after a perforation has occurred (compared with 2% without a perforation). About 50% of patients with toxic megacolon may improve with medical therapy (bowel rest, intravenous corticosteroids, antibiotics, and fluids); however, progressive abdominal distention and tenderness with hemodynamic instability are indications for immediate surgery.

A CT scan could further identify the extent of colonic dilatation and wall thickening as well as possible abscess formation or microperforation, but this would not change the required management of this patient.

Infliximab is a good treatment for flares of ulcerative colitis, but it is not an effective therapy for toxic megacolon and would not be indicated in this patient.

Intravenous hydrocortisone would be a good choice for an ulcerative colitis flare or possibly toxic megacolon, but only if the patient was clinically stable.

Bibliography
Gan SI, Beck PL. A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. Am J Gastroenterol. 2003;98(11):2363-2371. PMID: 14638335

This question was derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.



MKSAP 17


A 38-year-old man is evaluated in follow-up after a diagnosis of ulcerative colitis. Ten days ago he was started on prednisone, 60 mg/d, but his symptoms have not improved. He has six to nine bloody bowel movements per day and moderate abdominal pain. He has decreased his oral intake because eating exacerbates his pain and diarrhea.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/56 mm Hg, and pulse rate is 96/min. He is pale but in no distress. The abdomen is diffusely tender without distention, guarding, or rebound. Laboratory studies reveal a hemoglobin level of 9.7 g/dL (97 g/L) and a leukocyte count of 6300/µL (6.3 × 109/L). Stool culture and Clostridium difficile assay are negative.

Which of the following is the most appropriate treatment?

A. Increase prednisone to 80 mg/d
B. Initiate adalimumab
C. Initiate ciprofloxacin and metronidazole
D. Initiate mesalamine
E. Initiate sulfasalazine

Correct Answer
B. Initiate adalimumab

Key Point
Patients with moderate to severe ulcerative colitis whose disease does not respond to oral glucocorticoids should be treated with either intravenous glucocorticoids or an anti–tumor necrosis factor agent.

Educational Objective
Treat refractory ulcerative colitis with an anti–tumor necrosis factor agent.

The most appropriate treatment is to initiate an anti–tumor necrosis factor (anti-TNF) agent such as adalimumab. This patient has moderate to severe ulcerative colitis that is not responding to 60 mg/d of prednisone. Moderate to severe ulcerative colitis is often treated with oral glucocorticoids such as prednisone, 40 to 60 mg/d. Patients whose disease does not respond to oral glucocorticoids should be hospitalized and given intravenous glucocorticoids or should be treated with an anti-TNF agent. Randomized controlled clinical trials have shown three anti-TNF antibodies (infliximab, adalimumab, and golimumab) to be effective for inducing and maintaining remission in patients such as this with ulcerative colitis. Indications for hospital admission include dehydration, inability to tolerate oral intake, fever, significant abdominal tenderness, and abdominal distention.

A meta-analysis of clinical trials showed that using doses of prednisone above 60 mg/d provides little if any additional efficacy and produces more side effects.

Ciprofloxacin and metronidazole should be used in patients with severe colitis associated with high fever, significant leukocytosis, peritoneal signs, or toxic megacolon. However, antibiotics are not indicated in a patient such as this with colitis without signs of systemic toxicity.

Patients with mild to moderate ulcerative colitis respond well to 5-aminosalicylate agents. Patients with proctitis or left-sided colitis should receive topical therapy with a 5-aminosalicylate or hydrocortisone suppositories or enemas. If patients require repeated courses of glucocorticoids or become glucocorticoid dependent, thiopurines (6-mercaptopurine or azathioprine) or an anti-TNF agent should be initiated (methotrexate has not been shown to be effective in ulcerative colitis). Anti-TNF agents should be used in patients who do not maintain remission with thiopurines or patients whose disease is refractory to glucocorticoids. It is unlikely that 5-aminosalicylates would be beneficial in this patient with more severe disease that is refractory to prednisone.

Bibliography
Talley NJ, Abreu MT, Achkar JP, et al; American College of Gastroenterology IBD Task Force. An evidence-based systematic review on medical therapies for inflammatory bowel disease. Am J Gastroenterol. 2011 Apr;106 Suppl 1:S2-25; quiz S26. PMID: 21472012

This question was derived from MKSAP® 17, the Medical Knowledge Self-Assessment Program.



From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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