Annals for Educators - 18 February 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives18 February 2020Annals for Educators - 18 February 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202002180 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The Health of Our TraineesOn Being a Doctor: Open Letter to a Burned-Out InternDr. Singh writes to a current intern to say the things she wishes someone had said to her 5 years ago.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners if they feel inadequate as physicians.Do they have symptoms of burnout? Do they criticize themselves for how they feel? Do they worry others would be critical if they were to report how they feel? Do they feel alone?What systems are in place at your institution to ensure that trainees know to whom they may reach out for support? Is there a system in place that actively reaches out to be sure your trainees are well?Are mental health issues, including suicidality, among physicians (and among trainees specifically) proactively addressed at your institution? Or is addressing them discouraged, even if inadvertently? What resources and programs are in place? If you don't know, whom should you ask? Who should be talking about it?Clinical Practice PointsSurvival, Nonrelapse Mortality, and Relapse-Related Mortality After Allogeneic Hematopoietic Cell Transplantation: Comparing 2003–2007 Versus 2013–2017 CohortsAdvances in the care of patients having allogeneic hematopoietic cell transplant led to improved outcomes reported a decade ago. However, allogeneic transplant continues to be accompanied by substantial morbidity and mortality. This study assessed whether outcomes have continued to improve.Use this study to:Ask your learners what the rationale is for allogeneic hematopoietic cell transplantation. By what mechanisms might relapse and cure be achieved in malignancies that have been resistant to “standard” chemotherapeutic approaches?What are the potential acute side effects of the procedure? What about in the long term?Are the risks following autologous stem cell transplantation different? Pose the multiple-choice question provided below to your learners, and see if they catch the difference.How have outcomes changed for patients undergoing allogeneic hematopoietic cell transplantation over the past 2 decades? The authors note that cancer relapse remains the largest obstacle to better survival. Which data indicate this?Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008–2016Primary care improves patient outcomes and lowers health care costs. That is why most countries emphasize primary care and why the United States is trying to expand primary care programs. This article finds that the United States may be losing ground and provides some clues about why we are not doing better.Use this study to:Ask your learners to define “primary care.”Do your learners think it is important for a patient to have a primary care physician? Why? Are outcomes better?What did this study find?What are potential explanations for the decline in the number of primary care visits? The authors provide 3 possible explanations in the discussion.The editorialist notes that more people now have insurance than in the past. Why then might cost remain an impediment to care? What does the editorialist say? Do your learners think it is OK if services previously received from primary care are instead provided in alternative ways, such as at “ready clinics”? Why or why not? What are the potential advantages and disadvantages?What do your learners see for the future?Video LearningAnnals Consult Guys - Bridging Anticoagulation for Patients With Valvular Heart DiseaseHoward and Geno (the Consult Guys) dissect the nuances of anticoagulant management for procedures when a patient has valvular heart disease.Use this feature to:Ask your learners when anticoagulation is indicated for valvular heart conditions.Watch the short video with your learners.When may anticoagulation be temporarily stopped for a procedure? When is “bridging” needed?Use the multiple-choice questions to help introduce topics for discussion.Our Profession and CareerEliminating Medical School Debt: A Dean and Geriatrician's View From Opposite Ends of the Training PipelineFree medical school tuition is an idea that is gaining traction. This commentary proposes alternative solutions to the problem of overwhelming educational debt: making medical school debt-free for students with financial need and fully subsidizing loan repayment during training for those choosing less lucrative fields, such as geriatrics.Use this essay to:Ask your residents whether student debt has influenced their choice of career paths.What other variables are important to your learners as they consider their futures?Discuss trends in fellowship applications to areas such as geriatrics. Why are they declining? Is this a problem? What do your learners think can be done?MKSAP 18 QuestionA 73-year-old man undergoes follow-up evaluation after autologous hematopoietic stem cell transplantation (HSCT) 3 weeks ago for multiple myeloma. He had induction chemotherapy 1 year ago. He is doing well, without fever, chills, cough, or localizing symptoms of infection. Medications are acyclovir and omeprazole.On physical examination, vital signs are normal; BMI is 20. He weighs 2.5 kg (6 lb) less than he did 2 months ago before HSCT. Alopecia is noted.In the next 30 days, this patient is at increased risk for which of the following treatment-related complications?A. Acute graft-versus-host diseaseB. InfectionC. LymphomaD. Myelodysplastic syndromeCorrect AnswerB. InfectionEducational ObjectiveIdentify an increased risk of infection after autologous hematopoietic stem cell transplantation.CritiqueThis patient is at increased risk of infection. The most common indications for autologous hematopoietic stem cell transplantation (HSCT) are multiple myeloma and relapsed non-Hodgkin lymphoma. With appropriate supportive care, many older patients are eligible for autologous HSCT. Fatigue, altered taste, diminished appetite, and persistent mild diarrhea are common adverse effects of high-dose chemotherapy, an integral part of HSCT. The most common concern in patients who have undergone HSCT is the increased risk of infection, which persists for 6 to 12 months after HSCT. This risk is attributed to compromised function of neutrophils and lymphocytes and is sometimes associated with mild neutropenia and lymphopenia. For this reason, patients should be counseled to report warning symptoms, such as fever and respiratory or other localizing symptoms of infection, early in the course.Graft-versus-host disease (GVHD) is a major risk of allogeneic HSCT. Acute GVHD occurs when graft T cells recognize the patient's normal gut, skin, and liver sinusoids as foreign. Severe GVHD is life threatening and is treated with high-dose glucocorticoids. Anti–T-lymphocyte immune globulin as part of the myeloablative conditioning regimen can markedly reduce the prevalence of chronic GVHD 2 years after allogeneic HSCT in HLA-matched siblings. GVHD is not a complication of autologous HSCT.Hematopoietic clonal disorders, including myelodysplasia, leukemia, and lymphoma, can occur decades after completion of therapy. Typical agents associated with therapy-related myelodysplasia include alkylators, anthracyclines, and topoisomerase II inhibitors. Likewise, leukemia and lymphoma can develop as a late consequence of exposure to chemotherapy and radiation. But these disorders would not occur in the months immediately following uncomplicated autologous HSCT.Key PointImmediately following hematopoietic stem cell transplantation, patients are at increased risk of infection because of compromised function of lymphocytes and neutrophils.BibliographyHashmi SK. Basics of hematopoietic cell transplantation for primary care physicians and internists. Prim Care. 2016;43:693-701. doi:10.1016/j.pop.2016.07.003Do 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 February 2020Volume 172, Issue 4Page: ED4KeywordsCell transplantationGraft vs host diseaseHematopoietic stem cell transplantationInfectious diseasesLymphocytic leukemiaLymphomaMultiple myelomaNeutrophilsPatientsPrimary care physicians ePublished: 18 February 2020 Issue Published: 18 February 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...