Annals for Educators - 3 July 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives3 July 2018Annals for Educators - 3 July 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201807030 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice Points – Teaching About ScreeningIdentifying Patients for Whom Lung Cancer Screening Is Preference-Sensitive. A Microsimulation StudyImplications of Nine Risk Prediction Models for Selecting Ever-Smokers for Computed Tomography Lung Cancer ScreeningAlthough screening with low-dose computed tomography (LDCT) can reduce lung cancer mortality, the benefits may differ according to the balance of a patient's risk for lung cancer, risk for dying of lung cancer or other causes, and personal preferences with regard to screening. The first study evaluated each of these variables to help guide physician–patient discussions about whether to pursue LDCT screening for lung cancer. The second study compared the U.S. populations selected by 9 lung cancer risk models and examined their predictive performance.Use these studies to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners whether they discuss screening for lung cancer with their patients. If so, which ones?In whom is screening for lung cancer with LDCT currently recommended? Review the statement of the U.S. Preventive Services Task Force. Ask your learners why screening recommendations might be altered by a patient's risk for lung cancer. What factors influence the balance of risks and benefits? Use the editorials by Gould and Tammemägi to help frame your discussion. The first paper assesses how patient preferences influence the likely risk–benefit ratio of lung cancer screening. How are patient preferences studied? What are utilities and disutilities? These are explained in the editorial. The authors found that the benefit of lung cancer screening is influenced by a patient's disutility (“degree of dislike”) when there is either a low risk for lung cancer or a shorter life expectancy. Yet, the benefits of screening were not sensitive to patient preferences when there was a high risk for lung cancer and a longer life expectancy. Why do your learners think that might be?How would your learners use this information to counsel patients? Review Table 2 for “rules of thumb” and the editorial to help jump-start a discussion. Invite a colleague in your center's lung cancer screening program to join your discussion.Defining, Estimating, and Communicating Overdiagnosis in Cancer ScreeningThis special article defines overdiagnosis in cancer screening, identifies approaches to estimating overdiagnosis, shows how variation in estimates can arise, and describes best practices for communicating the potential for harm due to overdiagnosis.Use this paper to:Ask your learners what the potential benefits and harms are from a cancer screening program.What is overdiagnosis? How does it differ from a false-positive test result? What are the harms of overdiagnosis?Review the definitions that are important to understanding overdiagnosis in Table 1.Why does the public (and the medical profession) continue to have a difficult time envisioning how health care, and particularly testing, can be harmful?Why are we unable to measure overdiagnosis directly? How is it estimated? What are the challenges and limitations of these estimates?How would your learners explain overdiagnosis and its potential harms to a patient who believes screening and early detection must always be good?Invite an expert in epidemiology—or screening specifically—to join your discussion.Firearms and Dementia: Clinical ConsiderationsMany support limiting firearm access for persons whose mental illness would place them or others at heightened risk, but less attention has been paid to progressive cognitive impairment and firearm access. For persons with dementia, discussions about firearm access strongly parallel discussions about driving. This commentary discusses when persons with dementia need to “give up the keys,” whether they are to a gun safe or a car, and how to do so.Use this paper to:Ask your learners whether they discuss the safety of driving with patients with cognitive impairment or their families. Have they ever considered whether similar discussions should occur about access to firearms?What options exist for ensuring firearm safety?How might the degree of cognitive impairment influence what should be done? Review the Table.The authors propose discussing a “firearm retirement date,” similar to an “advance driving directive,” with patients with minimal cognitive impairment. Do your learners think this is a good idea?Resident Teaching Slide Set and Curriculum: High-Value Diagnostic Testing and Screening Download these free resources, including slides designed for resident teaching that review key concepts your learners must know to understand diagnostic testing and screening (such as specificity, positive predictive value, lead-time bias, and overdiagnosis). There is a facilitator guide to help organize teaching sessions and provide key points to emphasize, cases for group discussion, and more. In the Clinic: ConcussionConcussions are a common injury for which patients often present first to primary care physicians. They can affect the day-to-day function of patients in school and work, as well as in sports and recreational activities. Recognizing common physical signs and symptoms after injury facilitates timely diagnosis and treatment, permitting initiation of an active management approach to recovery while preventing secondary injury. Do your learners know how to diagnose and manage a patient