Annals for Educators - 1 September 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives1 September 2020Annals for Educators - 1 September 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202009010 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Reclaiming Our Voices as PhysiciansRestoring the Story and Creating a Valuable Clinical NoteThis important commentary highlights the limitations of today's clinical note, which is often populated by information from electronic health record templates that emphasize billing over clinical care. They are frustrating to create and read and may fail to assist in patient care. The authors contend that clinicians need to reclaim our clinical notes and suggest 2 ways to do this.Use this essay to:Ask your learners what purposes our progress notes serve.Ask your learners what aspects of other clinicians' notes they find to be helpful. Are there notes that infuriate them? Why?Do notes effectively convey thinking about the patient's condition and plans of care? Do they convey anything meaningful about the person for whom we are caring? If not, why not?Why have clinical notes become so bloated with information that is not helpful for clinical care? How does this “bloat” make it difficult to find what is important?Recall that your learners may have only ever read electronically generated progress notes with automatically populated fields. How did notes written by hand in the past differ? What was better, and what was worse?Ask what the difference is between documentation and communication. Read aloud the sample note presented on the left side of the Figure and then the one on the right side to your learners. Which note would they prefer be theirs?The authors point to changes in CMS billing requirements that offer the opportunity for clinicians to reclaim notes as tools for communication among our colleagues. Will your health system make changes to what it allows in templates to take advantage of the changes? Invite a member of your system's administration to discuss this with your team. What would your learners suggest be allowed and not allowed in the templates used to create notes?Use the On Being a Doctor essay discussed below to consider how the insertion of just a few extra words to describe the person, and not just the patient, might improve your practice of medicine. Clinical Practice PointsExtreme Risk Protection Orders in Washington. A Statewide Descriptive StudyFirearms are used in more than half of suicides and homicides. Extreme risk protection orders (ERPOs) may help prevent firearm-related injury and harm by preventing access to firearms among people who are at risk for injury to themselves or others. This statewide study evaluated the circumstances and characteristics of individuals involved in ERPOs.Use this study to:Ask your learners whether they ask about access to firearms in or around their patients' homes. Should they? Use the recent In the Clinic: Preventing Firearm-Related Death and Injury to help your learners know when and how to have such discussions. Are ERPOs an option in your state? When should your learners consider their use to help protect a patient or those around him or her? How would such action be taken? What else can be done to ensure safe storage of firearms to reduce the risk for harm?Why might ERPOs be “therapeutic” rather than “punitive”? Use the accompanying editorial to help frame your discussion. This study found that most persons whose access to firearms was restricted by the ERPO had a reported history of suicidality. Do your learners know about the increased danger of completed suicide when there is access to a firearm?How would your learners discuss options to help ensure safety with a patient who is at risk for harm to themself or others?Do your learners screen women of childbearing age for intimate partner violence as recommended by the U.S. Preventive Services Task Force? These women are at heightened risk for death by homicide when firearms are present.In the Clinic: Hepatitis C VirusHepatitis C virus (HCV) is the most common bloodborne pathogen in the United States, affecting approximately 2.4 million Americans, most of whom are unaware of their infection. Highly effective, well-tolerated therapies are now available with markedly simplified treatment algorithms. Are your learners prepared to identify HCV infection and care for their patients with it?Use this review to:Start a teaching session with multiple-choice questions. We've provided 2 below!Ask your learners who is at risk for HCV infection. Can someone cured of HCV infection be reinfected?Should we screen for HCV infection? In whom? How?Teach at the bedside! What physical examination findings suggest the presence of chronic liver disease?Why is it important to determine whether there is hepatic fibrosis or cirrhosis? What imaging and serologic markers are used in the evaluation? What is the Fibrosis-4 Index, and how is it helpful?What advice should be given to patients to avoid progression of liver disease?What vaccinations are indicated?What are