The Practical Elements of Practice

This week I was in the General Respirology clinic and had the opportunity to see a number of patients with obstructive lung disease.  There were a variety of pathologies including asthma, chronic obstructive pulmonary disease (COPD), asthma-COPD overlap syndrome (ACOS), and alpha-1 antitrypsin (AAT) deficiency leading to COPD.  Before seeing patients, they were each evaluated in the pulmonary function lab with full pulmonary function testing (PFT’s).

As a team, we were reflecting on the fact that several patients who have never had formal PFT’s may be labelled as COPD patients.  As a team, we were discussing that it would be fruitful to have spirometry upfront when patients present to hospital in the Emergency Department with respiratory distress.  That would be feasible given that we have respiratory therapists that can perform this for us on-call.  One downside is that if spirometry is performed when patients are acutely unwell then it may not be a marker of their best performance.  However, the benefits would be that having spirometry both at the beginning of admission and after admission for comparison would aid in assessing whether there is reversibility or improvement in their lung function.  Another consequence of not having a sense of a patient’s lung function upfront is that patients may be treated for an exacerbation of COPD but may not in fact have obstructive lung disease.  The average overall cost of a severe AECOPD is $9,557 given that it includes a hospitalization. (Mittmann et al., 2008) Therefore, if we can determine with early spirometry that a patient does not truly have obstructive lung disease, this can minimize their cost of inhalers and hospitalizations.  The cost of obtaining spirometry is less than $100.  (Choosing Wisely, 2014)

On the other hand, resource management also includes being judicious when ordering tests that may be expensive when the index of suspicion of a certain pathology is low.  For example, a sleep study is an expensive test and the American Association of Sleep Medicine and the American Board of Internal Medicine released guidelines on five things to know before ordering polysomnography and for treating sleep disorders. (Choosing Wisely, 2014)

At the Yale University School of Medicine, a session in the format of Morning Report was implemented to demonstrate the costs associated with work-up of clinical cases.  (Fogerty et al., 2014) The session was found to be useful in learning the impact of medical decision-making and promoting more realistic clinical work-up.  (Fogerty et al., 2014) The importance of learning about resource management is a topic that I have had the chance to reflect on throughout my selective.  We work in a system with a finite number of resources and it essential to appropriately order tests given their cost and utility and consider such factors in addition to your clinical assessment when making decisions. 

SH

Resources:

Mittmann, N., Kuramoto, L., Seung, S.J., Haddon, J.M., Bradley- Kennedy, C. & Fitzgerald, J.M. (2008). The cost of moderate and severe COPD exacerbations to the Canadian healthcare system. Respiratory Medicine, 102, 413-421. Retrieved at http://www.resmedjournal.com/article/S0954-6111(07)00432-5/pdf

Choosing Wisely. (2014). Spirometry for Asthma. Choosing Wisely, An initiative of the ABIM Foundation. Retrieved at http://www.choosingwisely.org/patient-resources/spirometry-for-asthma/ Accessed on March 1, 2018

Robert L. Fogerty , Jason J. Heavner , John P. Moriarty , Andre N. Sofair & Grace Jenq (2014) Novel Integration of Systems-Based Practice Into Internal Medicine Residency Programs: The Interactive Cost- Awareness Resident Exercise (I-CARE), Teaching and Learning in Medicine: An International Journal, 26:1, 90-94, DOI: 10.1080/10401334.2013.857338

Choosing Wisely. (2014).  American Academy of Sleep Medicine: Five Things Physicians and Patients Should Question.  Choosing Wisely, An initiative of the ABIM Foundation. Retrieved at http://www.choosingwisely.org/societies/american-academy-of-sleep-medicine/ Accessed on March 1, 2018

Learning to be a Teacher

On Friday afternoon, I gave a 30-minute teaching session for the third-year clinical clerks (CC3’s) on blood films using four cases as a framework: Hodgkin’s lymphoma, multiple myeloma, thrombotic thrombocytopenic purpura (TTP), and acute myeloid leukemia.  My aim was to target the teaching session towards their upcoming Internal Medicine Objective Structured Clinical Examination (OSCE).  The purpose of an OSCE is to have objective criteria by which to evaluate the clinical competence of trainees and their overall interaction with patients.  It has been shown in literature that the OSCE also evaluates areas such as communication skills and being able to handle unpredictable patient interactions.  (Zayyan, 2011). In Internal Medicine clerkship, both Faculty and students have indicated that incorporation of an OSCE motivates them and provides opportunities to reflect on learning. (Cruzeiro & Bollela, 2014)

