Annals for Educators - 18 April 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives18 April 2017Annals for Educators - 18 April 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201704180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsSurvival Comparison of Patients With Cystic Fibrosis in Canada and the United States. A Population-Based Cohort StudyPrevious studies suggested important differences in survival between patients with cystic fibrosis in Canada and those in the United States but were limited by discrepancies in the way national databases have been assembled. This study used comparable data from large Canadian and U.S. registries to better assess differences in survival and variables that might be associated with them.Use this study to:Ask your learners to describe the possible presentation and findings in an adult with undiagnosed cystic fibrosis.Ask how a diagnosis of cystic fibrosis is established. What is the differential diagnosis of bronchiectasis in an adult?Ask your learners to propose potential mechanisms for the marked difference in survival found between patients in the United States and Canada. What in the analysis and results points to differences in insurance coverage having so profound an effect? Use the accompanying editorial to help frame your discussion.Cytokine Inhibition in Patients With Chronic Fatigue Syndrome. A Randomized TrialFew proven effective treatments exist for chronic fatigue syndrome (CFS). This randomized controlled trial evaluated the benefits and harms of anakinra, an interleukin-1 receptor antagonist, for women with CFS and severe fatigue leading to functional impairment.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners when a diagnosis of CFS (also called systemic exertion intolerance disease) should be suspected.How is CFS diagnosed? Is laboratory testing required? What is the differential diagnosis? Use the information in DynaMed Plus: Chronic Fatigue Syndrome a benefit of your ACP membership.How is CFS treated? Are the current approaches to therapy effective?Why did the authors hypothesize that an antagonist of the proinflammatory cytokine interleukin-1 might be effective for treatment of CFS?Ask your learners what additional burdens are borne by a patient with a disease of unknown cause. How might they affect a patient beyond the direct manifestations of the illness itself? Do your learners discuss these issues with their patients? What would they say? Invite a specialist with expertise in CFS to join your discussion.Clinical GuidelinePharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in DiabetesThe American Diabetes Association annually updates the Standards of Medical Care in Diabetes. This synopsis focuses on the recommendations from the 2017 Standards about pharmacologic approaches to glycemic treatment of type 2 diabetes.Use this guideline to:Review the figures with your learners.Ask your learners whether their initial approach to the management of patients with type 2 diabetes is in line with the American Diabetes Association recommendations.Do your learners always choose metformin as initial therapy when pharmacologic treatment is indicated? When do they add a second agent? How do they choose?How do your learners inquire about adherence to lifestyle management in their patients? What problems do patients encounter? How do your learners talk to patients about the need to initiate insulin therapy? What are their patients' perceptions and concerns? Watch 2 short videos ( The Daily Grind and Not the Needle ) that depict the challenges and fears of patients struggling with the management of their diabetes.Analyzing Residency TrainingAllocation of Internal Medicine Resident Time in a Swiss Hospital: A Time and Motion Study of Day and Evening ShiftsLittle current evidence documents how internal medicine residents spend their time at work. This study recorded internal medicine residents' activities at a Swiss teaching hospital and found that they spend more time at work than scheduled. Activities indirectly related to patients predominated, with direct patient care coming in second. About half the workday was spent using a computer.Use this paper to:Have your learners estimate how much of their day is spent in direct contact with patients. How much time is spent at the computer?Review the results of this study. Do the findings surprise your learners or you?What do your learners think is the proper balance of time spent directly with patients, at computers, or in didactic or other teaching activities during residency?Can your learners have control of their time and how it is spent? What is required to care for patients? How should it be balanced with what is best for the educational experience of trainees?How much control over these factors can residency programs really have?Understanding Clinical ResearchAnnals Understanding Clinical Research: Implications of Missing Data Due to DropoutThis short article aims to help clinicians understand the implications of missing data due to dropout, a common problem that can affect the validity of clinical trial findings. Several analytic methods exist to handle this problem. Understanding the assumptions behind these methods can help clinicians decide whether and how to incorporate clinical trial findings into their own practice.Use this paper to:Ask your learners to list reasons data might be missing in a clinical trial.Consider the example the authors provide of a trial assessing whether adding spinal manipulative therapy to home exercise is effective for back pain. How might each type of missing data affect the results?Review the definitions of missing at random, missing completely at random, and missing not at random. The authors note that it is important to understand what assumptions have been made about missing data. Why? How does it dictate the analytic approach? Invite an expert in epidemiology and/or biostatistics to join your discussion.Humanism and ProfessionalismLectures on Inhumanity: Teaching Medical Ethics in German Medical Schools Under NazismAlthough Nazi medical authorities are often assumed to have spurned a consideration of ethics, Nazi-influenced medical ethics became an important part of the curriculum at all German medical schools between 1939 and 1945. The authors emphasize how medical ethics itself can be corrupted and that a political and public realm of reason and humanity may remain vital in