the goals of antiviral treatment, and which patients are candidates?Is viral genotyping necessary? Can antiviral therapy be initiated or monitored in the primary care setting, or is referral to a specialist always required?Humanism and ProfessionalismToward Historical Accountability and Remembrance: The German Society for Internal Medicine and Its Legacies From the Nazi PastThis paper tells how, during the Nazi period, the German Society for Internal Medicine abandoned established principles, expelled respected physician colleagues, and participated in the atrocities of the Holocaust. The authors assess why it took so long for the medical society to come to terms with and reflect on its past.Use this paper to:Ask your learners what roles the medical community should play in politics.Does our profession's commitment to protect the health of patients ensure that we hold the “moral high ground”?Did your learners know that a professional physicians' organization and individual physicians played active roles in perpetrating atrocities as members of the Nazi party? Does it shock us more to learn of physicians' complicity than that of others?Why did it take so long for the German Society for Internal Medicine to face and acknowledge its Nazi past?The authors note 2 myths that delayed honest discussion of the past: the assumption that physicians' distinguished social status must have distanced them from the vulgar and brutal Nazi regime, and the belief that physicians had no choice but to cooperate with the Nazi regime. Do your learners believe we might be deceived by these same myths if faced with moral challenges again?Why is it important to know about this history? Could it happen again? If so, what must we do to guard against it?On Being a Doctor: Chekhov on EpicDr. Durso wonders whether he is more “in the moment” when he asks himself: What is critical to knowing this patient? What is essential to communicate?Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have ever read a note that described the person and not just the patient's medical facts.The author reflects that slowing down to write just a few extra words about the person in the patient not only helps him to connect with the patient but also helps his diagnostic skills. Why might that be?Teach at the bedside! Insist that every presentation of a patient's history and daily progress include some nonmedical descriptor and/or story. Do it for both inpatients and outpatients.MKSAP 18 Question 1A 61-year-old woman is evaluated for joint pain, a rash on her legs, and weakness. She has chronic genotype 1 hepatitis C viral infection. She takes no medication.On physical examination, vital signs are normal. The lower extremities are shown. No evidence of muscle weakness, joint swelling or warmth is noted on musculoskeletal exam. The liver edge is palpable at the costal margin. The remainder of the physical examination is unremarkable.Laboratory values:Complete blood countNormalAlanine aminotransferase112 U/LAspartate aminotransferase84 U/LTotal bilirubin1 mg/dL (17.1 µmol/L)CreatinineNormalUrinalysisNormalWhich of the following is the most appropriate treatment?A. CyclophosphamideB. GlucocorticoidsC. Ledipasvir and sofosbuvirD. Pegylated interferon and ribavirinE. RituximabCorrect AnswerC. Ledipasvir and sofosbuvirEducational ObjectiveTreat cryoglobulinemia in a patient with chronic hepatitis C viral infection.CritiqueA combination of ledipasvir and sofosbuvir is the most appropriate treatment for this patient. The patient has Meltzer triad—consisting of asthenia, arthralgia, and palpable purpura—which is the classic presentation of type II mixed cryoglobulinemia, a vasculitis that most often arises in the context of chronic hepatitis C virus (HCV) infection. Meltzer triad is seen in less than 30% of patients, but nearly all patients with type II cryoglobulinemia develop cutaneous findings, as seen in this patient. Other findings may include peripheral neuropathy; membranoproliferative glomerulonephritis; and pulmonary, central nervous system, or gastrointestinal vasculitis. Urinalysis may show dysmorphic erythrocytes and proteinuria, which are features of glomerulonephritis, but this patient shows no evidence of kidney involvement or other end-organ damage. The best initial treatment for a mild presentation of mixed cryoglobulinemia arising from chronic HCV infection is to treat and eradicate HCV with sofosbuvir-ledipasvir. Other direct-acting antiviral agents that could be used interchangeably to treat genotype 1 HCV include grazoprevir-elbasvir; paritaprevir-ritonavir, ombitasvir, and dasabuvir; glecaprevir-pibrentasvir; sofosbuvir-daclatasvir; and sofosbuvir-velpatasvir. It is expected that other combinations of direct-acting antivirals will be developed. Treatment of HCV infection with direct-acting antiviral combinations results in a sustained virologic response (cure) in more than 90% of patients, even in those who were previously and unsuccessfully treated with pegylated interferon and ribavirin. In approximately 90% of cases, eradication of