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 to explain the role of uric acid in the pathophysiology of gout.
Do your learners monitor uric acid levels when treating gout? Should they? Why is this controversial? What do professional organizations recommend? Use a recently published guideline and 2 editorials (here and here) to help frame your discussion. Listen to the recent Annals On Call podcast, “The Gout Wars: When Guidelines Collide,” to get yourself up to speed on the debate!
Briefly describe the CANTOS trial on which this analysis was based. Were patients randomly assigned according to a history of gout or uric acid levels? Why is that important to consider when interpreting the results of this analysis?
What are the limitations to what may be concluded from an “exploratory” analysis of a randomized controlled trial?
Are there potential sources of bias that might have influenced the results of this study? Does it matter that gout attacks were self-reported by participants? The authors note that assessors in the trial were blinded and that reports of gout attacks were collected in an identical fashion in both groups. Might that alleviate concern for bias?
Review the list of “violation requests” noted in Table 1. Ask your learners how each might affect the reported result of a clinical study or its interpretation. How might each affect how the medical community applies the results of a clinical trial?
What might be the reasons for inappropriate statistical practices? Use the authors' discussion of their results for potential answers.
What training have your learners received in epidemiologic and statistical methods? If they have participated or plan to participate in research, who will be mentoring them?
What ethical obligations do researchers have when deciding how to analyze and report their study results? Does it matter if the inappropriate use of statistical methods was due to malfeasance or lack of knowledge on the part of the investigators?
The authors note that they could not tell whether the inappropriate requests were honored. If not, does the request matter?
Use the accompanying editorial to help frame your discussion.
Ask your learners whether the presence of hypertension in the OR should cancel or delay surgery. If so, what degree of hypertension should stop a procedure?
Now, take a break and watch the short video with your learners.
Have your learners' answers changed?
Log on and answer the brief multiple-choice questions to help teach and to earn CME/MOC credit for yourself!
Ask your learners whether they feel comfortable expressing uncertainty when “presenting” on rounds.
In what circumstances might sounding more or less confident be beneficial or harmful?
How does sounding confident differ from being confident? Might the difference be dangerous in clinical care?
Is a lack of confidence viewed or judged differently in women than in men?
Ask others who teach if they judge learners according to how confident they appear to be. Are male and female learners judged on the same criteria?
Why might fostering a culture that acknowledges uncertainty be beneficial? Are there potential dangers?
Ask your learners whether financial concerns are dictating their plans for residency or fellowship training.
Are financial concerns affecting where they plan to practice?
Are concerns about their future loan repayments causing your learners stress? Do they require assistance to help them deal with uncertainty and to plan? To whom may they turn for advice and support?
Do your learners believe that more physicians would pursue careers in primary care and/or in underserved communities if financial issues were not a consideration? Do your learners have accurate information on the incomes they might expect (or need) in different fields and locations?
Listen to an audio recording, read by Annals' Associate Editor for the On Being a Doctor series, Dr. Michael LaCombe.
Ask your learners if they have had similar experiences. What did they see that caused them concern? What did they do?
Should we approach strangers when we are concerned about a potential medical malady of which they might be unaware? Should we be concerned that we might be seen as invading the stranger's privacy?
What about when we know the person?
Is it our duty to check, or to inform everyone we see with a concerning physical finding?
Taichman DB. Annals for Educators - 16 October 2018. Ann Intern Med. 2018;169:ED8. doi: https://doi.org/10.7326/AFED201810160
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Published: Ann Intern Med. 2018;169(8):ED8.
Cardiology, Coronary Risk Factors, Gout, Hypertension, Nephrology.
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