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.
Ask your learners to describe the possible presentation and findings in an adult with undiagnosed cystic fibrosis.
Ask how a diagnosis of cystic fibrosis is established. What is the differential diagnosis of bronchiectasis in an adult?
Ask your learners to propose potential mechanisms for the marked difference in survival found between patients in the United States and Canada. What in the analysis and results points to differences in insurance coverage having so profound an effect? Use the accompanying editorial to help frame your discussion.
Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners when a diagnosis of CFS (also called systemic exertion intolerance disease) should be suspected.
How is CFS diagnosed? Is laboratory testing required? What is the differential diagnosis? Use the information in DynaMed Plus: Chronic Fatigue Syndrome a benefit of your ACP membership.
How is CFS treated? Are the current approaches to therapy effective?
Why did the authors hypothesize that an antagonist of the proinflammatory cytokine interleukin-1 might be effective for treatment of CFS?
Ask your learners what additional burdens are borne by a patient with a disease of unknown cause. How might they affect a patient beyond the direct manifestations of the illness itself? Do your learners discuss these issues with their patients? What would they say? Invite a specialist with expertise in CFS to join your discussion.
Review the figures with your learners.
Ask your learners whether their initial approach to the management of patients with type 2 diabetes is in line with the American Diabetes Association recommendations.
Do your learners always choose metformin as initial therapy when pharmacologic treatment is indicated? When do they add a second agent? How do they choose?
How do your learners inquire about adherence to lifestyle management in their patients? What problems do patients encounter? How do your learners talk to patients about the need to initiate insulin therapy? What are their patients' perceptions and concerns? Watch 2 short videos (The Daily Grind and Not the Needle ) that depict the challenges and fears of patients struggling with the management of their diabetes.
Have your learners estimate how much of their day is spent in direct contact with patients. How much time is spent at the computer?
Review the results of this study. Do the findings surprise your learners or you?
What do your learners think is the proper balance of time spent directly with patients, at computers, or in didactic or other teaching activities during residency?
Can your learners have control of their time and how it is spent? What is required to care for patients? How should it be balanced with what is best for the educational experience of trainees?
How much control over these factors can residency programs really have?
Ask your learners to list reasons data might be missing in a clinical trial. What are the potential causes?
Consider the example the authors provide of a trial assessing whether adding spinal manipulative therapy to home exercise is effective for back pain. How might each type of missing data affect the results?
Review the definitions of missing at random, missing completely at random, and missing not at random. The authors note that it is important to understand what assumptions have been made about missing data. Why? How does it dictate the analytic approach? Invite an expert in epidemiology and/or biostatistics to join your discussion.
Ask what your learners know of the activities of physicians under Nazi rule. Were physicians members of the Nazi party?
Ask your learners what teaching in medical ethics they received during medical school. Describe the basic tenets of medical ethics that were taught in medical schools during Nazi rule.
Does it disturb your learners to know that physicians were not “above” but rather were active participants in promoting the racist ideologies of the Nazis? Do we assume that ours is a “pure” profession? Do your learners agree that the medical professional ethos is more fragile than we might believe? Are we safer today?
The authors note that the medical profession alone does not determine what are considered medically appropriate approaches to patient treatment. In what ways does society today influence what the medical profession does or does not do?
The authors end by noting that, “…ideas of exclusion of certain people or visions of ethnic purity that have laid the groundwork for medico-ethical transgressions in the past remain in play across time.” Are they in play today?
Listen to an audio recording of the story, read by Dr. Michael LaCombe.
Ask your learners whether they have met patients who have inspired them as they faced an approaching death.
Have your learners found the approach taken by some patients to be less inspirational? Is that an appropriate question? Are we in a position to judge?
When patients decline therapy that your learners think is indicated and appropriate, what questions do they ask?
Do your learners ask patients who are dying whether they are afraid? Why or why not? Are we afraid to ask? Might some patients appreciate it? Might we more often learn something important, for our patient or for ourselves?
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Taichman DB. Annals for Educators - 18 April 2017. Ann Intern Med. 2017;166:ED8. doi: https://doi.org/10.7326/AFED201704180
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Published: Ann Intern Med. 2017;166(8):ED8.
Cardiology, Chronic Fatigue Syndrome/Fibromyalgia, Coronary Risk Factors, Diabetes, Endocrine and Metabolism.
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