Annals for Educators - 6 December 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives6 December 2016Annals for Educators - 6 December 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201612060 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAcupuncture for Chronic Severe Functional Constipation. A Randomized TrialChronic severe functional constipation is a common problem. Preliminary studies have suggested that acupuncture might be effective. This large randomized, controlled trial assessed acupuncture for treatment of this problem.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to define chronic constipation. See the definition the investigators used for “severe chronic constipation.”Ask how constipation should be evaluated. What are the common causes? Less common causes? When should tests be performed, and which ones? Use the recent In the Clinic: Constipation for more questions around which to build a teaching session.What nonpharmacologic and pharmacologic interventions should be considered?What effect does chronic constipation have on a patient's quality of life? Might it be a major medical problem? Do we pay enough attention to it?Review the results of this randomized trial. Would your learners consider referring patients for a trial of acupuncture? Do they think patients would adhere to the intervention schedule required in this study? What more needs to be known about the potential of this intervention?Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ DonationClinical decision rules known as termination-of-resuscitation rules help to identify cases where further resuscitation of patients with out-of-hospital cardiac arrest (OHCA) is futile. In this retrospective assessment using OHCA data from 2 registries and 1 trial, the authors evaluated 3 objective criteria for identifying patients with OHCA and no chance of survival to enable prompt orientation toward organ donation.Use this study to:Ask your learners how they decide whether to cease cardiopulmonary resuscitation (CPR) after initial efforts have not been successful.Is there a uniform approach to making these decisions? If not, is that problematic? Can there be a uniform approach?Have your learners ever stepped out from “a code” to inform the patient's family members of what is going on? How have they communicated the possible—and likely—outcomes? Have they ever asked family if CPR should be terminated?Studies have suggested that some family members “benefit” from observing a code performed on their loved one. Is that done at your hospital? How might it be helpful to the family? How might it be harmful? How might it make the physicians feel? Is that important?The accompanying editorial discusses the problems faced in deciding if and when resuscitative efforts should be redirected toward the goal of preserving organs for donation. What ethical problems might such decisions pose for physicians involved in performing CPR on a patient? How would one balance the ethical obligations to help the patient with obligations to help society? How would this be discussed with a patient's family?Preoperative Evaluation for Noncardiac SurgeryAlthough every surgical procedure carries some degree of risk, risk is usually relatively low. The goal of preoperative risk assessment is to identify procedure and patient factors that significantly elevate the risk for complications. Careful, directed preoperative evaluation enables implementation of strategies to mitigate risk. Are your learners prepared to provide an appropriate evaluation and recommendations?Use this review to:Ask your learners what variables must be considered when evaluating a patient for noncardiac surgery. What information do they need to know about the planned procedure?Do your learners ask patients about a personal or family history of difficulty with hemostasis? A history of malignant hyperthermia with exposure to anesthetics? Should they be asking about these issues?Ask your learners whether they routinely order preoperative chest radiography. An ECG? Labs? Should they be? When and what laboratory tests are needed? What should you do if a surgeon insists on a study that is not indicated?Use the multiple-choice questions provided at the end to help break up a teaching session and introduce new topics for discussion. Be sure to log on and enter your answers to earn CME credit for yourself!Use the already prepared teaching slides to help run a teaching session.Practicing MedicineAllocation of Physician Time in Ambulatory Practice: A Time and Motion Study in Four SpecialtiesOn Being a Doctor: Coeur d’AleneMany physicians express dissatisfaction with how they spend their patient care time, but data on the specific proportions of time devoted to various activities have been lacking. The first article is a time and motion study that assessed time spent on specific patient care–related activities (such as direct clinical face-to-face time and electronic health record and desk work) by physicians in family medicine, internal medicine, cardiology, and orthopedics. The second article is an On Being a Doctor essay that describes the experience of an older doctor teaching a new doctor a not-so-new trick.Use these papers to:Ask your learners whether the