Annals for Educators - 15 September 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives15 September 2020Annals for Educators - 15 September 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202009150 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAssociation Between Oral Corticosteroid Bursts and Severe Adverse Events. A Nationwide Population-Based Cohort StudyShort courses of oral corticosteroids (“steroid bursts”) are often prescribed for common medical ailments, such as skin disorders and upper or lower respiratory tract infections. This analysis of health care claims data from Taiwan describes the rates of 3 serious adverse events (acute gastrointestinal bleeding, sepsis, and heart failure) among patients who received a steroid burst.Use this study to:Ask your learners to list conditions for which short courses (<14 days) of corticosteroids are frequently prescribed. For each, ask if we know whether corticosteroids are beneficial.The editorialists note that 17% of the general population will be prescribed a short course of steroids this year, usually for common conditions such as upper respiratory infections and lower back pain. Do these numbers surprise your learners? Ask your learners to list the potential harms of long-term corticosteroid use. What are the potential harms of a short “burst” only?Review the results of this study. Are your learners surprised that the increased risk was seen among patients with and without comorbid conditions? Among younger patients?What are the limitations of this study?The study was designed as a self-controlled case series. How does that work, and how might that help control for unmeasured, time-invariant confounders? See the paper's Methods section.Will this study alter your learners' practice? Should it? Use the editorial to help frame your discussion. The New Normal: Key Considerations for Effective Serious Illness Communication Over Video or Telephone During the COVID-19 PandemicThe care of patients with COVID-19 has involved video- or telephone-based communication with families. The skills and sensitivities required during this pandemic may be applicable in other situations requiring telecommunication. This article provides helpful guidance on how to have meaningful conversations about serious illness using telecommunication.Use this paper to:Ask your learners how they prepare for meetings with patients' families.Have they conducted important clinical discussions over the phone or by video? How did it go? How might it have gone better?Review the pointers provided in the text and table (e.g., building rapport, asking permission, having several short discussions rather than one long one). Review what each of the mnemonics stands for (e.g., NURSE). Are these skills applicable to in-person discussions as well?Make a plan to always review and dissect on rounds the family discussions that occurred in the previous 24 hours. Discuss where things went well, where they might have been better, and how to improve the next time. Tell your team to plan on such discussions to help improve everyone's skills.Annals Clinical Decision Making: Communicating Risk and Engaging Patients in Shared Decision MakingPatients must be involved in weighing risks and benefits when deciding on their care, particularly when uncertainty exists regarding outcomes. This article in the Annals Clinical Decision Making series addresses how to best communicate risks and benefits to ensure the pertinent issues and facts are understood by the patient to enable meaningful, shared decision making.Use this feature to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what is meant by “shared decision making.”How should risk be communicated to patients? How are the potential benefits of an intervention best communicated?What is the difference between relative risk reduction and absolute risk reduction? Review the example in Table 1. Which do your learners think is more informative? Which is easier for patients to understand?How are gain and loss frames communicated? Use Table 2.What are visual arrays? How might they be helpful in educating a patient? Look at the example in Figure 2.How would your learners combine the information in Table 1, Table 2, and Figure 2 to help a patient understand the benefits and harms of tamoxifen chemoprophylaxis for breast cancer?Bias at Our Medical CentersAddressing Patient Bias Toward Health Care Workers: Recommendations for Medical CentersMany clinicians are subjected to demeaning behavior or inappropriate language from patients because of the clinician's social identity, such as their race, ethnicity, or gender. Most medical centers lack formal policies for managing this situation appropriately. This article describes the legal and ethical considerations for different parties involved in the patient–provider relationship and offers guidance for developing an institutional policy to address this situation.Use this paper to:Assess what written policies are or are not in place at your medical center to address inappropriate behavior by patients toward clinicians. To whom should events be reported? Who should respond, and how? Have staff been trained to know about these policies and procedures?Ask your team members if they know how to respond to inappropriate patient behavior. To whom should they turn for help? Be careful not to allow the conversation to make individuals who may have been the target of such behavior feel singled out or uncomfortable.What laws protect employees? What laws protect trainees?The authors recommend that, in most cases, bias-based requests for clinician reassignment should be rejected. Why?The authors also emphasize the importance of recognizing that not all requests for reassignment are rooted in bias. What are some such circumstances, and how should they be addressed?If written policies do not exist at your medical center, who should be asked to participate in addressing the issue?On Being a Doctor: Bonds in Every ColorDr. Mgbako describes how time spent together with other physicians of color laid bare the ubiquity of trauma in our profession.