Clinical Practice Points
Whether measures of central obesity, such as waist-to-hip ratio (WHR), provide additional
information beyond body mass index (BMI) in defining mortality risks is unclear. This
study examined data from a large cohort to compare the total and cardiovascular mortality
risks for different combinations of BMI and WHR categories. An elevated WHR was associated
with an increase in mortality even among individuals with a normal BMI.
Use this study to:
- Ask your learners to define overweight and obesity. Do they know how BMI is calculated
and what the “cut-offs” are for underweight, normal, and obese?
- Ask whether they assess the distribution of adiposity in their patients, such as measuring
- Review the findings of this study. Do your learners think that they should measure
their patients' WHR? Should it influence what they tell their patients? The decision
to pursue additional tests or treatments? The editorialist discusses the potential importance of WHR and why looking only at BMI might be insufficient.
This recommendation statement from the U.S. Preventive Services Task Force addresses
screening for abnormal blood glucose and type 2 diabetes mellitus in adults.
Use this guideline to:
- Review the risk factors for the development of type 2 diabetes mellitus. Which patients
should be screened for abnormal glucose and diabetes? How should screening be performed?
Use this guideline and a recent In the Clinic: Type 2 Diabetes to help prepare a teaching session.
- Ask your learners how good they are at routinely screening for abnormal blood glucose
and diabetes in their practices. How would they evaluate their performance?
- Design a study with your team to assess whether they screen patients at risk for abnormal
glucose and diabetes. Can your system's electronic health record help? How would you
identify the patients in whom screening should be considered? How would your team
assess whether screening had been performed? What would your team consider to be an
“acceptable” rate of screening? Might there have been cogent reasons
why individual patients identified by computer record as being “appropriate”
for screening were not screened?
- Is planning and carrying out such an evaluation of your practice harder than your
team members thought? What did it teach your team regarding how to interpret “quality
metrics” or standards for practice?
This concise review covers prostate cancer, including prevention, screening, diagnosis,
Use this review to:
- Start a teaching session with a multiple-choice question. We've provided one below.
- Ask your learners how they discuss whether to screen for prostate cancer with their
patients. Consider role-playing to be sure your learners can effectively explain the
potential harms and benefits of screening and answer patients' questions.
- Review the options for men with localized prostate cancer (e.g., watchful waiting,
active surveillance, radical prostatectomy). Ask your learners to define “shared
decision making” and what questions they would ask their patients to ensure
care plans are best tailored to the patient's informed preferences.
- Download the already-prepared teaching slides to help organize a teaching session.
Use the other multiple-choice questions provided to help introduce topics throughout
the session. Be sure to log on to enter your answers and claim CME for yourself.
Black box warnings have been the subject of controversy, due in part to their opaque
connection to the underlying body of evidence. This commentary proposes a new structure
for presenting black box warnings that takes into consideration the fundamental principles
of evidence-based medicine.
Use this paper to:
- Ask your learners if they read black box warnings. Do they find them useful sources
- What do your learners do when a drug's label carries a black box warning? In what
way does the presence of the warning alter their prescribing?
- Are they bothered by the authors' findings regarding the content of current black
box warnings? Do they believe the authors' proposal will help improve patient safety?
Our Health Care System
This position paper provides recommendations from the American College of Physicians
addressing the expansion of retail health clinics while underscoring patient safety,
communication, and collaboration among retail health clinics, physicians, and patients.
Use this paper to:
- Ask your learners if they are aware of the services available to patients at local
“retail” health clinics. Consider asking a physician or a nurse who
works at one to join your teaching session.
- Do your learners think there is a benefit to using such services, as compared with
seeing a physician or nurse in a more “traditional” medical practice?
What are the possible harms?
- Review the recommendations in this paper. Do your learners agree with each?
- Do your learners feel “threatened” by the emergence of this new model
of delivering and receiving health care services? Do they think it will impact their
own practices or income?
Provisions of the Affordable Care Act (ACA) help to reign in overuse within the Medicare
and private markets. However, the author argues that the ACA is relatively silent
on price control in the private market and that provisions that tend to promote the
consolidation of providers and reduce competition may command higher prices.
Use this paper to:
- Ask your learners to list policies that might help to reduce health care costs. Which
policies target the overuse of services, and which target prices for services?
- Review the author's description of how the ACA aims to reign in costs within Medicare
and in private markets. Use the table to help review.
- Why might the consolidation of health care providers increase costs?
The authors of a previously published clinical trial are retracting the paper because
they lacked confidence in the validity of the findings after data in a related study
was found to be have been fabricated by the paper's lead author. This other clinical
trial, published in another journal, has also been retracted by the authors.
Use this announcement to:
- Ask your learners what responsibilities authors have for the papers they publish.
- The authors of this paper note that although they no longer have confidence in the
data published (which is why they are retracting them from the scientific record),
they do not believe the problem has resulted in harm to patients. What other reasons
(beyond potential harm to patients) are there for retracting a published paper?
- Review the responsibilities and requirements of authors for scientific papers . Note the 4th criterion. Are the authors retracting this paper living up to their
responsibilities as authors?