During my teaching session, to address their upcoming exam, I tried to go through Q&A in a structured format.  I asked the CC3’s a variety of sequential questions for each case such as what questions they would ask on history of presenting illness, which physical examination maneuvers would be important, investigations and interpretation of the blood film or biopsy, and what their differential diagnoses were.  One of the challenges of physical examinations is that a focused physical examination for a complaint may actually involve multiple organ systems and having an approach is important.  One of the mock cases in my teaching session was the first case on Hodgkin’s lymphoma.  In the scenario, the patient presented with a neck lump and constitutional symptoms.  We reviewed the lymph node examination and the names of the nodal regions that should be palpated as well as the concerning features.  In addition, organomegaly would be part of a focused physical examination here and this allowed us to discuss the JAMA Rational Clinical Examination for splenic enlargement.  These cases also provided us with an opportunity to revisit the pathophysiology of these disease states and how the conditions are managed.

Thinking back to some of the experiences that I have had, there are several techniques for teaching that are engaging.  I particularly enjoyed the EBM rounds that we had earlier in this selective, in which we critically analyzed a paper on edoxaban for the treatment of cancer-associated venous thromboembolism.  We split up into smaller groups within a large audience to answer a subset of questions before reconvening and sharing our analyses.  Other techniques that work well include the team-based Jeopardy at morning report, hands-on learning such as with a simulator like Harvey, and the use of online surveys (or Student Response Systems/iClickers) such as the one used in the Harm Reductions lunch-time rounds to gauge medical professionals’ opinions and practices.  There are several creative ways to engage audiences when teaching and I hope to incorporate some of these strategies next time I get to teach!

SH

Resources:

Zayyan, M. (2011). Objective Structured Clinical Examination: The Assessment of Choice. Oman Med J, 26(4): 219 – 222.

Cruzeiro, M. & V. Bollela. (2014). Faculty development of an OSCE in an internal medicine clerkship. Medical Education, 48(5): 545 – 546. DOI: 10.1111/medu.12472 

The Art of Medicine

This past Thursday I spent the day in the Dermatology Clinic.  It was a special day for rounds that occurs once a month, in which dermatologists from the hospital bring outpatients that they have been following to be reviewed by the whole team.  The cases were undifferentiated and challenging and no formal diagnosis had been made yet.  As a group of medical students, residents, and attending physicians, we moved from one room to the next to see all of the patients.  In each room, we huddled around the patient, listened to the treating physician’s summary of the case and members of the Dermatology team asked any other relevant questions on history and examined the patient.

After seeing all of the patients, we sat around a table over lunch and discussed each case in detail, creating a differential diagnosis and an appropriate management plan for each.  The purpose was to pool everyone together and hear the input and opinions of several dermatologists.  At the end, a few of the final diagnoses were still somewhat uncertain but the goal of the discussion was to ensure that any worrisome and/or common diagnoses were being considered and that the possible avenues for therapeutic intervention had been trialled.

It was a unique learning opportunity for me to hear the thought processes of the team as they made decisions.  One of the cases was challenging given that most of the patient’s symptoms had resolved and it was difficult to make an assessment.  The patient had alopecia as per a few scalp biopsies, however the hair loss pattern did not neatly fit into one of our known alopecia diagnoses.  The discussion was centred around how to prevent this from happening again given the uncertainty of the cause.  Other patients had nail changes: one case was non-uniform nail hyperpigmentation NYD which was a nuisance for the patient, but there were no concerning features on examination and not likely to be any treatments for this.   Medicine is an art and making decisions with a team can often aid in determining the extent of a work-up, solidifying a diagnosis, knowing when to refer, and knowing when to treat.

Bedside rounding is particularly useful in a field like this where much of the learning and examination is done visually.  It creates an environment to learn from each other’s experiences and improve outcomes through combined decision-making and team consensus.   (Gonzalo et al., 2013) It has been shown that on internal medicine wards, patients receiving bedside rounds prefer this method.  (Gonzalo et al., 2010) During our Dermatology team rounds, one of the patients had nail findings similar to onychogryphosis but with some differing features.  She was encouraged that we were all at the bedside trying to help figure out why this had happened.  Team rounding at the bedside not only is an important educational tool as a trainee, but it also reinforces the importance of patient-centred care in medicine.