preventing immoral medical conduct.Use this paper to:Ask what your learners know of the activities of physicians under Nazi rule. Were physicians members of the Nazi party?Ask your learners what teaching in medical ethics they received during medical school. Describe the basic tenets of medical ethics that were taught in medical schools during Nazi rule.Does it disturb your learners to know that physicians were not “above” but rather were active participants in promoting the racist ideologies of the Nazis? Do we assume that ours is a “pure” profession? Do your learners agree that the medical professional ethos is more fragile than we might believe? Are we safer today?The authors note that the medical profession alone does not determine what are considered medically appropriate approaches to patient treatment. In what ways does society today influence what the medical profession does or does not do?The authors end by noting that, “…ideas of exclusion of certain people or visions of ethnic purity that have laid the groundwork for medico-ethical transgressions in the past remain in play across time.” Are they in play today?On Being a Doctor: A Strong and Simple HeartDr. Wilkinson recalls the grace and dignity of his patient as she chose what she did and did not want.Use this essay to:Listen to an audio recording of the story, read by Dr. Michael LaCombe.Ask your learners whether they have met patients who have inspired them as they faced an approaching death.Have your learners found the approach taken by some patients to be less inspirational? Is that an appropriate question? Are we in a position to judge?When patients decline therapy that your learners think is indicated and appropriate, what questions do they ask?Do your learners ask patients who are dying whether they are afraid? Why or why not? Are we afraid to ask? Might some patients appreciate it? Might we more often learn something important, for our patient or for ourselves?Teaching OpportunityClinical Skills Workshop Proposals Wanted for IM 2019Interested 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 the ACP Internal Medicine Meeting 2019, which will be held in Philadelphia, PA, on 11–13 April 2019.To submit a proposal, please complete the Clinical Skills Proposal for Internal Medicine 2019 . The deadline to submit proposals is 22 May 2017.MKSAP 17 QuestionA 36-year-old man is evaluated for a 1-year history of fatigue, intermittent headaches, sore throat, and joint and muscle pain. He reports no difficulties falling asleep and gets 10 hours of uninterrupted but nonrestorative sleep each night. He has seen several physicians over the past year. Evaluation has included a complete blood count with differential, thyroid-stimulating hormone level, and plasma glucose level that were normal at the time of initial presentation and again 2 months ago. HIV testing performed 4 months ago was negative. He is in a monogamous heterosexual relationship, and there is no history of blood transfusions or injection drug use. Medical history is otherwise unremarkable. Family history is significant for depression and type 2 diabetes mellitus. He takes no medications.On physical examination, the patient appears anxious. Vital signs and the remainder of the physical examination are normal. The patient's evaluation for sleep disorders is normal. A screening test for depression is negative.Which of the following is the most appropriate diagnostic test to perform next?A. Epstein-Barr virus titerB. Lyme disease titerC. Repeat HIV testingD. No further testingCorrect AnswerD. No further testingEducational ObjectiveEvaluate a patient with systemic exertion intolerance disease (formerly known as chronic fatigue syndrome).CritiqueNo further testing is indicated in this patient who meets the clinical criteria for systemic exertion intolerance disease (SEID), previously termed chronic fatigue syndrome. He has fatigue that has persisted for more than 6 months that is not due to exertion and is not relieved by adequate sleep. He also experiences unrefreshing sleep, muscle pain, joint pain without synovitis, headaches, and recurring sore throat.There is no specific objective laboratory test to diagnose SEID, and since the presenting symptoms are nonspecific, it remains a diagnosis of exclusion. Recommended value-based screening tests include complete blood count, glucose levels, and thyroid function tests. If indicated by the history and physical examination, electrolytes, calcium level, serum creatinine level, hepatic enzyme levels, liver chemistry tests, and antinuclear antibody test may be performed. This patient has undergone evaluation for underlying medical conditions in which fatigue is a common symptom, and all test results were normal. At present, no further testing is indicated, and attention should be directed to management with either graded exercise or cognitive-behavioral therapy.Although Lyme disease and Epstein-Barr virus have been implicated in the development of SEID, no single infectious cause has been definitively linked. An Epstein-Barr virus titer would not be indicated, as this test is nondiagnostic and not value based. Additionally, antiviral treatment has been shown to be ineffective. Lyme disease testing is also unwarranted because this patient's nonspecific symptoms are not consistent with Lyme disease. Additionally, the pretest probability of Lyme disease is low, and testing for Lyme antibodies is not recommended by the American College of Rheumatology.Repeat HIV testing in this patient would be low value care. He had a recent negative HIV test and has not had high-risk exposure since that time.Key PointThere is no specific objective laboratory test to diagnose systemic exertion intolerance disease (formerly known as chronic fatigue syndrome); recommended value-based tests to rule out this disease include complete blood count, glucose level, and thyroid function tests.BibliographyYancey JR, Thomas SM. Chronic fatigue syndrome: diagnosis and treatment. Am Fam Physician. 2012 Oct 15;86(8):741-6.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. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 18 April 2017Volume 166, Issue 8Page: ED8KeywordsChronic fatigue syndromeEpstein-Barr virusExercise therapyFatigueHIVLyme diseaseMedical ethicsPatientsSystemic diseasesType 2 diabetes ePublished: 18 April 2017 Issue Published: 18 April 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...