- Does the retraction of a paper always mean there was wrongdoing on the part of an
author? If an honest mistake was made in the analysis of a paper that renders its
conclusions invalid, should the paper be retracted? When should a correction or erratum
be published, and when should a paper be retracted? See the advice provided by the
International Committee of Medical Journal Editors: Corrections and Version Control and Scientific Misconduct, Expressions of Concern, and Retraction.
Humanism and Professionalism
Dr. Patel tells how a conversation with the family of his dying patient helped him
to realize where he needed to be, and what he needed to do, in his own home.
Use this essay to:
- Listen to an audio recording of this essay, read by Annals editor for On Being a Doctor, Dr. Michael LaCombe. Be sure to look at the cover of
this issue of Annals, where a picture of Dr. LaCombe is featured.
- Ask your learners if they worry they will have regrets about their family relationships
later in life. In what ways does practicing medicine make it hard to avoid such regrets?
Is it only the time required?
- Are there ways in which being a physician helps us to focus on our own families and
avoid such regrets later?
More Teaching Tools
In collaboration with the Alliance for Academic Internal Medicine (AAIM), ACP will
host a one-day meeting for faculty interested in learning how to better engage, mentor
and assess trainees in high value care quality improvement projects. The program will
be held on March 16, 2016, 9 a.m.-4 p.m. in Philadelphia. Learn more.
ACP Leadership Academy
Harvey J. Makadon, MD, FACP, will lead this webinar. Dr. Makadon is one of the authors
of the Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health – which is now in its second edition. He is a Professor of Medicine at Harvard
Medical School and the Director of Education and Training at the Fenway Institute
in Boston, one of the most trusted and respected community-based research, education,
and care centers. This webinar will be held on Wednesday, December 16, 2015 at 6:30
p.m. ET Register online.
Registrants will receive CME credit for participation in this webinar. ACP designates
this live activity for a maximum of 1 AMA PRA Category 1 Credit(s)™.
A 66-year-old man requests evaluation for prostate cancer. He is asymptomatic. Following
a discussion of the risks and benefits of prostate cancer screening, the patient decides
to be screened.
Physical examination findings are normal. Digital rectal examination is normal.
Serum prostate-specific antigen level is 5.8 ng/mL (5.8 µg/L).
Transrectal ultrasound–guided prostate biopsy is done and shows adenocarcinoma
in 2/12 cores, confined to the right lobe (Gleason score: 3 + 3 = 6).
Which of the following diagnostic imaging studies should be done next?
A. Bone scan
B. Computed tomography of the chest, abdomen, and pelvis
D. Positron emission tomography/computed tomography
E. No imaging studies are needed
E. No imaging studies are needed
Imaging studies are not indicated for men with newly diagnosed early-stage prostate
cancer in the absence of symptoms or other high-risk features.
Educational Objective: Determine need for diagnostic imaging studies in a patient
with low-risk prostate cancer.
No imaging studies are indicated at this time. The United States Preventive Services
Task Force has concluded that the harms of screening for prostate cancer outweigh
the benefits in men of any age regardless of risk factors. In contrast, the American
Cancer Society and American Urological Association recommend offering both serum prostate-specific
antigen (PSA) measurement and digital rectal examination to men annually beginning
at the age of 50 years. The American College of Physicians and American Academy of
Family Physicians both recommend that clinicians have individualized discussions with
their patients regarding obtaining PSA measurements and support measuring PSA levels
after such discussions in patients 50 years and older who have life expectancies of
at least 10 years. This patient has low-risk prostate cancer based on the presence
of a TNM stage T1c tumor (identified after an elevated screening serum PSA level is
found in the absence of symptoms), a serum PSA level less than 10 ng/mL (10 µg/L),
and a Gleason score less than 8. Imaging studies are currently not recommended for
men with low-risk disease, as there is no evidence that such studies reliably alter
Prostate cancer is among the most commonly diagnosed cancers in men in the United
States. Most men are diagnosed with clinically occult cancer, which is identified
on the basis of an abnormal serum PSA value. Most often, there are no symptoms or
indicative physical findings as in the patient described here. Once the diagnosis
of prostate cancer is made, the focus moves to assessment and treatment decision making.
The role of imaging studies in men diagnosed with prostate cancer is to assess disease
status, particularly the presence of metastatic disease. Imaging studies are indicated
to evaluate symptoms suggestive of metastatic disease and also to evaluate patients
at high risk for occult metastatic disease. Currently accepted parameters for imaging
studies include a serum PSA level of 20 ng/mL (20 µg/L) or higher, a PSA level
of 10 ng/mL (10 µg/L) or higher associated with a T2 tumor, a Gleason score
of 8 or higher, or a T3 or T4 tumor.
Eberhardt SC, Carter S, Casalino DD, et al. ACR Appropriateness Criteria prostate
cancer–pretreatment detection, staging, and surveillance. J Am Coll Radiol.
2013 Feb;10(2):83-92. PMID: 23374687
This question was derived from MKSAP® 17, the latest edition of the Medical Knowledge Self-Assessment Program.
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.