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Annals for Educators - 3 May 2016Annals for Educators - 3 May 2016 FREE

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.

Ann Intern Med. 2016;164(9):ED9. doi:10.7326/AFED201605030
© 2016 American College of Physicians
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Patients may vary in their expressed preferences about how to attempt smoking cessation. Whether an initial gradual reduction in cigarette use before an attempt to quit is as effective as abrupt cessation is not known. This randomized trial compared gradual with abrupt cessation to assess short- and long-term abstinence.

Use this study to:

  • Start a teaching session with a multiple-choice question. We've provided one below.

  • Ask your learners what the barriers are to smoking cessation. Are they physical addiction alone?

  • Review the recent In the Clinic: Smoking Cessation . Review the 5 A's, which recommend that we set a quit date with our patients. Have your learners encountered patients who are interested in cutting down gradually rather than stopping abruptly? What do your learners advise them? What might be the advantages to a firm quit date? To gradually cutting down?

  • What do the results of this trial tell us about gradually cutting down before quitting? Do the results indicate that cutting down is harmful? Why or why not? If a patient cuts down but does not quit, is that not better than nothing? Is it better than nothing if it interferes with quitting completely? Use the accompanying editorial to help prepare for such a discussion.

  • This trial used prequit nicotine replacement in the lead-up to the planned quit date. What do your learners teach their patients about when and how to use nicotine replacement?

Influenza vaccination is recommended before discharge for surgical inpatients who have not yet been vaccinated. Vaccination rates are low in this population, perhaps because of concerns that adverse effects of the vaccine could be confused with surgical complications. In this cohort study, the authors evaluated whether influenza vaccination in the perioperative period increases health care utilization and evaluations for postsurgical infection after discharge.

Use this study to:

  • The Advisory Committee on Immunization Practices currently recommends that eligible hospitalized patients receive the influenza vaccine before discharge. This preventive strategy is measured in quality metrics of inpatient immunization by the Joint Commission and the Centers for Medicare & Medicaid Services. Yet, patients hospitalized for surgical procedures are often not targeted for immunization. Ask your learners why not. What fears might surgeons have about vaccinating their patients? See this paper's introduction for ideas.

  • When your learners perform medical consults on surgical patients, do they use the opportunity to make recommendations regarding needed immunizations? Do they think that they should? After reading this study, will your learners recommend influenza vaccination for surgical patients they see as medical consultants?

  • The use of administrative records is common for health services outcomes research. Use this study to help your learners understand the benefits of large administrative databases and why they enable certain kinds of studies that might otherwise be difficult or impossible to conduct, while appreciating their weaknesses.

  • Review the design of this cohort study. What was the target population? What were the key exposure and key outcomes? How were they measured? Was this a prospective or retrospective cohort? Why does it matter? Look at how the exposure and outcomes were assessed (through administrative records). What limitations might this place on their ascertainment?

This practical review answers key questions regarding the prevention, evaluation, and treatment of Lyme disease.

Use this review to:

  • Break up a teaching session using the multiple-choice questions provided to introduce key topics. Be sure to log on after and enter your answers to earn CME for yourself.

  • Ask your learners what they should advise their patients regarding prevention. Is there a role for prophylactic antibiotics for patients in high-risk situations? See the answer in the review.

  • Review the potential clinical manifestations of Lyme and the differential diagnosis (see the Table). How is Lyme diagnosed?

  • How should Lyme be treated? Can a person be infected more than once?

  • Why is there controversy over “chronic Lyme disease”? Review the epidemiologic material and randomized studies presented in this section of the In the Clinic review. What do your learners think? Role-play talking to a patient with a prior exposure who requests treatment for “chronic Lyme disease” to help with fatigue. What will your learners say?

  • Download the already-prepared teaching slides to help present material to your learners.

In its position paper, the ACP calls for government and the health care sector to address climate change. The editorialists describe the approach their health system has taken to act locally to understand and improve air quality and to help patients avoid the health effects of poor air quality.

