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April 7, 2015 Issue

Clinical Practice Points

Medical Knowledge
Patient Care
Interpersonal and Communication Skills

Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis. A Randomized Trial

Evidence on nonsurgical alternatives to surgical decompression for patients with symptomatic lumbar spinal stenosis (LSS) is limited. This trial randomly assigned patients with LSS, who were candidates for and had consented to surgery, to physical therapy for 6 weeks or surgical decompression. The physical therapy and surgery groups achieved similar symptom relief and improvements in physical functioning at 2-year follow-up. However, half of patients in the physical therapy group crossed over to receive surgery.

Use this study to:

  • Ask your learners what the symptoms of LSS are.
  • Use the recent In the Clinic: Low Back Pain to help review the differential diagnosis of lower back pain.
  • Teach at the bedside: Demonstrate how to perform the straight-leg raising and crossed straight-leg raising tests, evaluate deep tendon reflexes and for clonus. Review what the findings for each test mean.
  • Invite a physical therapist to show your team what exercises are likely to be prescribed to a patient with LSS. Do they differ from the exercises used for treatment of other causes of lower back pain?
  • Ask your learners how the substantial “cross-over” from physical therapy to surgery in this randomized trial affects its interpretation. The authors discuss its potential implications in the paper’s discussion. Do “deviations” from the treatment allocation in a randomized trial render it an “observational study?” Do we nonetheless learn what the results might be in “the real world?”

Medical Knowledge
In the Clinic:


This clinical review provides concise information on the risk factors for constipation, its differential diagnosis, evaluation, and treatment. It includes eminently helpful tables as well as an algorithm for evaluation and treatment.

Use this review to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask your learners to list primary and secondary causes of constipation. What are normal and delayed transit constipation and dyssynergic defecation?
  • What medications may be associated with constipation? See the box on the third page for a list.
  • When should testing be performed and which ones?
  • What nonprescription agents should be recommended? Do your learners know what foods contain soluble and insoluble fiber? When should prescription agents be considered?
  • Review the algorithm for evaluation and treatment. How does one order manometry? Invite a specialist to discuss such testing, when it is needed, and what a patient will experience.
  • Download the already prepared slides to help you prepare for a teaching session.
  • Complete the additional multiple-choice questions provided at the end to help introduce topics in a teaching session, and log-on to claim CME for yourself with your answers!

Medical Knowledge
Interpersonal and Communication Skills

Beyond the Guidelines: What would you do?

Ms. D. is a 60 year old former smoker with multiple medical problems; not an ideal surgical candidate. She has given some thought to whether she would like to be screened for lung cancer.

What do you do when a REAL patient doesn’t fit perfectly within the “guidelines”? Help your learners become accustomed with such tough situations. This new Annals series makes it easy to plan patient-centered education in a series of engaging activities. Here’s how:

  • Have your learners read the short description of Ms. D. Watch the brief video interview of Ms. D. to hear her thoughts in her own words.
  • Before April 21: Ask your learners if they would order a CT scan on Ms. D. to screen for lung cancer. Have them each the complete the poll at and “vote” for what they would do.
  • April 21: Watch the moderated expert discussion, and read the accompanying article in Annals. Ask your learners what they would do for Ms. D now. Vote again. We’ll remind you in the April 21 Annals for Educators Alert.

Guns and Doctors

Systems-based Practice
Interpersonal and Communication Skills

Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association

Firearm-Related Hospitalization and Risk for Subsequent Violent Injury, Death, or Crime Perpetration. A Cohort Study

Reducing Firearm-Related Harms: Time for Us to Study and Speak Out

Using statewide epidemiological data, this study identified a high risk for subsequent violent victimization or crime perpetration after a firearm-related hospitalization. The leaders of 7 major medical professional societies, the American Public Health Association, and the American Bar Association reiterate their organizations’ commitment to addressing the public health crisis of firearm-related harms, calling for more research as well as policies to reduce firearm-related injuries and deaths. The policies that are advocated could reduce firearm-related injury and death without violating the Second Amendment. The editors call upon physicians to join in speaking up to demand more research and unfettered access to the results to help learn how to better prevent gun-related violence.

