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 how they diagnose and treat an initial episode of CDI. How about recurrent CDI? Use Dynamed Plus: Clostridium difficile infection to help you prepare to teach (a benefit of your ACP membership).
Review the overall difference in cure rates between the intervention and control groups in this trial with your learners. Then, note the differences observed between the 2 trial sites. Ask your learners to discuss why these differences might have occurred. The authors present ideas in the discussion.
Ask your learners to list the symptoms of postinfectious irritable bowel syndrome. What else is on the differential diagnosis of recurrent CDI?
What shortcomings of observational and open-label controlled trials do the findings of this double-blind, randomized trial point out? What more do we need to know regarding the diagnosis of recurrent CDI and who might benefit from FMT?
How might patients' and clinicians' fears of persistent or recurrent CDI drive overzealous management? Use the accompanying editorial to help frame your discussion.
Is polymerase chain reaction testing for C difficile useful in the diagnosis of CDI? The authors and the editorialist provide insight regarding why not.
Ask your learners when to consider the presence of renal artery stenosis (RAS)? How is it managed? Are all cases of RAS due to atherosclerosis?
What are the options for the treatment of ARAS? How would one judge their success? Ask an interventionalist to show your team radiographic images of ARAS before and after PTRAS. Do your readers believe PTRAS is appropriate for most patients as compared with medical management alone?
The authors concluded that the strength of evidence regarding the relative benefits and harms of PTRAS versus medical therapy alone for patients with ARAS is low. Ask your learners what variables are used to assess the strength of a body of evidence. In the discussion, the authors summarize why the strength of evidence is low for randomized and observational studies.
Look at Table 3. How are directness, consistency, and precision defined? How is the risk of bias assessed? Invite an expert in systematic reviews to help your learners understand these important ideas. Why do we need systematic reviews? Did your learners think that randomized trials were the “last word” on a therapy?
Log on and answer the multiple-choice questions to claim CME credit for yourself!
Download the prepared slides to help prepare a teaching session.
Ask your learners to list risk factors for GCA. What are the possible localized and systemic presentations? Use Table 1.
Why is the name “giant cell arteritis” preferred over either “temporal arteritis” or “cranial arteritis?”
Why might GCA and polymyalgia rheumatic represent a spectrum of one rather than distinct diseases? This is addressed in the paper's discussion of important physical examination findings. What are the differential diagnoses of each? Use Tables 2 and 3.
When should a temporal artery biopsy be obtained, and how do you arrange for it promptly at your institution? How does one approach a “negative biopsy”? What is the role of imaging or other testing? Do all patients need to be seen by a rheumatologist?
How should therapy be initiated and managed over the initial months of treatment? What is the rationale for also using aspirin as part of management? Should a nonsteroidal immunosuppressant be considered?
How should patients be monitored on therapy, and what is their prognosis?
Download the multiple-choice questions in the CME section, and use them to introduce sequential teaching points for discussion. Be sure to log on and enter your answers to claim CME credit for yourself!
Listen to an audio recording of the essay read by On Being a Doctor editor, Dr. Michael LaCombe.
Ask your learners for their reactions to what happened to Dr. Gupta. How do they think they would have responded?
Have you or any of your learners ever experienced or witnessed something similar?
Are we “obligated” to put up with such comments from patients? Are there right and wrong ways to respond? How does the responsibility to ensure the best care for the patient influence what is appropriate? Are we obligated to accommodate prejudicial requests? What if a patient's antagonism makes productive interactions for the provision of appropriate care impossible?
What resources are available to help physicians navigate such situations?
Taichman DB. Annals for Educators - 1 November 2016. Ann Intern Med. 2016;165:ED9. doi: https://doi.org/10.7326/AFED201611010
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Published: Ann Intern Med. 2016;165(9):ED9.
Autoimmune Kidney Disease, Giant Cell Arteritis/Polymyalgia Rheumatica, Nephrology, Neurology, Rheumatology.
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