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October 20, 2015 Issue

Clinical Practice Points

Medical Knowledge
Interpersonal / Communication Skills

Effects of Initiating Moderate Alcohol Intake on Cardiometabolic Risk in Adults With Type 2 Diabetes: A 2-Year Randomized, Controlled Trial

The long-term benefits and risks of moderate alcohol intake among patients with type 2 diabetes mellitus (T2DM) are unclear. This trial found that moderate alcohol intake, particularly red wine, among patients with T2DM was associated with improved plasma lipid levels and no significant adverse events. It also found that genetic typing for alcohol dehydrogenase may identify patients who may experience improved glycemic control from moderate alcohol consumption.

Use this study to:

  • Moderate alcohol intake has been studied for its potential beneficial cardiovascular effects. Ask your learners to define moderate and heavy alcohol intake. How do your learners ask patients about the amount of alcohol they imbibe?
  • On the basis of this study, will your learners recommend moderate alcohol intake to their patients with well-controlled T2DM? If so, how will they describe moderate alcohol intake, and how will they follow to be sure their patients are not heavy drinkers?
  • Ask your learners to list cardiometabolic risk factors (e.g., blood pressure, plasma lipids). How do they differ from cardiovascular disease? How does one define a surrogate end point? What is the advantage to using risk factors, such as the ones assessed in this study, when conducting a clinical trial? What are the disadvantages?

Medical Knowledge
Patient Care
Interpersonal / Communication Skills

Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement

Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force

Tobacco use is the leading preventable cause of disease, disability, and death in the United States. This review and clinical guideline address important behavioral and pharmacologic interventions to help patients stop smoking.

Use these papers to:

  • Start a teaching session with a multiple-choice question. We've provided one below!
  • The guideline notes the 5 A's framework as a useful strategy to engage patients in discussions about smoking cessation. Review what the 5 A's are with your learners.
  • Teach at the bedside! Talk about smoking cessation with patients on your team who smoke. Be sure to ask what barriers your patients anticipate to quitting. Do your learners have ideas that might help?
  • Do your learners know how to refer a patient for behavioral therapy for smoking cessation?
  • Review the pharmacologic interventions available for smoking cessation, including nicotine replacement, bupropion, and varenicline. How do your learners choose which to prescribe?
  • Ask your learners what the potential effects of maternal smoking are on infants (e.g., preterm birth, fetal growth retardation, placental abruption, miscarriage, and others). Why does the guideline not recommend the use of pharmacotherapy for smoking cessation in pregnant women?
  • Ask if your learners' patients use electronic nicotine delivery devices (vape). What do they know about their benefits and harms? Use a recent pair of In the Balance essays to review what is known, and not known, about electronic cigarettes: Electronic Cigarettes: Aggregate Harm and Electronic Cigarettes: Perhaps the Devil Unknown Is Better Than the Devil Known.

Systems-based Practice
Practice-based Learning / Improvement

Cleaning Hospital Room Surfaces to Prevent Health Care–Associated Infections: A Technical Brief

Contamination of high-touch surfaces plays an important role in the transmission of pathogens in the hospital. This report reviews what is known, and not known, about the effectiveness and comparative effectiveness of surface cleaning practices.

Use this study to:

  • Review with your learners the epidemiology of nosocomial infections. What pathogens are most common, and how are they spread?
  • Ask your learners what broad approaches are required to eliminate nosocomial infections (e.g., hand hygiene, antimicrobial stewardship, and environmental cleaning and disinfection). Invite a member of your institution's infection control or hospital epidemiology team to lead the discussion.
  • Ask what roles your learners need to play in this effort. Do they cleanse their hands each time they enter and leave a patient's room? Review the contact precaution policies in your hospital. How compliant are your learners with these? Ask a member of your infection control team to share monitoring data evaluating how good (or not) physicians are at your institution.
  • How would your learners improve the efforts at your institution? What studies might help plan improvements at your hospital and others? Use the accompanying editorial to help frame your discussion.

Video Learning

Medical Knowledge
Consult Guys logo

The Consult Guys: Strokes and Surgery? What Are the Risks?

