Annals for Educators - 2 April 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives2 April 2019Annals for Educators - 2 April 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201904020 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsThyroidectomy Versus Medical Management for Euthyroid Patients With Hashimoto Disease and Persisting Symptoms. A Randomized TrialDespite adequate hormone replacement, some patients with Hashimoto disease have residual symptoms that may be related to immune pathophysiology rather than to hypothyroidism. This randomized trial compared the effect of medical therapy with and without thyroidectomy on fatigue, health-related quality of life, and antibody levels.Use this study to:Ask your learners what symptoms might suggest a diagnosis of Hashimoto disease. How should patients be evaluated?What other entities may cause painless thyroiditis? Use the information at DynaMed Plus: Hashimoto Thyroiditis, a benefit of your ACP membership, to help prepare for a teaching session. What are potential complications of Hashimoto disease?What was the rationale for thyroidectomy in this trial? Why was it hypothesized that it might be helpful? Was it? On the basis of this study's results, do your learners think they should consider thyroidectomy for patients similar to those enrolled in this study? Why or why not?Ask your learners how they go about providing thyroid replacement therapy. How should it be monitored?What do the “normal” ranges of thyroid function test results tell us? How should we approach patients who have persistent symptoms that are potentially attributable to abnormal thyroid function despite having values within the normal range?Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women. A Systematic Review and Network Meta-analysis of Clinical OutcomesThis network meta-analysis of 84 randomized trials compared the effectiveness of 14 categories of nonpharmacologic and pharmacologic treatments for urinary incontinence (UI) in women.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how common UI is. Are they surprised to hear that it affects about 17% of nonpregnant women?How might UI affect a woman's physical and mental health?Do your learners think that patients might not tell them about UI? Should your learners ask, and if so, how?What are the differences among stress, urgency, and mixed UI? How is a diagnosis made? Does the approach to treatment differ according to the type of UI?What nonpharmacologic and pharmacologic interventions are available? What does this review tell us about their effectiveness?How does one arrange for behavioral treatments for UI at your institution?In the Clinic: Generalized Anxiety DisorderGeneralized anxiety disorder (GAD) is a common and disabling illness that is often underdiagnosed and undertreated. It is the most common anxiety disorder seen in primary care, affecting approximately 4% to 7% of U.S. adults. Patients with GAD are at increased risk for suicide as well as cardiovascular-related events and death. Are your learners prepared to recognize, evaluate, and manage GAD?Use this review to:Ask who is at elevated risk for GAD.Ask what the diagnostic criteria are for GAD. What other diagnoses should be considered? Use Table 1 to help prepare for a teaching session. What physical examination findings might indicate possible GAD?When should your learners consider consultation with a psychologist, psychiatrist, or other specialist?Are there helpful nonpharmacologic interventions? How are they provided? What pharmacologic therapies are available, and when should they be used? How should they be monitored? Use the tables to help review.Use the provided multiple-choice questions to help introduce topics during a teaching session. Be sure to log on and enter your answers to earn CME/MOC credit for yourself!Beyond the GuidelinesWould You Refer This Patient With Cancer to a Palliative Care Specialist? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterThe importance of palliative care is often emphasized in the treatment of cancer and other serious diseases. However, the necessary features of such care, as well as the term “palliative care” itself, are widely debated. Here, 2 oncologists, 1 of whom is also a palliative care specialist, discuss their approaches to the care of a woman with advanced cancer.Use this feature to:Watch the interview of Ms. F, a 71-year-old woman with metastatic neuroendocrine carcinoma.Ask your learners whether they would refer Ms. F to palliative care. If so, what are the goals?Ask whether palliative care can and/or should be provided by a patient's primary oncologist.What is the difference between palliative care and hospice care? Are patients referred “too late” to palliative care? If so, why?What are the potential benefits of palliative care? Where do the 2 consultants agree and disagree regarding how it should be provided? This is summarized succinctly at the end of the article.Humanism and ProfessionalismOn Being a Doctor: Telemedicine and the Tattooed LadyDr. Taylor had to navigate across spatial, social, and even political divides to provide care via the Internet.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have provided telemedicine. How? Was it strange or uncomfortable? What are its limitations? Are there advantages?What social and interpersonal issues had the potential to derail this medical encounter? Are they different in any way with telemedicine versus in person?How did Dr. Taylor successfully navigate these issues? How did the order in which he chose to address the patient's issues affect the outcome of the visit? How might this have gone if he had done things in a different order? What potential mistakes were avoided? Are these lessons any different in a telemedicine visit versus in person?Teaching Opportunity!Clinical Skills Session ProposalsInterested in teaching procedural, physical examination, or communication skills?Clinical Skills Session Proposals are now being accepted for ACP's Internal Medicine Meeting 2021.The ACP is accepting proposals for hands-on, interactive workshops that focus on the acquisition or improvement of procedural skills, physical examination skills, and communication skills for Internal Medicine 2021, which will be held April 29–May 1, 2021, in Orlando, Florida.To submit a proposal, please complete the Clinical Skills Session Proposal form. The deadline to submit proposals is April 26, 2019. MKSAP 18 QuestionA 59-year-old woman comes to the office for a follow-up evaluation of a 2-year history of worsening urinary urgency and frequency. Episodes of urinary incontinence have occurred more often in the past 6 months because she cannot walk fast enough to get to the bathroom in time. Recently, she also has experienced intermittent urinary hesitancy and a frequent feeling of incomplete emptying, sometimes requiring changing body position or manual pelvic pressure. The patient has a 5-year history of secondary progressive multiple sclerosis. She