with concussion?Use this review to:Ask your learners who is at risk for concussion and which types of trauma are most likely to cause it. Can they be prevented?What acute symptoms after head injury should prompt consideration of concussion, and how should the patient be evaluated? What symptoms may be present within minutes to hours, and which ones may appear within days or weeks? What should the examination include? What imaging or other testing is required, and when?How is concussion diagnosed? How is severity assessed?What restrictions on work, school, or other activities should be instituted, and in whom? How is the safety of returning to these activities determined?What are the potential complications of concussion? Are specialists required for evaluation and treatment? When should rehabilitation be considered?What is the prognosis of concussion?Download the teaching slides to help with a teaching session, and use the CME/MOC questions to help introduce topics for discussion. Be sure to log on and enter your answers to earn CME/MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: The BoxIn preparing to present the “facts” for an autopsy, Dr. Migliore learns who a patient was and how we failed him.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners what assumptions they made when they heard early in the essay that the autopsy was of a man in his 30s with a history of heroin abuse who died after an opioid overdose. If they are uncomfortable answering, ask them to at least think about it.How did their image of the man who died change by the end of the essay?Do your learners worry that they may contribute in some way to similar tragedies? What can we each do to avoid it?Ad Libitum: AutopsyDr. Zuckerman sees inside his patient's lungs where once lived her soul.Use this poem to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have seen the autopsy of a patient they had known well. Were they, like Dr. Zuckerman, “of two minds”?How does the death of a patient, whose soul we have come to know, affect us as physicians? Do we talk about this enough? Do we allow ourselves to contemplate and grapple with the loss while learning from the death?Annals Graphic Medicine - Finding the Funny: EverythingTake a break and read more of Jade Blue's comical and poignant depictions of her journey with breast cancer.MKSAP 17 QuestionA 59-year-old man is evaluated during a health maintenance visit. He is asymptomatic. He has a 35-pack-year smoking history, but he quit smoking 5 years ago. He takes no medications.Vital signs and the results of the physical examination are normal.Which of the following is the most appropriate screening test to obtain?A. Abdominal ultrasonographyB. Chest radiographyC. Low-dose chest CTD. SpirometryCorrect AnswerC. Low-dose chest CTEducational ObjectiveScreen for lung cancer in a former smoker.CritiqueIn patients who are at high risk for lung cancer, annual low-dose CT is recommended to screen for lung cancer. High-risk patients are adults aged 55 to 80 years with a 30-pack-year or more smoking history, including former smokers who have quit in the last 15 years. Candidates for screening should have a reasonable life expectancy and be willing to undergo curative lung surgery. The U.S. Preventive Services Task Force (USPSTF) recommends that screening be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the willingness to have curative lung surgery. A large randomized controlled trial, the National Lung Screening Trial (NLST), found a 20% reduction in lung cancer mortality in patients who were screened with low-dose CT compared with those screened with chest radiography. The number of high-risk patients needed to screen with low-dose CT to prevent one lung cancer death was 320. Potential harms related to screening include a high false-positive rate, radiation exposure, potential for discovering incidental findings, risks associated with follow-up, and overdiagnosis. Twenty-four percent of those screened with low-dose CT had a positive screening, and 96% of those cases were false-positive results.The greatest risk factors for the development of abdominal aortic aneurysm (AAA) are age, male sex (men outnumber women by up to 6:1), and a history of smoking. The USPSTF recommends one-time screening for AAA with abdominal ultrasonography in all men aged 65 to 75 years who have smoked at least 100 cigarettes in their lifetime and selective screening in men in this age group who have never smoked. Men in this category might include those with a first-degree relative who required repair of an AAA or died of a ruptured AAA. This patient should be screened for AAA when he is 65 years of age.Plain chest radiography is not recommended to screen for lung cancer in any population.Routine spirometry is not recommended in asymptomatic individuals, including asymptomatic smokers, to screen for chronic obstructive lung disease.Key PointScreening for lung cancer with annual low-dose chest CT is recommended for high-risk patients, defined as adults aged 55 to 80 years with a smoking history of 30-pack-years or more, including former smokers who have quit in the last 15 years.BibliographyNational Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011 Aug 4;365(5):395-409.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 3 July 2018Volume 169, Issue 1Page: ED1KeywordsAbdominal aortic aneurysmCancer screeningCognitive impairmentComputed axial tomographyFirearm injuriesLife expectancyLung and intrathoracic tumorsLungsMortalityThorax ePublished: 3 July 2018 Issue Published: 3 July 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...