Annals for Educators - 5 November 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives5 November 2019Annals for Educators - 5 November 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201911050 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Humanism and ProfessionalismOn Being a Doctor: How Did I Get Here? Career Choice in MedicineDr. Goldberg wonders how one can learn to accept that critical career decisions are made with an imperfect data set.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners if they have decided on a career path. How did they reach their decisions? How certain are they? In what ways are they uncertain?Should uncertainty about the training and career paths we're on concern us? How should we manage uncertainty?How should your trainees assess the paths they're on? What questions should we ask ourselves?Does a career in medicine provide the opportunity to switch directions?Consider arranging a series of informal meetings (perhaps meals) with your learners and more senior individuals whose careers have taken diverse twists and turns. Ask them to share the lessons they learned about navigating and adjusting paths.Clinical Practice PointsScreening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of PhysiciansColorectal cancer is the second leading cause of cancer-related death among adults in the United States. This guidance statement from the American College of Physicians aims to assist clinicians with colorectal cancer screening in adults by evaluating existing guidelines and their evidence reviews.Use this guidance statement to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how they approach colorectal cancer screening in their practices.At what ages do they recommend screening begin? Is there an age after which they no longer recommend screening? Do they make that decision on their own, or do they discuss it with their patients?How do we determine at what ages to start and stop screening? Use the accompanying editorial to help frame your discussion. How do your learners explain the relative advantages and disadvantages of the available means to perform screening? Do they discuss the patient's preferences or just make a recommendation? For which patients do they recommend colonoscopy? What about stool-based tests?Variation in Prescription Drug Prices by Retail Pharmacy Type. A National Cross-sectional StudyStudies suggest that drug prices vary widely across retail pharmacies. In this study, researchers used drug pricing data from GoodRx to describe cash prices across categories of retail pharmacies throughout the United States for commonly used generic and brand-name drugs.Use this study to:Ask your learners whether they ask patients how much they pay for their prescriptions.Should we ask? Why might it matter?Teach at the bedside! Ask patients on rounds how much they pay for their prescriptions. Ask whether cost is ever a factor in how they use their drugs. Do they “shop around”? How much effort does that require?Ask whether your patients purchase some of their prescriptions from one pharmacy and others from a different source. What medical problems might this cause?Why is it difficult to know ahead of time how much a prescription you write will cost your patient? Can we rely on the conclusions of this article to advise patients? Use the accompanying editorial to help frame your discussion. In the Clinic: Type 2 DiabetesType 2 diabetes (T2D) is a prevalent illness that causes major vascular, renal, and neurologic complications. Prevention and treatment of diabetes and its complications are of paramount importance. Many new treatments have emerged over the past 5 to 10 years, and some may substantially reduce risk for cardiac and renal disease and thereby change treatment paradigms. This review summarizes the evidence supporting diabetes prevention and treatment, focusing on aspects that are commonly in the purview of primary care physicians.Use this review to:Ask your learners whether we should screen for T2D. In whom? How? Can it be prevented?How is a diagnosis established? What initial evaluation is in order after diagnosis?What nonpharmacologic interventions should be initiated?What approach should your learners take to choosing pharmacologic therapy? What considerations should be discussed with patients? When should insulin be considered?Should patients with newly diagnosed T2D see a specialist? How about patients with long-standing disease?Use the multiple-choice questions to help introduce topics for discussion during a teaching session. And, be sure to log on and enter your responses to earn CME and MOC credit for yourself!MKSAP 18 QuestionA 65-year-old man is evaluated during a visit to establish care. He is interested in colorectal cancer screening; however, he adamantly refuses to undergo colon preparation, and he does not want to modify his diet for screening. He has never undergone colorectal cancer screening. Medical and family histories are unremarkable. He takes no medications.Physical examination, including vital signs, is normal.After discussing the colon preparation process and dietary restrictions with the patient and exploring his concerns, he is steadfast in his refusal.Which of the following is the most appropriate screening test for this patient?A. Circulating methylated SEPT9 DNA testB. CT colonographyC. Fecal immunochemical testD. Sensitive guaiac-based fecal occult blood testCorrect AnswerC. Fecal immunochemical testEducational ObjectiveScreen for colorectal cancer in an average-risk patient with fecal immunochemical testing.CritiqueThe most appropriate screening test for this patient is a fecal immunochemical test (FIT). The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in asymptomatic adults aged 50 to 75 years. For patients with average risk for colorectal cancer, several screening strategies are available, including fecal occult blood testing, direct endoscopic visualization, radiologic examination, and testing the blood for molecular markers of cancer. There is little head-to-head comparative evidence that any one recommended screening modality provides a greater benefit than the others. In addition, despite unequivocal evidence that colon cancer screening reduces mortality, an estimated one in three U.S. adults who are eligible for colon cancer screening has not been screened. Therefore, the USPSTF supports using the test that is most likely to result in completion of screening. Test selection should be guided by evidence, patient preferences, and local availability. Two fecal blood detection tests are available: a sensitive guaiac-based fecal occult blood test (gFOBT) and an FIT that uses antibodies to detect human hemoglobin. Sensitive gFOBT requires dietary restriction in order to reduce false-positive results, whereas FIT does not. The FDA has approved a third stool-based screening test that is combined with FIT and detects cancer DNA in the stool (the multitargeted stool DNA test). Mortality data for this screening strategy are not available. Because this patient would prefer not to modify his diet, FIT is the most appropriate screening option.The plasma circulating methylated SEPT9 DNA test is an FDA-approved colorectal cancer screening test that holds promise, as blood tests may result in increased screening adherence. However, its sensitivity for detecting colorectal cancer is suboptimal at 48%, and mortality data are lacking.Endoscopic tests include flexible sigmoidoscopy and colonoscopy. The mortality benefit of flexible sigmoidoscopy is limited to cancers of the distal bowel. Colonoscopy can visualize the entire bowel but requires colon preparation, which can be a barrier to completing the study. CT colonography is a radiologic technique that also requires colon preparation, which this patient has refused.Major guidelines differ in their recommendations regarding screening strategy and frequency. The 2016 USPSTF guideline recommends sensitive gFOBT or FIT annually or multitargeted stool DNA testing every 3 years. Flexible sigmoidoscopy is recommended every 5 years, but if combined with FIT (or possibly gFOBT), the interval can be increased to every 10 years, the same interval recommended for colonoscopy. CT colonography can be performed every 5 years.Key PointThe U.S. Preventive Services Task Force recommends screening for colorectal cancer in asymptomatic adults aged 50 to 75 years; the choice of screening test should be guided by evidence, patient preferences, and local availability.BibliographyInadomi JM. Screening for colorectal neoplasia. N Engl J Med. 2017;376:149-156. doi:10.1056/NEJMcp1512286Do 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 5 November 2019Volume 171, Issue 9Page: ED9KeywordsCancer screeningColonColonoscopyColorectal cancerColorectal cancer screeningDNADrugsFlexible sigmoidoscopyHematologic testsMortality ePublished: 5 November 2019 Issue Published: 5 November 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...