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.
Teach at the bedside! Examine a patient with aortic stenosis with your team. What is the quality and timing of the murmur? Do you hear an S4? If so, what does it represent? What is meant by, “pulsus parvus and tardus?” To help prepare for teaching, use the information at DynaMed Plus: Aortic Stenosis (a benefit of your ACP membership).
Ask your learners what the clinical manifestations are of aortic stenosis. What is the cause of angina? What does syncope signify?
How is the severity of aortic stenosis evaluated, and how should mild disease be followed? What are the indications for intervention? How would your learners choose between surgical aortic valve replacement and TAVR for a patient?
In this study, outcomes after TAVR differed between women and men. What are some potential reasons for these differences? Use the editorial to help frame your discussion.
Before reviewing the results of this study with your learners, ask which of the incentive approaches they think would be most effective.
Ask if they feel it is ethically appropriate for employers to offer incentives to their employees regarding health-related actions. Is it okay to offer and then take away incentives as was done here?
Can your learners think of other ways in which they might use “incentives” to help improve their patients' health-related actions in other areas?
Ask you learners to use the step-counter app on their smartphones (or other devices) to record their own activity. Do they achieve the goals set in this study? How often do we encourage our patients to do things we don't do ourselves? Do we adhere to the dietary and exercise guidelines we recommend to our patients? Is it okay to ask patients to do things we don't do ourselves?
Ask your learners who is at risk for contrast-induced nephropathy.
What is currently done at your institution to reduce the risk of contrast-induced nephropathy? How strong is the evidence in support of your approach? Should you consider alternative means of prevention? If so, which?
Given the low strength of available evidence identified in these reviews, how will your learners decide what to do, if anything?
Ask your learners if there are clinical circumstances where studies using intravenous contrast are commonly ordered, but might be readily avoided?
What are the circumstances in which antibiotics should be considered for the treatment of an acute respiratory tract infection? Review with your learners the 4 high-value care advice statements and the information in Table 1. What are the benefits of antibiotic use for acute bronchitis, pharyngitis, acute rhinosinusitis, and the common cold? What are the harms?
When is testing for group A streptococcus appropriate for a patient with acute pharyngitis? What circumstances should prompt consideration of a more severe infection (e.g., an abscess, epiglottitis, or Lemeirre syndrome)?
We have all heard many times that antibiotics are inappropriate for most patients with acute respiratory tract infections. Ask your learners why antibiotics continue to be prescribed inappropriately so often.
Have your learners role-play the evaluation of patients with acute respiratory tract infections whose history and risk factors indicate that antibiotics are not indicated. How do your learners respond when the patient requests an antibiotic (“But a Z-pack always makes me feel better” or “If I don't get an antibiotic, this always goes down to my chest”)?
Ask your learners what a PCMH is. Is your center or practice designated as a PCMH? If so, invite a director to explain to your group how you achieved this status and what it means for the clinicians and patients involved.
Check out what the National Committee of Quality Assurance says about PCMH. Do you or your learners feel the definitions are clear? Why do the definitions matter? Read the accompanying editorial to help frame a discussion.
What do this paper's results regarding the differences between paper and EHRs indicate? Are your learners surprised by the lack of differences in outcomes between practices using paper and EHRs? What would our learners expect to be different? In the absence of clearly identified changes in patient outcomes, what do your learners think is the motivation for so many institutions to adopt EHRs at high cost? In what way(s) might EHRs have a negative impact on patient care or outcomes?
Listen to an audio recording read by Dr. Michael LaCombe.
Ask your learners whether a new patient might reasonably expect a similar experience at your practice? If not, why not?
Can your learners think of ways to make the experience of their patients more like Stella's?
Taichman DB. Annals for Educators - 15 March 2016. Ann Intern Med. 2016;164:ED6. doi: https://doi.org/10.7326/AFED201603150
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Published: Ann Intern Med. 2016;164(6):ED6.
Cardiology, Nephrology, Valvular Heart Disease.
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