Annals for Educators - 15 May 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives15 May 2018Annals for Educators - 15 May 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201805150 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsHIV Incidence, Prevalence, and Undiagnosed Infections in U.S. Men Who Have Sex With MenHIV infection is a persistent health concern in the United States. Data from the National HIV Surveillance System were used to estimate recent changes in HIV incidence and prevalence, as well as in the percentage of undiagnosed HIV infection, in men who have sex with men. Such data may inform efforts to reduce undiagnosed HIV infection, improve access to care, and optimize treatment in this population.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to list reasons why it's important to identify HIV infection. The authors provide a list in the paper's introduction.Do your learners screen their patients for HIV? Are they aware of the recommendations of the U.S. Preventive Services Task Force on screening for HIV infection? Why have improvements in the rate of HIV infection and the number of undiagnosed patients differed among racial and ethnic groups?What are essential interventions among patients with newly diagnosed HIV? Use the information in the recent In the Clinic: Management of Newly Diagnosed HIV Infection to help teach. Do your learners ask their patients about their sexual activity? How do they ask? What do they discuss with men who report having sex with men about how to reduce the risk for infection to themselves and others?Interactions Between Physicians and Skilled Home Health Care Agencies in the Certification of Medicare Beneficiaries' Plans of Care: Results of a Nationally Representative SurveyThe Centers for Medicare & Medicaid Services form 485 (CMS-485) is typically used for certification of plans of care for patients who receive Medicare skilled home health care (SHHC) services. In this article, the authors summarize results from a nationally representative survey that sought to determine how physicians interact with SHHC agencies and use the CMS-485 in care coordination for patients receiving SHHC services.Use this study to:Ask your learners whether they know how SHHC plans of care are developed, and by whom.Have they seen or been asked to review and sign a CMS-485 form? Review one with your team. Is the information presented in a useful manner?Why do your learners think that many physicians spend less than a minute reviewing the form before certifying it? Is this a missed opportunity to improve care? How would your learners propose to improve communications between primary care providers and SHHC services without increasing the administrative burdens? How might such changes improve patient care and professional satisfaction?Invite a home care nurse or other health care professional involved in your center's home care program to join your discussion.Improving Our ProfessionAchieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of PhysiciansAlthough women have made substantial progress in medical school enrollment, residency training opportunities, and composition of the physician workforce, much remains to be done to improve equity and increase leadership opportunities for women in medicine. This American College of Physicians (ACP) position paper provides recommendations to achieve gender equity in physician compensation and career advancement.Use this paper to:Ask your learners whether they believe there are different expectations of women and men in your training program. Are women and men judged by different standards with regard to what makes them good physicians and colleagues?How does gender discrimination harm both women and men in medicine?The ACP calls on training programs to develop and distribute medical leave policies. Does your program have a written policy? Are your trainees aware of what it says? Do women and men face different pressures from your program when asking for time away to care for a newborn or newly adopted child or a seriously ill family member?Do your trainees receive help navigating applications and negotiations regarding jobs after their training? How should they approach concerns about equitable pay?Is there transparency in compensation at your institution?Use the accompanying editorial to help frame your discussion. Information for Program Directors/Medical EducatorsCreating Entrustable Professional Activities to Assess Internal Medicine Residents in Training. A Mixed-Methods ApproachCompetency-based medical education has not advanced residency training as much as expected, and some medical educators now advocate reorienting competency-based approaches to focus on a resident's ability to do authentic clinical work. In this study, the authors used a modified Delphi process to develop descriptions of clinical work for which internal medicine residents must gain proficiency to deliver meaningful patient care. They identified 29 activities and developed guidelines for their use in assessing residents.Humanism and ProfessionalismOn Being a Doctor: Lessons Learned?Dr. Yachimski considers how his involvement in the care of patients with terminal illness has shaped how he responds to the hardest question such patients ask him.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners what they have learned from the deaths of patients.Have their prior experiences strengthened their confidence in counseling others with a terrible prognosis and whether to recommend a focus on comfort only? Has it made them less confident? Both?How should we respond to the question, “Put yourself in my shoes. What would you do?”MKSAP 17 QuestionA 25-year-old man is evaluated in follow-up after HIV testing. He states he has sex with other men and usually uses condoms. He had a negative HIV test result 1 year ago. He feels well today but reports having a flulike illness last week with mild fever, headache, myalgias, and fatigue; these symptoms have resolved. Medical history is unremarkable for sexually transmitted or other infections. Other than taking over-the-counter ibuprofen last week, he takes no medications.On physical examination, he is afebrile and has small palpable anterior and posterior cervical, axillary, and inguinal lymph nodes. The remainder of the examination is normal.HIV-1/2 antigen/antibody combination immunoassay is reactive. Result of an HIV-1/HIV-2 antibody differentiation immunoassay is negative for HIV-1 and HIV-2. Result of an HIV-1 nucleic acid amplification testing is positive, with 51,455 copies/mL.Which of the following is the most appropriate next step in management?A. Repeat HIV-1/HIV-2 antibody differentiation immunoassay in 6 weeksB. Saliva rapid HIV testingC. T-cell subset testingD. Western blot HIV-1 antibody testingCorrect AnswerC. T-cell subset testingEducational ObjectiveDiagnose acute HIV-1 infection.CritiqueThis patient should be informed that he has acute HIV-1 infection, and further baseline evaluation of new HIV infection with T-cell subset testing and other appropriate laboratory studies should be pursued. The antigen/antibody combination immunoassay is reactive, indicating the presence of HIV-1 or HIV-2 antibody or HIV p24 antigen. The result on a differentiation immunoassay for HIV-1 and HIV-2 antibodies is negative, suggesting that the initial immunoassay was detecting the presence of viral p24 protein. This is confirmed by the nucleic acid amplification test, which had strongly positive results for HIV RNA, indicating the presence of virus even though the patient did not yet have detectable antibodies. These results are most consistent with acute HIV infection presenting in the “window period” before development of a serologic response. His nonspecific febrile illness the previous week may have represented symptoms of acute HIV infection.The rapid tests for HIV infection, such as a saliva assay, are convenient for patients but are based on detecting HIV antibodies. They would therefore be expected to yield negative or indeterminate results in this patient because he is presenting in the “window period” of acute infection before antibody development.The Western blot test is no longer recommended for confirmatory HIV testing. Because this patient has early HIV infection, results of Western blot testing for HIV antibody would likely be negative or indeterminate anyway.Repeating the HIV 1/HIV-2 antibody differentiation immunoassay at a later time is not necessary because acute HIV infection has been diagnosed on the basis of the high level of viral RNA. Antibody testing results will become positive within a few weeks to a few months, but it would not be appropriate to delay further management for HIV until that time.Key PointPositive antigen/antibody immunoassay, negative antibody differentiation assay, and positive nucleic acid amplification test results are consistent results for patients presenting in the “window period” of acute HIV infection before development of a serologic response.BibliographyBranson BM, Owen SM, Wesolowski LG, et al; Centers for Disease Control and Prevention; Association of Public Health Laboratories. Laboratory testing for the diagnosis of HIV infection: updated recommendations. Published June 27, 2014. Accessed July 21, 2015. 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 15 May 2018Volume 168, Issue 10Page: ED10KeywordsAntigensHIVHIV infectionsHIV-1ImmunoassaysNucleic acidsPatientsResearch laboratoriesSalivaWestern blot ePublished: 15 May 2018 Issue Published: 15 May 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...