takes no disease-modifying therapy. Her only medication is a vitamin D supplement.Physical examination findings are unremarkable.Urinalysis results are normal.Which of the following is the most appropriate next step in management?A. Dalfampridine administrationB. Oxybutynin administrationC. Solifenacin administrationD. Urodynamic testingCorrect AnswerD. Urodynamic testingEducational ObjectiveEvaluate urinary symptoms in patients with multiple sclerosis.CritiqueThis patient should undergo urodynamic testing. Her symptoms and history of multiple sclerosis (MS) suggest the presence of a neurogenic bladder. Given the mix of symptoms of urgency and frequency (symptoms of an overactive, spastic bladder) plus hesitancy and retention (symptoms of a hypotonic bladder or overactive sphincter), the patient has aspects of both hypertonic and hypotonic bladder. She also may have bladder-sphincter dyssynergia, in which the contraction of the bladder wall is not properly timed with relaxation of the urinary sphincter. Management of complicated forms of neurogenic bladder involves proper diagnosis through urodynamic testing (which will guide medication choices), potential use of urinary catheterization, and monitoring of postvoid residuals while the patient is treated to avoid urinary retention. Involvement of a urologist is often required.Dalfampridine has been shown to improve walking speed in patients with MS. Although the patient says that incontinence occurs when she is unable to get to the bathroom fast enough, use of this medication would not address the underlying cause of her urinary symptoms. Further, frequent urinary tract infections are a common adverse effect of this medication, and thus using it without first addressing her current urinary symptoms would be counter-productive.Urinary frequency and urgency are more readily managed than other patterns of bladder dysfunction and are often amenable to abstinence from caffeine, timed voids, and anticholinergic medications, such as oxybutynin or tolterodine. Patients with urinary hesitancy or retention, such as this patient, should not be treated with anticholinergic agents because these medications can worsen retention and lead to predisposition to urinary tract infections. This patient with mixed bladder symptoms should be evaluated with urodynamic testing.Solifenacin has been shown to reduce symptoms of overactive bladder in patients with MS. However, this patient's mixed bladder symptoms suggest that she is prone to urinary retention. Use of this medication without concurrent use of catheterization and monitoring of postvoid residuals would result in worsened urinary retention and predispose the patient to more frequent urinary tract infections and, possibly, bladder cancer.Key PointIn a patient with multiple sclerosis and mixed urinary symptoms that suggest both a hypertonic and a hypotonic bladder, urodynamic testing to guide medication choices is appropriate, as are the potential use of urinary catheterization and monitoring of postvoid residuals while the patient is treated.BibliographyPhé V, Chartier-Kastler E, Panicker JN. Management of neurogenic bladder in patients with multiple sclerosis. Nat Rev Urol. 2016;13:275-88. doi:10.1038/nrurol.2016.53Do 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 Prof.Dr.Tanu Pramanik Principal, Dr. Evertz Solomon Associate Professor, Dr. Orette Williams Associate Professor, Dr. Anaya Pramanik lecturer, Lincoln College, Hargreaves Hospital Complex, Mandeville, Manchester, Jamaica,WI.[www.lincolncollege.org]8 April 2019 Humanism and professionalism--A matter of major concern for medical educators In recent years, clinical practice has been modernised to a great extent all over the world introducing several advanced equipment and automated computerised instrumentation in different speciality units of teaching hospital settings. Dr. Darren B. Taichman deserve our sincere applause for his attempt to emphasize the training of humanism and professionalism in medical programme [1]Humanised clinical practice is fading away from medical training curriculum at a rapid space. Majority of our students will never understand, realize or practice humanised medicine. We are promoting commercialised clinical practice where behavioural science is disappearing and doctor-patient relationship is losing ground. In the name of professionalism, we underestimate training for compassionate communication skills which is important to reveal patient complains often left unsaid.Professionalism training is equally important in medical practice though. We need to balance between humanisation and professionalism in medical curriculum.Compassionate behavioural skills—using the right words expressed in the right way—can help minimise patient distress and offer reassurance to accompanying relatives [2]Previously we reported that when we are sick, injured, or facing an existential life crisis, our greatest human need is loving kindness and compassion in response to our vulnerability and suffering. Most commonly young generation medical graduates find it difficult to initiate respectful and compassionate dialogues with their patients while working in a crowded out-patient department. Many of them fail to maintain professional conduct in a stressful working environment. Some of them often feel sick due to burn out state of their mind after long hours of emergency ward duties. It is most unfortunate that many of them did not get an opportunity to learn about behavioural science as a part of their curriculum during their medical school training program. They were never been exposed to the local community for a supervised health screening program with a mission to develop doctor-patient relationship and professional communication skills in real life scenario [ 3].Too often, what patients actually receive is rushed, clinical, and emotionally detached care. Physicians have many evidence based guidelines for disease management but little evidence based medicine for care of the whole person [4].1. Darren B. Taichman (2019) Annals for Educators (Humanism and Professionalism.https://annals.org/aim/fullarticle/2729967/annals-educators-2-april-20192. Tanu Pramanik: Teaching caring and compassionate communication: https://blogs.bmj.com/bmj/2017/05/30/tanu-pramanik-teaching-the-doctor-patient-relationship/3. Tanu Pramanik (2017) Impact of behavioral science curriculum in medical education Re: Humanizing Health care. https://www.bmj.com/content/355/bmj.i6262/rapid-responses.4. Humanising health care BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6262 (Published 13 December 2016)Cite this as: BMJ 2016;355:i6262 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 2 April 2019Volume 170, Issue 7Page: ED7KeywordsBladderGeneralized anxiety disorderMultiple sclerosisPalliative careTelemedicineThyroidThyroidectomyUrinary tract infectionsUrodynamics ePublished: 2 April 2019 Issue Published: 2 April 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...