HCV leads to resolution of the mixed cryoglobulinemia.Most of the data pertaining to the treatment of HCV infection in patients with mixed cryoglobulinemia involve treatment with pegylated interferon and ribavirin. However, pegylated interferon and ribavirin are no longer recommended for treatment of HCV infection due to adverse effects and lower efficacy compared to interferon-free, direct-acting antiviral therapy.For severe end-organ damage from mixed cryoglobulinemia, including kidney failure, gastrointestinal vasculitis, rapidly progressive neuropathy, pulmonary or central nervous system vasculitis, or heart failure, rituximab is a first-line agent and may be used with pulse-dose glucocorticoids. However, this patient has mild manifestations of mixed cryoglobulinemia and, therefore, does not require immunosuppressive therapy with rituximab, cyclophosphamide, or glucocorticoids.Key PointMixed cryoglobulinemia arising from chronic hepatitis C viral infection resolves after treatment and eradication of the virus.BibliographyDammacco F, Sansonno D. Therapy for hepatitis C virus-related cryoglobulinemic vasculitis. N Engl J Med. 2013;369:1035-45. doi:10.1056/NEJMra1208642MKSAP 18 Question 2A 62-year-old woman is evaluated during a follow-up appointment 12 weeks after she completed treatment for genotype 1a hepatitis C virus (HCV) infection. She has Child–Turcotte–Pugh Class A cirrhosis (well-compensated cirrhosis). Small esophageal varices were noted on upper endoscopy 1 year earlier.On physical examination, vital signs are normal; BMI is 26. Palmar erythema, spider angiomata over the chest, a firm liver edge 3 cm below the costal margin, and a palpable spleen tip are noted. The examination is otherwise normal.Her HCV RNA is undetectable and her calculated Model for End-Stage Liver Disease score is 8.Which of the following is the most appropriate management for this patient?A. Liver transplantation evaluationB. Measurement of HCV RNA in 12 weeksC. Ultrasonography of the liver every 6 monthsD. Upper endoscopyCorrect AnswerC. Ultrasonography of the liver every 6 monthsEducational ObjectiveScreen for hepatocellular carcinoma in a patient with cirrhosis.CritiqueThe most appropriate management for this patient is ultrasonography screening for hepatocellular carcinoma every 6 months. Liver diseases associated with the highest risk for hepatocellular carcinoma are hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and hemochromatosis. Approximately 80% of hepatocellular carcinoma occurs in patients with cirrhosis, but it can develop in the absence of cirrhosis in patients with HBV infection. All patients with cirrhosis from any cause should undergo liver ultrasonography every 6 months with or without α-fetoprotein measurement. Patients with HCV infection who achieve sustained virologic response (which is synonymous with virologic cure) have a reduced risk for hepatocellular carcinoma. Regardless of virologic response, surveillance is recommended for patients with stage 3 or stage 4 fibrosis (stage 4 fibrosis signifies cirrhosis, as found in this patient).Liver transplantation evaluation is not indicated for this patient with Child–Turcotte–Pugh Class A cirrhosis and a very low Model for End-Stage Liver Disease (MELD) score. Indications for liver transplantation are a MELD score of at least 15 or decompensated cirrhosis. Virologic cure in patients with compensated cirrhosis prevents decompensation. However, development of hepatocellular carcinoma would be a reason for referral for liver transplantation evaluation.Measuring HCV RNA again in 12 weeks is not indicated because this patient has achieved virologic cure with undetectable HCV RNA at week 12 after completing treatment for HCV infection. Large studies have demonstrated 98% to 99% concordance between sustained virologic response at 12 and at 24 weeks. Therefore, sustained virologic response at 12 weeks is considered to be consistent with virologic cure, and additional testing is unnecessary.Upper endoscopy is not necessary because the patient had an upper endoscopy 1 year ago. The standard follow-up interval for small varices in a patient who is not taking a nonselective β-blocker is 2 years.Key PointPatients with hepatitis C viral infection who achieve sustained virologic response have a reduced risk for hepatocellular carcinoma; regardless of virologic response, ultrasonographic surveillance is recommended for patients with stage 3 or stage 4 fibrosis.BibliographyMorgan RL, Baack B, Smith BD, Yartel A, Pitasi M, Falck-Ytter Y. Eradication of hepatitis C virus infection and the development of hepatocellular carcinoma: a meta-analysis of observational studies. Ann Intern Med. 2013;158:329-37.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 1 September 2020Volume 173, Issue 5Page: ED5KeywordsCirrhosisFirearm injuriesHepatitis AHepatitis C virusHepatocellular carcinomaLiver diseasesLiver transplantationRNAUltrasound imagingVasculitis ePublished: 1 September 2020 Issue Published: 1 September 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...