Use these papers to:

  • Ask your learners if they know how air quality is measured, and what it means when they hear on the news that it is poor on a given day. Do they know what the Air Quality Index (AQI) is, and how to interpret it? Do they consider what the AQI might mean for their patients with respiratory disease? Cardiovascular disease? Those who are pregnant?

  • Go to the authors' Web site (Outdoor Air Quality and Health ). Review the information provided on the adverse health effects of poor air quality. Pay particular attention to the charts and figures that provide advice to patients regarding changes to activities according to the AQI.

  • Review briefly the actions called for by the ACP regarding climate change. Do your learners believe that such statements are useful? Do they really influence change or governmental actions? Do they believe that physician groups should be involved? Do they think that your health system, and they individually, can influence change? Could your system emulate what the editorialists have done? Would your learners like to make a plan? To whom should they talk?

Dr. Lynes describes the circumstances that led to attempted suicide and the end of his practice of medicine.

Use this essay to:

  • Play an audio recording of this On Being a Doctor, read by Associate Editor Dr. Michael LaCombe.

  • Ask your learners whether they worry that burnout might affect them.

  • What conditions contribute to burnout? Which can we control? Which are out of our control? Can we learn skills to help us deal with these conditions and our reactions to them in a manner that is helpful?

  • Dr. Lynes notes that he never sought the help of his colleagues. Why might that happen? Is there anything about the culture of medical practice that might make physicians feel “weak” in admitting such feelings to colleagues? Does that contradict with the advice we give our own patients? How can we change that?

  • Invite a mental health professional to join your discussion. What advice might help us help ourselves and each other deal with the fact that, as Dr. Lynes puts it, “The life of a physician is stressful, period.”

A 38-year-old woman is evaluated during a routine examination. She is a mother of two children and works full time at a high-stress job. She smokes 10 cigarettes daily, eats fast food three times per week, and drinks two alcoholic beverages most nights. She does not exercise. Family history is noncontributory. She takes no medications.

On physical examination, the patient is afebrile, blood pressure is 122/76 mm Hg, and pulse rate is 80/min. BMI is 26. The remainder of the physical examination is normal.

Which of the following interventions will have the largest impact on this patient's health?

A. Decrease alcohol consumption

B. Exercise 30 minutes daily, 5 days per week

C. Healthful diet including fruits and vegetables

D. Smoking cessation

E. Stress management and relaxation techniques

Correct Answer

D. Smoking cessation

Educational Objective

Identify the relatively large impact of smoking cessation on improving health.


This patient would most benefit from smoking cessation counseling. Cigarette smoking increases the risk of cancer, heart disease, stroke, and lung disease and is the leading preventable cause of death in the United States. Quitting smoking is the single most important thing that smokers can do to improve their quality and quantity of life. Smoking cessation before age 40 years reduces the risk of death associated with continued tobacco use by approximately 90%. The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for tobacco users. Behavioral counseling for smoking cessation in primary care settings has been found to improve quit rates and sustained abstinence at 1 year. Even minimal in-office interventions, defined as less than 3 minutes in duration, are effective in improving smoking cessation rates.

A meta-analysis suggested that women who consume an average of two or more alcoholic drinks per day had an increased mortality rate compared with nondrinkers; therefore, this patient may benefit from counseling regarding reducing her alcohol consumption. Nonetheless, the benefit of brief intervention for smoking cessation is still likely to be more impactful in this patient.

Exercising and eating a healthful diet both have a significantly positive impact on health and have been strongly linked with decreased incidence of cardiovascular disease. However, the effect of behavioral counseling in promoting healthful diet and physical activity in adults without known cardiovascular disease, hypertension, hyperlipidemia, or diabetes is small. Given small potential effect, time limitations, and opportunity costs, the USPSTF recommends offering dietary and exercise behavioral counseling based only on individual patient circumstances. In this patient, smoking cessation counseling will have a greater benefit than counseling that promotes a healthful diet and physical activity.

Stress reduction and relaxation techniques have the potential to improve this patient's health; however, the health benefits of smoking cessation are likely to be greater.

Key Point

The U.S. Preventive Services Task Force recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for tobacco users.


Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med. 2013 Jan 24;368(4):341-50.

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