In this episode of the consultative medicine talk show, The Consult Guys tackle a tough problem: How soon after a stoke may a patient proceed with elective surgery?

Use this video to:

  • Watch the brief video with your learners.
  • Ask them to list the variables that are used in the CHA2DS2-VASc score. How do the results help in deciding who may proceed to noncardiac surgery?
  • Be sure to log in and complete the brief multiple-choice questions to earn CME credit for yourself!

Humanism and Professionalism


On Being a Doctor: A Meeting at Autopsy

In this essay, Dr. Sathiamoorthi describes the jarring experience of witnessing an autopsy.

Use this essay to:

  • Listen to an audio recording of the piece with your learners, read by Dr. Michael LaCombe.
  • Ask if learners have witnessed an autopsy being performed. Did it upset or scare them?
  • Should physicians feel afraid when “confronting” or “meeting” death in this way?
  • Why do we still do autopsies? Do your learners ask the families of their deceased patients if an autopsy should be performed?
  • Arrange for your team to witness the pathology results when an autopsy is performed on a patient from your service.

More Teaching Tools

ACP Journal Club

ACP Journal Club, a monthly feature in Annals, provides concise summaries of papers from multiple journals that have been rated highly by clinicians for their importance. Brief commentaries help contextualize the study and examine its strengths and weaknesses. It's a great tool when hunting for a journal club article. This month's ACP Journal Club features studies of direct-acting oral anticoagulants, the treatment of lower urinary tract symptoms in older adults, the treatment of intra-abdominal infections, and more.


A 46-year-old woman is evaluated during a routine examination. Her 72-year-old mother was just diagnosed with lung cancer, so the patient asks you for help with quitting smoking. She has a 27-pack-year smoking history. She made one previous quit attempt several years ago using over-the-counter nicotine gum, but she was unable to quit for more than a few days. Medical history is significant for seizure disorder. Review of systems discloses mild shortness of breath with exertion and occasional wheezing. Medications are a multivitamin and phenytoin.

On physical examination, vital signs are normal. Lung examination reveals occasional wheezing and a prolonged expiratory phase. The rest of the examination is normal.

In addition to counseling regarding tobacco use, which of the following is an appropriate adjunct to increase her likelihood of successful smoking cessation?

A. Benzodiazepine
B. Bupropion
C. Electronic smokeless cigarette use
D. Nicotine replacement therapy

Correct Answer
D. Nicotine replacement therapy

Key Point
Smoking cessation is achieved more effectively with a combination of counseling and anti-smoking medication use than with either intervention alone.

Educational Objective
Counsel a patient regarding methods for smoking cessation.

Although both counseling and pharmacotherapy are effective strategies for smoking cessation, the combination of counseling with medication use is more effective than either intervention alone. Nicotine replacement is effective for smoking cessation; its availability in multiple formulations (gum, lozenge, patch, aerosol) allows for alternative options in patients who have not benefited from one type of therapy, as in this patient. Although centrally acting agents (bupropion, varenicline) are also effective treatment options, bupropion would be contraindicated in this patient with an underlying seizure disorder. The choice of cessation method is less important than that an effective method is used correctly by the patient; the array of treatment options allows for individualization based on patient preference, previous experience, cost, and potential side effects. Counseling may be brief or intensive; the two most effective counseling components include practical problem-solving skills and social support.

Many smokers indicate that stress reduction is a primary reason for their tobacco use. Although selected individuals with true anxiety disorders may benefit from anxiolytic therapy, the use of benzodiazepines as a smoking cessation medication has not been documented.

Electronic smokeless cigarettes deliver a warmed aerosol through a cigarette-like device that bears the appearance, physical sensation, and possibly the taste of tobacco smoke, with the intention of helping smokers maintain the activities associated with smoking but without the harmful effects. However, their use in smoking cessation has not been established.

2008 PHS Guideline Update Panel, Liasons, and Staff. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care. 2008;53(9):1217-1222. PMID: 18807274

This question was 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, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University.


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