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December 1, 2015 Issue


Clinical Practice Points

Medical Knowledge
Patient Care

Normal-Weight Central Obesity: Implications for Total and Cardiovascular Mortality

Whether measures of central obesity, such as waist-to-hip ratio (WHR), provide additional information beyond body mass index (BMI) in defining mortality risks is unclear. This study examined data from a large cohort to compare the total and cardiovascular mortality risks for different combinations of BMI and WHR categories. An elevated WHR was associated with an increase in mortality even among individuals with a normal BMI.

Use this study to:

  • Ask your learners to define overweight and obesity. Do they know how BMI is calculated and what the “cut-offs” are for underweight, normal, and obese?
  • Ask whether they assess the distribution of adiposity in their patients, such as measuring the WHR.
  • Review the findings of this study. Do your learners think that they should measure their patients' WHR? Should it influence what they tell their patients? The decision to pursue additional tests or treatments? The editorialist discusses the potential importance of WHR and why looking only at BMI might be insufficient.


Medical Knowledge
Patient Care
Practice-based Learning / Improvement

Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement

This recommendation statement from the U.S. Preventive Services Task Force addresses screening for abnormal blood glucose and type 2 diabetes mellitus in adults.

Use this guideline to:

  • Review the risk factors for the development of type 2 diabetes mellitus. Which patients should be screened for abnormal glucose and diabetes? How should screening be performed? Use this guideline and a recent In the Clinic: Type 2 Diabetes to help prepare a teaching session.
  • Ask your learners how good they are at routinely screening for abnormal blood glucose and diabetes in their practices. How would they evaluate their performance?
  • Design a study with your team to assess whether they screen patients at risk for abnormal glucose and diabetes. Can your system's electronic health record help? How would you identify the patients in whom screening should be considered? How would your team assess whether screening had been performed? What would your team consider to be an “acceptable” rate of screening? Might there have been cogent reasons why individual patients identified by computer record as being “appropriate” for screening were not screened?
  • Is planning and carrying out such an evaluation of your practice harder than your team members thought? What did it teach your team regarding how to interpret “quality metrics” or standards for practice?


In the Clinic

Medical Knowledge
Patient Care
Interpersonal / Communication Skills

Prostate Cancer

This concise review covers prostate cancer, including prevention, screening, diagnosis, and treatment.

Use this review to:

  • Start a teaching session with a multiple-choice question. We've provided one below.
  • Ask your learners how they discuss whether to screen for prostate cancer with their patients. Consider role-playing to be sure your learners can effectively explain the potential harms and benefits of screening and answer patients' questions.
  • Review the options for men with localized prostate cancer (e.g., watchful waiting, active surveillance, radical prostatectomy). Ask your learners to define “shared decision making” and what questions they would ask their patients to ensure care plans are best tailored to the patient's informed preferences.
  • Download the already-prepared teaching slides to help organize a teaching session. Use the other multiple-choice questions provided to help introduce topics throughout the session. Be sure to log on to enter your answers and claim CME for yourself.


Medical Knowledge
Patient Care
Systems-based Practice

Content, Consistency, and Quality of Black Box Warnings: Time for a Change

Black box warnings have been the subject of controversy, due in part to their opaque connection to the underlying body of evidence. This commentary proposes a new structure for presenting black box warnings that takes into consideration the fundamental principles of evidence-based medicine.

Use this paper to:

  • Ask your learners if they read black box warnings. Do they find them useful sources of information?
  • What do your learners do when a drug's label carries a black box warning? In what way does the presence of the warning alter their prescribing?
  • Are they bothered by the authors' findings regarding the content of current black box warnings? Do they believe the authors' proposal will help improve patient safety?


Our Health Care System

Patient Care
Systems-based Practice
Professionalism

Retail Health Clinics: A Policy Position Paper From the American College of Physicians

This position paper provides recommendations from the American College of Physicians addressing the expansion of retail health clinics while underscoring patient safety, communication, and collaboration among retail health clinics, physicians, and patients.

Use this paper to:

  • Ask your learners if they are aware of the services available to patients at local “retail” health clinics. Consider asking a physician or a nurse who works at one to join your teaching session.
  • Do your learners think there is a benefit to using such services, as compared with seeing a physician or nurse in a more “traditional” medical practice? What are the possible harms?
  • Review the recommendations in this paper. Do your learners agree with each?
  • Do your learners feel “threatened” by the emergence of this new model of delivering and receiving health care services? Do they think it will impact their own practices or income?


Systems-based Practice

The Blind Spot in the Patient Protection and Affordable Care Act's Cost-Control Policies

Provisions of the Affordable Care Act (ACA) help to reign in overuse within the Medicare and private markets. However, the author argues that the ACA is relatively silent on price control in the private market and that provisions that tend to promote the consolidation of providers and reduce competition may command higher prices.

Use this paper to:

  • Ask your learners to list policies that might help to reduce health care costs. Which policies target the overuse of services, and which target prices for services?
  • Review the author's description of how the ACA aims to reign in costs within Medicare and in private markets. Use the table to help review.
  • Why might the consolidation of health care providers increase costs?


Scientific Ethics

Professionalism

Notice of Retraction: Ramipril Markedly Improves Walking Ability in Patients With Peripheral Arterial Disease

The authors of a previously published clinical trial are retracting the paper because they lacked confidence in the validity of the findings after data in a related study was found to be have been fabricated by the paper's lead author. This other clinical trial, published in another journal, has also been retracted by the authors.

