<i>Annals</i> for Educators - 2 August 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives2 August 2016Annals for Educators - 2 August 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201608020 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsYes, You Can: Physicians, Patients, and FirearmsAlthough many physicians report believing that health care professionals should play an active role in helping to protect patients from firearm-related violence, few do so. This article addresses important barriers physicians face in discussing firearm safety with their patients, as well as when to ask patients about guns, what questions to ask, and what to do with the answers.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners if they think the presence of firearms in the home poses a risk to patients or their families. Who is at increased risk for firearm-related violence? What are the risk factors for suicide? The authors review the answers to each.Ask what firearm storage practices increase and decrease the risk for accidental harm to children in the home. These also are reviewed in this paper.Have your learners ever asked their patients about the presence of firearms in their homes? Why or why not? What do they know about physician “gag laws”? Review the concise discussion in this paper and explain that physicians are permitted to discuss firearms when they think it is important for their patients' safety, even where such laws have been enacted. Why is this important? Use the accompanying editorial to help frame your discussion.Would your learners be comfortable asking and counseling patients about firearm safety? Is a lack of experience in this area an acceptable excuse for not doing so? In what other potentially “difficult” areas, or subjects about which your learners have no personal hands-on experience, have they learned to counsel patients (e.g., intravenous drug use, risky sexual behavior, or end-of-life care)? Should firearm-related safety be any different?How can your learners learn to effectively counsel patients? Look at the resources listed in Table 5. For example, go the “Means Matter” Web site, quickly register and start the online course for health care providers, “Counseling on Access to Lethal Means” (CALM). Use the precourse questions to assess your learners' knowledge and help focus their attention to important points as they view the free online program.The Emergence of Zika Virus. A Narrative ReviewPersonal Actions to Minimize Mosquito-Borne Illnesses, Including Zika VirusThe limited understanding of Zika virus (ZIKV) presents a challenge for responses to this global threat to human health. This article reviews the literature on ZIKV and poses important questions for vaccine development and other areas of research. The second article provides advice on how to reduce the risk for mosquito-borne disease.Use these papers to:Ask your learners what is known about the transmission of ZIKV. What important information do we lack?What other diseases are transmitted by mosquitoes?How would your learners counsel a patient who is considering a trip to Brazil? What should patients returning from an area at high risk for ZIKV exposure know regarding the potential for spreading the infection? Are any precautions needed regarding sexual contact upon return home to protect others?What should our learners advise patients regarding how best to reduce the risk for mosquito bites? Use the recent, concise review that provides targeted, practical advice on avoidance and repellants.Beyond the Guidelines: Should We Offer Medication to Reduce Breast Cancer Risk? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThis Grand Rounds summarizes a discussion between a specialist and a primary care physician about offering medication for breast cancer prevention and how they would balance the benefits and harms both in general and in a specific patient.Use this feature to:Watch the patient interview with your learners. Now ask your learners if they would recommend breast cancer prevention for this patient.Ask who is at heightened risk for breast cancer. How should a patient's risk be assessed? At what risk threshold is consideration of preventive therapy recommended by the U.S. Preventive Services Task Force and by the American Society of Clinical Oncology?Ask your learners to outline the major points in favor of and against recommending breast cancer prevention medication. How effective are they? What are their side effects? Use the already prepared slides to help you prepare.Have your learners pretend to explain the risks and benefits to a postmenopausal woman with an estimated 5-year risk for breast cancer of 1% who asks if she should take breast cancer prevention medication.After reviewing the Grand Rounds discussion, ask your learners what they would recommend to the featured patient.Be sure to log on to complete the CME questions to earn credit for yourself.Venous Leg UlcersVenous leg ulcers are a major health problem, in part due to their high prevalence, often long healing time and high recurrence rate, high cost of care, and effect on patients' quality of life.Use this concise and eminently practical review to:Ask your learners why venous insufficiency increases the risk for ulceration.Can they name other risk factors?Download the already prepared teaching slides and show the figures to your learners. Do they know what lipodermatosclerosis is? What about atrophie blanche? What do they signify?What testing should be considered in patients with venous leg ulcers? When should biopsy be considered?Practice at the bedside! Have your learners measure each other's ankle-brachial index or that of patients. How is the index calculated, and how are the results interpreted?How should ulcers be managed? Use Figure 5 to help teach. When are medications needed? When should surgery be considered?Can recurrence be prevented?Use the already prepared multiple-choice questions to introduce topics during a teaching