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! Review with your team the admitting medication list of several nursing home residents on your service. Are the lists long? Are all of the drugs necessary? Do any present potential problems?
Ask your learners how they would define polypharmacy. In what ways might it lead to adverse events? The authors address these issues in the introduction to their study. Need the list be long for it to include inappropriate drugs?
Review the intervention used in this cluster randomized controlled trial (Table 1). Who was involved? How were medications assessed?
How well do your learners think they can assess the appropriateness of each medication for all of their patients? Ask them to do so for each of the patients on their service (or each of the outpatients they see) before your next meeting. Did they identify any potentially inappropriate drugs?
Ask whether your learners ever leave patients on drugs they do not think or are not sure are needed. Are they hesitant to discontinue drugs they did not prescribe? How should they approach this issue? To whom should they talk?
Who reviews a patient's discharge medication list at your hospital? Look at the Annals Graphic Medicine piece described below. How do patients end up using long lists of medicines they no longer need?
Ask what a cluster randomized trial is. How does it differ from more traditional clinical trials? What is the unit of randomization in each? How does this difference influence what may be learned?
This study did not find a difference in the secondary outcomes that were assessed. The authors note that the trial was not powered to assess them. What does it mean if a study is “underpowered”? Look at the 95% confidence intervals around the point estimates for the secondary outcomes (Table 4). How should they be interpreted?
Why might the study have found only modest effects? Use the accompanying editorial to help frame your discussion.
Ask your learners which patients require an evaluation for secondary causes of hypertension. What should the evaluation include? Use In the Clinic: Hypertension to quickly find answers.
What are the presenting signs and symptoms of primary aldosteronism? How is it currently diagnosed? Use the information in DynaMed Plus: Primary Aldosteronism (a benefit of your ACP membership).
Review with your learners the regulation of renin and aldosterone. How is urinary sodium affected by renin and aldosterone concentrations? Invite a nephrologist to join your discussion.
Review the key results of this study. The authors suggest that a state of clinically relevant renin-independent aldosteronism might be common and could affect the risk for subsequent cardiovascular disease. Do your learners think that we should test normotensive patients for this? What additional studies would they want before adopting such a practice? Use the accompanying editorial to help inform your discussion.
Go down the list of recommendations in Table 1 with your team. Check off items your learners believe they should address with each of their diabetic patients. How would they assess whether they are doing these things? Can your EHR help? Should they review the charts of several of their own patients?
Does your practice have a telehealth system available to improve the care of patients with diabetes? What members of the health care team are available to assist in providing diabetes care?
The authors discuss the importance of individualizing glycemic goals according to patients' risks, life expectancy, personal goals, and other variables. How should each of these be considered when determining glycemic goals? Do your learners know how to discuss them with patients when choosing a goal, and what questions to ask?
The authors discuss how their guideline differs from others. Why do glycemic targets differ in this manner? Use the accompanying editorial to help frame your discussion.
Does your institution have protocols for inpatient glycemic control among diabetic patients? What do the authors recommend? Why don't they recommend as tight control for patients outside the ICU compared with those in the ICU? The authors recommend a “basal–bolus-plus-correction” approach to care outside the ICU but note that many inpatients are managed only with “correction” doses of insulin on a sliding-scale basis. What is the difference? What is done at your center, and why?
Ask your learners to list risk factors for AKI. Compare their list with the one provided in the Box.
What measures are effective at preventing AKI, and in which patients should they be used?
What are the major causes of AKI? Review Figure 2 with your learners. What features help distinguish between decreased kidney perfusion and acute tubular necrosis? List drugs that may cause AKI, and how. Use the information in the boxes for quick lists to help teach.
Teach at the bedside (or microscope)! How do urinary tract findings help differentiate among the potential causes? Do your learners know how to assess urinary sediment? Take fresh samples of urine from patients on your service with AKI to the laboratory and review the sediment. Invite a nephrologist to help.
Use the multiple-choice questions to introduce new topics for discussion in a teaching session. Download the teaching slides. Log in to answer the multiple-choice questions and claim CME/MOC credit for yourself!
Show the cartoon to your learners. Do they think there is truth to what the author depicts?
What drives our medical system's desire to label everything? What practices can help to prevent needless labeling and inappropriate treatment of patients?
How might this cartoon relate to the use of inappropriate medications addressed in the first study noted above?
Listen to an audio recording, read by Dr. Virginia Hood.
Accept that sometimes discussion is not needed. Just listening together might be best.
Consider asking if your learners worry that we sometimes brush aside a patient's suffering as mere “hysteria.” Do we sometimes worry about looking foolish for caring too much?
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Taichman DB. Annals for Educators - 7 November 2017. Ann Intern Med. ;167:ED9. doi: 10.7326/AFED201711070
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Published: Ann Intern Med. 2017;167(9):ED9.
Acute Kidney Injury, Adrenal Disorders, Cardiology, Coronary Risk Factors, Diabetes.
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