results of the research study surprise them. Do they surprise you or your colleagues in practice?Are your trainees concerned about what practicing medicine will be like on a day-to-day basis after residency? Do they think the settings in which the physicians who participated in this study are representative of those in which they might find themselves?Does your health system use medical scribes? What do your learners think can be done to address the problems identified in this study? Use the accompanying editorial to help frame your discussion.Now read the On Being a Doctor essay—or listen to the audio recording available online. Do your learners think that familiarity with using an EHR was the only reason for the differences in styles between Drs. Weinberg and Manning?Invite several physicians who are good role models to participate in a panel discussion. Try to include a range of practices (primary care or subspecialty) and years since the completion of training. How do they spend their time? What are the most rewarding and most frustrating aspects of their daily routines? What questions do your learners want to ask?Humanism and ProfessionalismOn Being a Doctor: The Law of Unintended ConsequencesDr. Haber's journey with a patient following a procedure-related complication reminds him of the importance of being present for your patient when that is all you can do.Use this essay to:Listen to an audio recording with your learners, read by Dr. Michael LaCombe.Ask your learners what they have done when one of their patients has had a treatment-related complication. How did they explain what happened?Have your learners ever continued to “follow” a patient who is no longer on their service? Have any of the patients on your service been transferred to the ICU? Has your team gone to see how the patient is doing and/or to check on his or her family? Consider making such a trip to ask how things are going, how the patient and family are feeling, and if they can help in some way even though they are not the patient's doctors now. How did doing so make them feel?Do they think doctors sometime “run” from patients in whom a complication of treatment has occurred?MKSAP 17 QuestionA 52-year-old man is evaluated in follow-up for a large, inoperable pelvic osteosarcoma that is currently being treated palliatively. He reports increasingly worsening pelvic and abdominal pain. His pain had previously been controlled with as-needed nonopioid analgesics, although he is experiencing increased pain with tumor growth. Except for pain, he has no other symptoms. Medical history is otherwise unremarkable, and his current medications are as-needed naproxen and acetaminophen.On physical examination, the patient appears to be in mild painful distress. Vital signs are normal. BMI is 22. There is a mass in the right pelvis that is moderately tender to palpation. The remainder of the examination is unremarkable.Scheduled oral hydromorphone is prescribed for pain control.Which of the following daily adjunctive treatments should be given to this patient?A. DocusateB. Fiber supplementationC. MethylnaltrexoneD. SennaCorrect AnswerD. SennaEducational ObjectiveManage the gastrointestinal side effects of opioid therapy.CritiqueThe most appropriate management of this patient is to add a scheduled stimulant laxative, such as senna. Opioid-induced constipation is nearly universal in patients on regularly scheduled opioid therapy. Unlike other side effects of opioid medications such as nausea or somnolence, tolerance to constipation does not develop over time. Therefore, all patients on scheduled opioids should be prescribed a scheduled stimulant laxative, such as senna or bisacodyl. If this therapy does not adequately control opioid-associated constipation, osmotic agents (polyethylene glycol powder, sorbitol, lactulose) can be added.Stool softeners, such as docusate, are inadequate to manage opioid-induced constipation when given alone. However, stool softeners may be given along with a stimulant laxative to further aid in preventing constipation in patients on chronic opioid therapy. Similarly, fiber supplements or other bulking agents are ineffective in managing opioid-induced constipation.Methylnaltrexone, an injectable peripheral opioid antagonist, is very effective in treating opioid-induced constipation without adversely affecting analgesia. However, it is reserved for opioid-induced constipation that has failed to respond to an aggressive laxative regimen, and as such, it is considered second-line therapy. This patient has not had a trial of aggressive laxative therapy; therefore, methylnaltrexone is not yet indicated.Key PointAll patients on scheduled opioid therapy should be prescribed a scheduled stimulant laxative.BibliographySwetz KM, Kamal AH. In the clinic. Palliative care. Ann Intern Med. 2012;156:ITC2-1-16. doi:10.7326/0003-4819-156-3-201202070-01002Do 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 6 December 2016Volume 165, Issue 11Page: ED11KeywordsAcupunctureCardiopulmonary resuscitationConstipationElectronic medical recordsGraduate medical educationOpioidsSurgeonsSurgeryThoraxVital signs ePublished: 6 December 2016 Issue Published: 6 December 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...