Use these papers to:

  • Review with your learners the epidemiology of gun-related violence in the United States and the associated health care costs. Figures are quoted at the beginning of these papers. Do your learners believe gun-related violence is a public health crisis?
  • Do they believe that health professionals should have a role in studying the problem or implementing solutions? Why or why not? How is this different from other public health problems, such as epidemics of infectious diseases or motor vehicle–related injuries?
  • Do your learners believe that public funds should be allocated to research on gun-related violence? Does such research violate the provisions of the Second Amendment? Why might Congress have restricted the funding of such research by the CDC?
  • Do your learners agree with the policies called for by the leaders of these medical societies? Discuss whether they should write, individually or as a group, to state and federal government representatives to express their opinions as physicians. The editorial provides links to find the addresses.

Humanism and Professionalism

Interpersonal and Communication Skills
Annals Graphic Medicine

Annals Graphic Medicine: Betty P.

A comic in Annals? In this graphic narrative, a physician recalls his feelings of complicity in the harms resulting from a “code” performed on a patient with no hope of benefit and determines not to let circumstances lead to such an occurrence in another patient without discussion.

Use this graphic narrative to:

  • Ask your learners if they have taken part in resuscitative efforts without knowing if the patient would want them?
  • Ask your learners why this happens. How can we do a better job ensuring our interventions harmonize with our patients’ needs and wishes?
  • Read the accompanying Ideas and Opinions piece that discusses these issues.
  • Do your learners think illustrated “stories” (comics) have a place in a serious medical journal? Do we relate to the authors’ intended messages in different ways than in written pieces? Do any of your learners have stories they believe would be uniquely portrayed in such a way? Encourage them to try, share them with each other, and even submit them for possible publication.

Interpersonal and Communication Skills

On Being a Doctor: Homesick: From Beirut to Rochester

Dr. Davidson describes how a probing question and the patience to listen helped him to appreciate his patient’s struggles.

Use this essay to:

  • Listen to an audio recording, read by On Being a Doctor’s editor, Dr. Michael LaCombe.
  • Ask your learners whether they think the patient’s symptoms have a somatic basis? How do they raise the possibility with a patient that psychological issues might be the cause of a medical complaint? Do they always feel the need to perform tests?
  • Do they think that merely listening can be therapeutic? For whom?


A 65-year-old woman is evaluated because of constipation. The patient has had to strain to have bowel movement all of her adult life and she occasionally has to place pressure on her left lower abdominal quadrant to aid evacuation. She has about three to five bowel movements each week, and uses enemas and laxatives on alternate days. There is no blood in her stool, and her weight has been stable. The patient has hypertension, treated with Lisinopril and hydrochlorothiazide, and hypothyroidism, managed with levothyroxine.

General physical examination is unremarkable. Rectal examination discloses increased rectal tone with pellet-like stool in the rectal vault. Complete blood count, serum electrolytes, liver chemistry studies, thyroid function tests are normal. Colonoscopy done 1 year ago, showed sigmoid diverticulosis but was otherwise unremarkable.

Which of the following diagnostic studies should be done next?

A. Anorectal manometry
B. Plain radiographs of the abdomen
C. CT scan of the abdomen and pelvis
D. Flexible sigmoidoscopy

Correct Answer
A. Anorectal manometry

Educational Objective
This patient has dyssenergic defecation (pelvic floor dysfunction), which refers to impaired defecation caused by inappropriate contraction or impaired relaxation of the puborectalis and external anal sphincter muscles. The anorectal angle subsequently becomes more acute and increases the pressure in the anal canal so that evacuation is difficult. Patients typically report experiencing marked straining during defecation, having to use aids to induce defecation, and a feeling of incomplete evacuation. The most appropriate diagnostic study is anorectal manometry, which can identify abnormal sphincter responses during attempted expulsion of the rectal probe. Normal persons have increased intrarectal pressure and decreased external sphincter pressure during attempted expulsion of the probe, whereas patients with dyssenergic defecation have increased external sphincter pressure. Treatment includes dietary fiber, stool softeners, and possibly biofeedback retraining.

Rao SS. Constipation: evaluation and treatment. Gastroenterol Clin North Am. 2003; 32: 659-83. [PMID: 12858610]

This question is derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.

From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.


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