Use this announcement to:

  • Ask your learners what responsibilities authors have for the papers they publish.
  • The authors of this paper note that although they no longer have confidence in the data published (which is why they are retracting them from the scientific record), they do not believe the problem has resulted in harm to patients. What other reasons (beyond potential harm to patients) are there for retracting a published paper?
  • Review the responsibilities and requirements of authors for scientific papers . Note the 4th criterion. Are the authors retracting this paper living up to their responsibilities as authors?
  • Does the retraction of a paper always mean there was wrongdoing on the part of an author? If an honest mistake was made in the analysis of a paper that renders its conclusions invalid, should the paper be retracted? When should a correction or erratum be published, and when should a paper be retracted? See the advice provided by the International Committee of Medical Journal Editors: Corrections and Version Control and Scientific Misconduct, Expressions of Concern, and Retraction.


Humanism and Professionalism

Professionalism
Interpersonal / Communication Skills

On Being a Doctor: Just One More Hug

Dr. Patel tells how a conversation with the family of his dying patient helped him to realize where he needed to be, and what he needed to do, in his own home.

Use this essay to:

  • Listen to an audio recording of this essay, read by Annals editor for On Being a Doctor, Dr. Michael LaCombe. Be sure to look at the cover of this issue of Annals, where a picture of Dr. LaCombe is featured.
  • Ask your learners if they worry they will have regrets about their family relationships later in life. In what ways does practicing medicine make it hard to avoid such regrets? Is it only the time required?
  • Are there ways in which being a physician helps us to focus on our own families and avoid such regrets later?


More Teaching Tools

High Value Care

Learn to Teach and Assess High Value Care and Quality Improvement Milestones

In collaboration with the Alliance for Academic Internal Medicine (AAIM), ACP will host a one-day meeting for faculty interested in learning how to better engage, mentor and assess trainees in high value care quality improvement projects. The program will be held on March 16, 2016, 9 a.m.-4 p.m. in Philadelphia. Learn more.



ACP Leadership Academy

Patient Care
Interpersonal / Communication Skills

Free Webinar: Achieving Health Equity for Lesbian, Gay, Bisexual, and Transgender People

Harvey J. Makadon, MD, FACP, will lead this webinar. Dr. Makadon is one of the authors of the Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health – which is now in its second edition. He is a Professor of Medicine at Harvard Medical School and the Director of Education and Training at the Fenway Institute in Boston, one of the most trusted and respected community-based research, education, and care centers. This webinar will be held on Wednesday, December 16, 2015 at 6:30 p.m. ET Register online.

Registrants will receive CME credit for participation in this webinar. ACP designates this live activity for a maximum of 1 AMA PRA Category 1 Credit(s)™.



mksap17

A 66-year-old man requests evaluation for prostate cancer. He is asymptomatic. Following a discussion of the risks and benefits of prostate cancer screening, the patient decides to be screened.

Physical examination findings are normal. Digital rectal examination is normal.

Serum prostate-specific antigen level is 5.8 ng/mL (5.8 µg/L).

Transrectal ultrasound–guided prostate biopsy is done and shows adenocarcinoma in 2/12 cores, confined to the right lobe (Gleason score: 3 + 3 = 6).

Which of the following diagnostic imaging studies should be done next?

A. Bone scan
B. Computed tomography of the chest, abdomen, and pelvis
C. Immunoscintigraphy
D. Positron emission tomography/computed tomography
E. No imaging studies are needed

Correct Answer
E. No imaging studies are needed

Key Point
Imaging studies are not indicated for men with newly diagnosed early-stage prostate cancer in the absence of symptoms or other high-risk features.

Educational Objective
Educational Objective: Determine need for diagnostic imaging studies in a patient with low-risk prostate cancer.

No imaging studies are indicated at this time. The United States Preventive Services Task Force has concluded that the harms of screening for prostate cancer outweigh the benefits in men of any age regardless of risk factors. In contrast, the American Cancer Society and American Urological Association recommend offering both serum prostate-specific antigen (PSA) measurement and digital rectal examination to men annually beginning at the age of 50 years. The American College of Physicians and American Academy of Family Physicians both recommend that clinicians have individualized discussions with their patients regarding obtaining PSA measurements and support measuring PSA levels after such discussions in patients 50 years and older who have life expectancies of at least 10 years. This patient has low-risk prostate cancer based on the presence of a TNM stage T1c tumor (identified after an elevated screening serum PSA level is found in the absence of symptoms), a serum PSA level less than 10 ng/mL (10 µg/L), and a Gleason score less than 8. Imaging studies are currently not recommended for men with low-risk disease, as there is no evidence that such studies reliably alter management decisions.

Prostate cancer is among the most commonly diagnosed cancers in men in the United States. Most men are diagnosed with clinically occult cancer, which is identified on the basis of an abnormal serum PSA value. Most often, there are no symptoms or indicative physical findings as in the patient described here. Once the diagnosis of prostate cancer is made, the focus moves to assessment and treatment decision making. The role of imaging studies in men diagnosed with prostate cancer is to assess disease status, particularly the presence of metastatic disease. Imaging studies are indicated to evaluate symptoms suggestive of metastatic disease and also to evaluate patients at high risk for occult metastatic disease. Currently accepted parameters for imaging studies include a serum PSA level of 20 ng/mL (20 µg/L) or higher, a PSA level of 10 ng/mL (10 µg/L) or higher associated with a T2 tumor, a Gleason score of 8 or higher, or a T3 or T4 tumor.

Bibliography
Eberhardt SC, Carter S, Casalino DD, et al. ACR Appropriateness Criteria prostate cancer–pretreatment detection, staging, and surveillance. J Am Coll Radiol. 2013 Feb;10(2):83-92. PMID: 23374687

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



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.

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