<i>Annals</i> for Educators - 19 April 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives19 April 2016Annals for Educators - 19 April 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201604190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsConsumer Perceptions of Interactions With Primary Care Providers After Direct-to-Consumer Personal Genomic TestingPatients may share the results of direct-to-consumer personal genomic testing with their primary care provider. This study describes a group of consumers who shared their results with their primary care provider and whether they were satisfied or dissatisfied with the experience.Use this study to:Ask your learners if any of their patients have pursued direct-to-consumer genomic testing. Look at the reports promised by one company. Do your learners feel prepared to review the results of such testing with their patients? If a patient provides a list of such results, what obligation do your learners feel to review and understand them? How long would it take to fully understand them? Is it different from any other test result that a patient may have had elsewhere?Should your learners try to counsel a patient about the meaning of the presence of a gene variant? Do all such questions require evaluation by a geneticist? How will your learners decide? Invite a geneticist to join your conversation.What do patients who have such testing anticipate? Look at the Web sites of some companies offering these services. Do your learners feel such testing is of value? Use the accompanying editorial to help frame your discussion.Long-Term Outcomes of Patients With Recent-Onset Rheumatoid Arthritis After 10 Years of Tight Controlled Treatment. A Randomized TrialStudies have shown that a “treat-to-target” strategy results in improved clinical outcomes among patients with early active rheumatoid arthritis (RA), but long-term data on this approach are lacking. The authors present outcomes among patients treated with this approach for 10 years as part of a trial that examined 4 treat-to-target strategies for RA.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below.Review when to consider and how to diagnose RA. Use the information in DynaMed Plus: Rheumatoid Arthritis to help prepare to teach (a benefit of your ACP membership).Teach at the bedside! Examine the joints of patients with and without RA with your team. Ask a radiologist to review with your team the radiologic changes found in patients with RA.Review the results of this randomized trial. What targets are used in a treat-to-target strategy? Ask your learners what the goals of therapy for RA are. How are they monitored? What should they ask their patients about, and how often? Is any testing routinely required?Clinical GuidelineDiagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in DiabetesThis synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes focuses on key areas necessary for managing the disease, preventing complications, and improving outcomes.Use this guideline to:List the variables noted in Table 1, and ask your learners if they know the ranges used to diagnose pre-diabetes and diabetes. Ask your learners if they know how to order an oral glucose tolerance test.How frequently should hemoglobin A1c be measured? What are the limitations of hemoglobin A1c testing?Ask what advice your learners would provide to a patient with hypoglycemia unawareness. How should treatment be adjusted in such patients?How should glycemic targets be selected? Use Appendix Figure 2 to visualize the interplay among important variables to consider (e.g., life expectancy, the presence of vascular complications)How do your learners select antihyperglycemic therapy for type 2 diabetes? Review the information in Figure 1. How and when do they select second and third agents?Humanism and ProfessionalismJudging the Past: How History Should Inform BioethicsDiscussions of past scandals have become an obligatory part of bioethics courses in undergraduate, graduate, medical, and other health professional schools. This paper revisits several scandals that are typically discussed in bioethics education and training to generate a more historically informed assessment of immoral behavior. It concludes with a quote from historian Susan Reverby: “It is too simple for us to see [these physicians] merely as evil men doing bad things a long time ago that contemporary researchers would never do and that somehow written informed consent alone protects against.”Use this paper to:Review succinctly the experiments performed in Tuskegee and Willowbrook, the lobotomies performed on patients with mental illness, and the other events described by the authors. Ask what breach of ethics occurred in each.The authors stress that it is essential to understand the context in which the physicians who participated in these events found themselves. Ask your learners why. Might such contextualization be used to justify what happened? Instead, might it help us understand why it happened when it did?The authors state that by understanding the context, “… we are forced to question whether the ethos and rationales of that era could resurface.” What motivations present at the time of these unethical practices are still present today? How have things changed?The authors argue that such an emphasis is too often missing when these events are presented as though they merely involved monsters from an alien past. Read the quote above from