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners to consider how they would respond if a patient made a biased comment to them. Be careful not to make anyone on your team feel singled out in the discussion. Do not require anyone to share his or her response.Dr. Mgbako comments, “Medicine's implicit curriculum taught us to suppress our feelings to seem strong in the face of adversity, put the patient first, and avoid being seen as ‘difficult.’” What do your learners think? What should each of us be doing?On Being a Doctor: UnitedDr. DeWaters felt marked as belonging to the unit no one wanted to enter, so she headed to her office to lie low and work.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners how they can offer comfort to patients who feel isolated, or even abandoned.Are there ways we can avoid making our colleagues and patients feel ostracized in these situations, even as we take precautions and fear for our own safety?MKSAP 18 QuestionA 40-year-old woman seeks advice on whether she should undergo breast cancer screening with mammography. Her family history is negative for breast and ovarian cancers, and she has no other risk factors for breast cancer.On physical examination, vital signs and the remainder of the examination are normal.The patient is engaged in a discussion of the potential benefits and harms of initiating mammography now, including the potential for false-positive results and overdiagnosis. After the discussion, she states that she is not overly concerned about her risk for breast cancer but is anxious about the potential harms associated with screening.Which of the following is the most appropriate screening test for this patient?A. Breast self-examinationB. Breast tomosynthesisC. Screening mammographyD. No testingCorrect AnswerD. No testingEducational ObjectiveUse a shared decision-making approach to guide the initiation of breast cancer screening in a younger woman.CritiqueThis patient should not be screened for breast cancer at this time. In women aged 50 to 74 years, there is a clear benefit to screening mammography, and all breast cancer guidelines recommend screening mammography in this age group. Biennial screening mammography imparts most of the benefit of annual screening mammography with fewer harms, although the recommended screening frequency differs between guidelines. In women younger than 50 years or aged 75 years or older, the balance of benefits and harms is less clear, and screening recommendations vary widely. Most guidelines recommend individualized screening decisions for women aged 40 to 49 years based on patient context and values regarding specific benefits and harms. The American College of Physicians states that the potential harms of screening mammography outweigh the benefits in average-risk patients aged 40 to 49 years and suggests that screening occur only if an informed woman requests it. The U.S. Preventive Services Task Force (USPSTF) concludes that, compared with screening mammography in older women, the number of women in their 40s who benefit from screening mammography is smaller, and the harm is higher; however, the benefit still outweighs the harm. Therefore, the value the patient places on averting death from breast cancer compared with the importance she places on avoiding potential harms (false-positive results, anxiety, and overdiagnosis) can help guide her decision. This patient places more importance on avoiding potential harms and therefore should not pursue screening mammography or breast tomosynthesis at this time; no further testing is the best option.The USPSTF and ACP both recommend against teaching breast self-examination (BSE), as BSE does not reduce breast cancer mortality and is associated with increased rates of breast biopsy.The USPSTF found insufficient evidence to assess the balance of benefits and harms of using breast tomosynthesis, or three-dimensional mammography, as a primary screening method for breast cancer; however, National Comprehensive Cancer Network guidelines indicate that breast tomosynthesis can be considered as an initial screening strategy for average-risk women. In studies, breast tomosynthesis is often associated with double the rate of radiation but lower recall rates.As women progress through their 40s, the number of women who benefit from screening mammography increases, while the chance for harms slightly decreases. A woman's values and preferences may also shift over time; therefore, breast cancer screening should be periodically discussed.Key PointThe decision to initiate breast cancer screening in women aged 40 to 49 years should be an individualized one based on patient context and values regarding specific benefits and harms.BibliographyNelson HD, Pappas M, Cantor A, Griffin J, Daeges M, Humphrey L. Harms of breast cancer screening: systematic review to update the 2009 U.S. Preventive Services Task Force recommendation. Ann Intern Med. 2016;164:256-67.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 September 2020Volume 173, Issue 6Page: ED6KeywordsBehaviorBreast cancerBreast cancer screeningBreast self-examinationDecision makingGraduate medical educationMammographyRacial and ethnic issuesScreening guidelinesTomosynthesis ePublished: 15 September 2020 Issue Published: 15 September 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...