Stay tuned for more,

SH

Resources:

Gonzalo, J. D. et al. (2013). The Value of Bedside Rounds: A Multicenter Qualitative Study. Teaching and Learning in Medicine, 25(4): 326 – 333. doi: 10.1080/10401334.2013.830514.

Gonzalo, J. D. et al. (2010). The Return of Bedside Rounds: An Educational Intervention.  J Gen Intern Med, 25(8): 792 – 798.  doi:  10.1007/s11606-010-1344-7

Transition to Residency

Transition to Residency

On Wednesday I was on the hospitalist medicine team for General Internal Medicine (GIM).  On the team, there was the attending staff, a fellow that was doing Emergency Department (ED) consults with me and ICU transfers, and another fellow rounding on the team’s inpatients. This was a unique experience for me as it was the first time that I have been involved in day-time ED consults and admissions for GIM.  It is entirely different as you have many of the day-time resources available and this changes the options you have available for patients’ disposition plans. 

One of the cases that I saw was a patient who presented with symptoms of a few days of lower limb pain.  Despite the pain, she was improving and was still ambulating.  After doing my consult, she brought up to me that she did not have coverage for hospital costs or medications.  As I was coming up with my plan before reviewing with my staff, I was thinking about how to best balance a few things: the patient’s wishes, what we think may be medically necessary, and resources.  When ordering further investigations, we thought carefully about the rationale for our tests and which ones are medically necessary and would change our management.  For example, ordering a lower leg ultrasound to rule out a deep vein thrombosis was something that was acutely relevant.  In terms of a connective disease work-up, we ordered a few higher yield investigations but an entire work-up at present was not warranted given the clinical picture.

We had one of our subspecialists see the patient and their team deemed that this was a transient episode, and we planned for her discharge from the ED.  In managing this patient throughout the day, I felt that I had a lot of resources at my disposal to make a safe discharge plan while considering her situation holistically (namely her health coverage limitations) and still ruling out worrisome causes of her presentation.  Our social worker came by to see her with regard to providing resources to cover her hospital costs.  I counselled the patient on reasons to return to the ED and gave her a list of over-the-counter pain medications that she can use (with maximum doses and side effects explained).  She had the contact information of a subspecialist in case her symptoms did not improve.

Making safe decisions with regard to admission versus discharge and counselling patients are skills that develop over time and I was afforded the opportunity to practice that during my day on hospitalist medicine.  Transitioning to residency will be challenging as we develop more autonomy and responsibility – there will be more difficult conversations and decision-making on a regular basis.  A study from UCSF’s School of Medicine, looking at their transition to residency course, showed that students found the course helpful for: recognizing unstable or sick patients, identifying help and backup, communicating effectively, teaching others, maintaining well-being, understanding resources, and carrying out daily patient care responsibilities.  (Teo et al., 2011) This highlights the importance of our current Transition to Residency course which includes lectures, rotations, and assignment thats have a large impact on preparing us for what is to come!

SH

Resources:

Teo, A. R. et al. (2011). The Key Role of a Transition Course in Preparing Medical Students for Internship.  Acad Med, 86(7): 860 – 865.

Coming full circle

Yesterday was a relatively short day. I had a half-day of clinics and spent noon teaching the GIM core CC3’s about TB. Teaching those only a year more junior in their training helped me reflect on my own path and how far I’ve come.

I remember starting my clerkship on Internal Medicine more than a year ago. It was an anxiety-provoking time knowing I was about to make the transition from a full-time learner in the classroom to health care provider on the wards. It didn’t help that every patient seemed impossibly complex and that everyone else on the team seemed to know infinitely more than I did. I remember feeling dejected and helpless at times. To compound matters, there was always the nagging reminder that I had to study for an exam at the end of the rotation. I painstakingly chipped away at the multitude of topics from various specialties within Internal Medicine. Overall, it was a difficult but highly rewarding period of my training.