Susan Reverby. Do your learners believe that the evil of the past could not surface in our more modern, ethically “enlightened” era?Ask if written informed consent protects against abuse? How might a patient be coerced into participation? Are participants truly “informed” when signing an informed consent agreement?Role Models and TeachersOn Being a Doctor: A Few Good Words“Do you have any questions?” I asked. My brain immediately began chanting, “Please don't, please don't, please don't.” I thought the chant was quiet enough that only I could hear it, but my patient seemed to read my mind.In this essay, Dr. Moriates discusses the small changes he and other teaching attendings made in the questions they asked on rounds to help improve patients' experiencesUse this essay to:Prompt your trainees to discuss their own responsibilities as role models. But first, use it to ask yourself what language you use on rounds (body and words), and how it might shape the experience of your patients and the future practice of your trainees.Teaching Opportunities From the American College of PhysiciansClinical Skills Workshop Proposals Wanted for IM 2018Interested in teaching procedural, physical examination, or communication skills?The ACP is now accepting proposals for hands-on, interactive workshops that focus on the acquisition or improvement of procedural skills, physical examination skills, and communication skills for Internal Medicine 2018, which will be held in New Orleans, Louisiana, on April 19-21, 2018.To submit a proposal, complete the Proposal for Internal Medicine 2018 application. The deadline for applications is May 23, 2016.MKSAP 17 QuestionA 42-year-old woman is evaluated for a 6-month history of pain and swelling of several small hand joints, an elbow, and an ankle. She gets modest relief with naproxen. She has no other medical problems and takes no additional medications.On physical examination, vital signs are normal. There are tenderness to palpation and swelling of the second and third proximal interphalangeal joints bilaterally, second and fifth metacarpophalangeal joints bilaterally, left wrist, right elbow, and right ankle. The remainder of the physical examination is normal.Laboratory studies are significant for a rheumatoid factor of 85 U/mL (85 kU/L) and positive anti–cyclic citrullinated peptide antibodies.Radiographs of the hands and wrists show periarticular osteopenia at the metacarpophalangeal joints and a marginal erosion at the right second metacarpal head.Which of the following is the most appropriate initial treatment?A. HydroxychloroquineB. MethotrexateC. RituximabD. TofacitinibCorrect AnswerB. MethotrexateEducational ObjectiveTreat rheumatoid arthritis with methotrexate.CritiqueTreatment with methotrexate is indicated for this patient with rheumatoid arthritis (RA). She has a polyarticular inflammatory arthritis involving the small joints of the hands as well as a wrist and an ankle, with radiographically demonstrated marginal erosions and periarticular osteopenia and positive anti–cyclic citrullinated peptide antibodies and rheumatoid factor, all of which support a diagnosis of RA. Methotrexate with or without the addition of another disease-modifying antirheumatic drug (DMARD) should be instituted immediately in patients with erosive disease documented at disease onset. Methotrexate is the gold standard therapy because it is usually better tolerated than other DMARDs and has good efficacy, long-term compliance rates, and relatively low cost.Hydroxychloroquine is indicated to treat early, mild, and nonerosive disease. Hydroxychloroquine therapy alone has not been shown to retard radiographic progression of RA and therefore should be used only in patients whose disease has remained nonerosive for several years. This patient has erosive disease, and hydroxychloroquine as a single agent is not appropriate.Rituximab, the anti-CD20 B-cell depleting monoclonal antibody, is FDA approved for the treatment of moderately to severely active RA in combination with methotrexate in patients who have had an inadequate response to tumor necrosis factor α inhibitor therapy. Rituximab may also be considered for patients with high disease activity and poor prognostic features despite sequential nonbiologic DMARDs or methotrexate in combination with other DMARDs. It is not appropriate initial treatment for RA in a patient who has not been given a trial of methotrexate.Tofacitinib is also indicated for use in the management of RA but only in patients who have already not responded to methotrexate alone. This relatively recent addition to the treatment armamentarium for RA is the first oral agent to be introduced in decades but is indicated for use in patients who are intolerant to or have had an inadequate response to methotrexate.Key PointMethotrexate is the initial treatment of choice for patients with new-onset, rapidly progressive, or erosive rheumatoid arthritis.BibliographySingh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College Of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012 May;64(5):625-39.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 19 April 2016Volume 164, Issue 8Page: ED8KeywordsAnklesDisease modifying antirheumatic drugsGenomicsGraduate medical educationHemoglobinHydroxychloroquineInflammationMethotrexateOsteopeniaRheumatoid arthritis ePublished: 19 April 2016 Issue Published: 19 April 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...