session. Be sure to log on and enter your answers to get CME credit for yourself!Humanism and ProfessionalismOn Being a Doctor: From Kitchen Bench to BedsideDrs. George and Srinivasan describe how a simple, inexpensive innovation brought relief to patients and inspiration to their physician.Use this piece to:Listen to an audio recording of the story, read by On Being a Doctor editor, Dr. Michael LaCombe.Ask your learners whether they think they could practice in a resource-poor setting, such as the one described in this piece.Does Vatsala's actions inspire your readers? In what ways?Does hearing the limitations in available resources described here alter your learners' thinking about our health care system? Should it? Should the fact that others might be in a worse situation vis-à-vis access to treatments alter efforts to improve things at home? Should we feel spoiled? If so, how should we react? Are there patients in your communities whose access is similar to that described in this essay?Annals Graphic Medicine: I'd Want a Natural DeathThis graphic piece illustrates one patient's understanding of what a “natural” death might include.Use this piece to:Show the cartoon to your learners.Have any of them had patients or their families express a desire for an approach to end-of-life care similar to that requested by the man illustrated in the comic?How have your learners responded?What questions would your learners ask a patient such as the man portrayed here? What do they want to know about the patient's goals? What goal would they have when explaining what resuscitation and life-support measures might or might not be used?MKSAP 17 QuestionA 30-year-old woman is evaluated for a 2-week history of irritability, inability to sleep, feelings of emptiness, and suicidal thoughts. Just prior to the onset of her symptoms, her boyfriend, whom she describes as a “loser,” broke up with her. The patient was seen 1 month ago for a preventive services evaluation, including a pelvic examination and Pap smear. At that time, she described her then-new boyfriend, whom she met online, as “perfect” even though he was unemployed and had previously been incarcerated. Immediately after meeting, they spent nearly all of their time together, and she described herself as the happiest she has ever been. However, they quickly engaged in arguments, and he broke up with her. Over the years, she has had similar relationships associated with emotional ups and downs. Medical history is notable for previous hospitalizations for suicide attempts.Which of the following is the most likely primary diagnosis?A. Bipolar disorderB. Borderline personality disorderC. DepressionD. Generalized anxiety disorderCorrect AnswerB. Borderline personality disorderEducational ObjectiveDiagnose borderline personality disorder.CritiqueThis patient has borderline personality disorder (BPD). Features of BPD include interpersonal hypersensitivity (for example, intense and unstable relationships and intense efforts to avoid abandonment), difficulty controlling emotions such as anger, impulsive or destructive behavior (for example, spending money or promiscuous sex), recurrent suicidal gestures, and unstable self-image. BPD can be misdiagnosed as depression or bipolar disorder. About 6% of primary care patients have BPD. The mainstay of treatment for BPD is psychotherapy. Pharmacologic treatment of BPD is adjunctive to psychotherapy. There are no FDA-approved medications for personality disorders; medications are used to relieve symptoms (for example, mood stabilizers for mood swings and impulsivity).Patients with bipolar disorder report different neurovegetative symptoms than patients with BPD, such as a decreased need for sleep and waking with increased energy; they report an increase in activities but may move from one thing to another without completing tasks and may become more social or hypersexual but without indication of interpersonal loss. The patient's speech is often loud and full of jokes and puns, and he or she may be distractible, responding to irrelevant stimuli. Patients with BPD tend to behave angrily, impulsively, or self-destructively in the context of real or perceived interpersonal loss, whereas no such pattern is apparent in those with bipolar disorder.Depressed mood, anhedonia, lack of motivation, lack of energy or mood reactivity, overeating, and oversleeping are typical characteristics of a depressive disorder. BPD depressions are often characterized by feelings of emptiness; patients' mood often improves after being reunited with a “lost” partner or finding a new loved one.Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry about various events or activities on most days for at least 6 months, with difficulty controlling worrying. Associated symptoms include fatigue, irritability, restlessness, insomnia, and difficulty concentrating. Such patients often have comorbid anxiety disorders, depression, or substance abuse. Patients with GAD often have somatoform symptoms, which can make them high utilizers of health care resources. This patient does not exhibit any of these symptoms, making this diagnosis unlikely.Key PointFeatures of borderline personality disorder include interpersonal hypersensitivity, difficulty controlling emotions such as anger, impulsive and destructive behavior, recurrent suicidal gestures, and unstable self-image.BibliographyGunderson JG. Clinical practice. Borderline personality disorder. N Engl J Med. 2011 May 26;364(21):2037-42.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: 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. Previousarticle Advertisement FiguresReferencesRelatedDetails Metrics 2 August 2016Volume 165, Issue 3Page: ED3KeywordsBreast cancerBronchopulmonary dysplasiaCancer preventionEmotionsFire safetyFirearm injuriesGeneralized anxiety disorderPersonality disordersUlcersZika virus ePublished: 2 August 2016 Issue Published: 2 August 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...