When I look back on this experience, I’m grateful for the countless colleagues who spent time out of their day to ensure they passed on some small trove of knowledge. Whether it was an hour in the Simulation Lab with Harvey learning about diastolic cardiac murmurs or a 5-minute lesson about cardio-selective beta-blockers on the fly, everything helped. Today was the first time in my training where I’ve had the opportunity to pay it forward. I hope what I’ve learned about TB during this brief elective will prove helpful to others. As I’ve been encouraged by my seniors during this trying period on Internal Medicine, I told the CC3’s today that everything would be fine as long as they studied appropriately.

How strange that I’ve come full-circle just a year into my training. It makes me excited for what’s ahead!

- AX

Learn, then apply

What I love most about being a medical trainee is the abundance of learning opportunities. Enthusiastic preceptors are always passionate about creating the ideal learning environment to suit a learner’s specific interests. Even our patients are keen to teach us about their own battles with illness and will go out of their way to facilitate our training as future doctors. At times, all these experiences can be overwhelming. Today, I think I found the perfect tactic to combat this issue.

During this morning’s team huddle, our discussion centered on a patient who had developed bacteremia from recurrent UTI’s. The team had been treating her for several days using a first-line empiric agent but her symptoms were not improving. Unfortunately, the official culture and sensitivities were still pending. While the fellows and senior residents brainstormed potential differentials, my preceptor asked whether the team had examined our patient’s previous cultures. Unfortunately, we had not. Upon doing so, we quickly ascertained that urine from her previous admission grew an organism resistant to her current therapy. We immediately adjusted the patient’s antibiotic regimen.

Shortly after morning rounds, one of the residents and I were paged to see an ER consult. The patient was an elderly gentleman presenting with a presumed diagnosis of recurrent pneumonia. He was not doing well with an O2 sat of 70% on room air and a respiratory rate of 44. The patient had just been admitted 2 weeks ago for pneumonia and was sent home with a 10-day course of antibiotics. After finishing his therapy yesterday, he returned with deterioration in his clinical status. Clearly, something didn’t add up. The resident and I quickly applied the teaching point we learned during this morning’s rounds and looked up the patient’s microbiology reports during his last admission. His sputum culture had grown an organism resistant to his discharge therapy. We quickly selected an empiric antibiotic that covered this organism and started his first IV dose.

Today, one patient’s treatment failure taught us to be thorough in formulating treatment plans. This resulted in extra diligence in assessing our next patient. Applying new knowledge and skills on the go helps facilitate consolidation for medical trainees. This iterative process helps learners benefit from every learning opportunity. 
- AX

Health Promotion at every stage of the game!

I never thought there’d be much room for primary prevention in a GIM setting, whether ambulatory or ward. My rationale was that the process of engaging patients in lifestyle modifications and health promotion strategies takes time. It often requires a longitudinal therapeutic relationship and multiple visits over years to truly reinforce these topics. However, today’s events in ambulatory care clinic challenged this notion.

My last consult of the morning was a “surprise”. My preceptor quickly prepared me by stating “the patient is a young gentleman and that’s all I know. Good luck!” Mr. A was a young male in his early 20s presenting after a recent asthma exacerbation. He was accompanied by his mom during the clinic visit. Mom stated that he had “grown out” of his childhood asthma and had been symptom-free for more than 15 years before his most recent exacerbation. Notwithstanding some recreational substance use, his past medical history was fairly unremarkable. However, he drank at least 3 beers every day in addition to ½ pack per day of tobacco and routine marijuana use.

As a healthy guy who rarely saw his family physician, this recent episode of respiratory distress was particularly traumatic for him. He asked me a lot of questions about the progression of asthma and how to prevent future attacks. I spent the majority of our appointment counseling him on many aspects of primary care including the importance of smoking cessation, annual flu shots, proper inhaler techniques, and low-risk drinking guidelines. Mr. A seemed particularly engaged, probing me on medications to help him quit smoking and asking me about other inhaler delivery methods which might improve his compliance with the medications. As we hit upon each topic, it struck me how similar of a visit this might have compared to that in a family physician’s office. I’ve always thought of GIM as a tertiary subspecialty: a field where complex consults require expert eyes to examine a patient’s chart for a unifying diagnosis to help guide treatment. This visit challenged me to broaden my perspective on GIM as a holistic specialty dedicated to guiding patient care on many levels.

I envision my future career as a Family Physician but today’s lesson has helped me better understand the parallels between my area of interest and that of GIM. It’s reassuring to know another set of eyes is equally committed to engaging patients in preventative care.
-AX