Online Learning and the Tree-in-bud Sign

Working in a Tuberculosis (TB) clinic I saw a patient who had a history of active TB and received a full course of treatment several years ago. She was presenting with new onset hemoptysis. Her CT scan showed abnormalities in the right middle lobe and the report described evidence of the "Tree-in-bud" sign. I had never heard of this before. It presented an opportunity to learn something new. There is usually a few minutes between cases to look things up before reviewing with the preceptor. I did a quick online search and discovered a blog called Radiopaedia, a wiki type resource that provides well cited explanations around radiographic signs with corresponding images. It contained an excellent article on the tree-in-bud sign. I learned that the sign refers to a pattern on CT of multiple areas of centrilobular nodules with a linear branching pattern, resulting in the appearance of a small budding tree. This sign can occur in many different conditions, but the physiologic principles underlying the presentation are usually endobronchial spread of infection or infiltration of the pulmonary arteries and interstitium. Some etiologies include: infective bronchiolitis (ie. from TB), cystic fibrosis, connective tissue disorders (rheumatoid arthritis and Sjogrens syndrome), obstruction/bronchiolitis, and neoplasms (bronchioalveolar carcinoma, lymphoma). One possible cause is atypical mycobacterial infections such as Mycobacterium avium complex. This was our main suspicion, as it fit with continued CT abnormalities and symptoms despite a full treatment for TB. This experience taught me the value of online medical blogs as learning resources. Certainly they are no substitute for peer-reviewed literature. However they are excellent starting points for a trainee to develop a basic understanding of a concept in the middle of a busy day. Radiopaedia was very useful as it gave me a brief overview of the concepts with images to solidify my understanding of the radiographic features. Additionally, it provided detailed references. This allowed me to use the online article as a jumping off point for my own studying of the primary literature.  I believe that when used correctly, community built medical wikis and blogs like Radiopaedia occupy a vital place in the heirarchy of medical literature. As the body of medical knowledge increases, I believe these resources will have a bigger and bigger role in shaping medical education.

- MH

Grounding your teaching

This past week I've been brainstorming about the CEEP teaching session, thinking about 
two things in particular:

1. What information will be high-yield for the clerks (including my classmates who will be 

starting residency in a few months), and

2. What is it that makes a teaching session good?

Over clerkship we've had countless clinical teaching sessions put on by residents, staff, and our own peers. When I think back to those presentations that really hit home (or even register more than once in my memory), a few key features come to mind:

1. Starting with a story

Countless medical lectures have taught us that having a patient in front of us sharing their unique story about how they became sick, and their experience with their illness is often far more impactful and motivating in furthering our own knowledge, than simply picking up a textbook and diving into a particular topic. A story can often situate you quickly into a particular environment, allowing you to build a an understanding of the clinical encounter, and begin to lay the foundation for your learning about a particular case. In fact, I've found it especially helpful when teachers periodically "zoom out" to reconnect to the initial case, ensuring that the group still understands the relevance of the Hx/Px/Invx to this patient's presentation.

2. Make it relevant (give the people what they want!)

Another good motivator is a known gap - for instance, knowing that you always wonder whether the patient you're admitting - who has diabetes - should have their medication adjusted. I remember a particularly useful review session on hypercalcemia, where the presenting resident messaged our cohort before the session, and asked everyone to send in specific questions they had about the topic. This not only helped to engage us as learners in the topic, but also made it especially relevant, creating space to answer those questions we had had overnight on-call, or address concepts we had failed to really get our heads around, despite prioir attempts. Similar to highlighting a patient story, it can be just as useful to frame the approach around common questions we as trainees pose to ourselves, colleagues, and supervisors when working through a given clinical problem. 

3. Provide clinical pearls

When working through comprehensive approaches, DDx, and management plans, it can be easy to get lost in the forest of information. To ensure you still get some use out of the session, many staff will anchor your attention in a few key clinical pearls about the case - when this is done well (and throughout a given presentation), it can also help learners further build their understanding around these key features. In addition to promoting gross understanding, identifying clinical pearls can also serve as an opportunity to review important patient safety items, which can increase the confidence of more junior trainees who may have reservations about particular clinical entities for fear of not being able to care for patients safely.

4. Connect to useful resources/situate in real clinical setting

The last item I'll discuss involves providing learners with tools to simulate engagement in their real clinical environment, with the aim of developing skills, and making it that much easier for trainees to situate themselves in their role that next time they have a patient with _x_.  Recently we had a seminar where we had the chance to practice filling out ODSP forms; this served to not only familiarize our cohort with the form itself, but allowed us to envision that particular clinical encounter, and what we would need to discuss with our patients to help address this important piece of their care. One of the topics I'm considering for my presentation involves in-hospital diabetes management, and over the weekend I found helpful flow sheets (published online) that I could see myself making use of on the wards, as an adjunct to my own management plan. Providing these tools in your session allows learners to walk away with a sense of how they might actually operationalize their plan for a given patient. 

Reflecting on these items has given me some food for thought about how I'll approach my own presentation this week - over the next few days, I'm looking forward to briefly scanning the literature for other tips and tricks, as well as checking in with my colleagues on what works to them, to try to make the session as worthwhile as possible for the third and fourth year clerks. 

-AS

Under pressure

This week in Cardiology clinic I met a patient with who had been diagnosed with pulmonary hypertension. During his appointment we reviewed his echocardiogram, noting some tricuspid regurgitation, an elevated RVSP, and some other findings of note. As he and I read through the report, I began to imagine his heart - the right ventricle perhaps larger than most, after years of contracting against elevated pulmonary pressures. I thought back to maneuvers we were taught in Year 1 - feeling for things like thrills and heaves - as I rested my palm gently on his chest, finding a suggestive thump. I scanned his neck and ankles, and listened to his lungs for extra fluid before I went to review with my staff. Together she and I pushed my initial exam musings further, explicitly noting the pathophysiologic changes we expected to see in pulmonary hypertension - for example, considering the implications of a loud S2 - before returning to the examination room. At the bedside, we confirmed my initial findings, and tuned our ears carefully to characterize the quality of his second heart sound (which in fact, was quite prominent, even at the apex). On reflection, I was glad to have this opportunity to meet this patient, and develop my skills in bringing together (and making sense of) my history, exam, and investigations (in this case, echocardiogram) for pulmonary hypertension. It was incredibly helpful to then review my exam, describe my rationale for the different signs, and stretch my assessment further to look for other findings. Finally, I was glad to be able to practice honing my skills in detecting these findings, with feedback from my staff in real-time - I think this teaching will be very helpful in the coming month (and year) attending to other patients, and further refining my assessments.

-AS

A Case of Clubbing

I saw a patient in the rapid referral GIM clinic this patient was referred for digital clubbing. He was a younger patient who had never been seriously ill. He mentioned in his past he had been worked up for a "leaky valve". Reviewing the chart showed he had mild aortic insufficiency. During his current workup he had seen a cardiologist who did not believe that this issue would be able to explain his symptoms. The patient felt well and had no symptoms he could mention, but told me that his nails had visibly changed shape in the past few months. His main concern was curiosity about what was going on and worry about possible serious issues. I began my physical exam, and realized that while I had been exposed to clubbing as a concept, my knowledge base was not deep in this area. I was able to appreciate an abnormality in the morphology of the patients nails, but didn't have a firm grasp of definitive physical exam maneuvers to rule in or rule out true clubbing. I checked for the Schamroth Sign (which was negative), but not much beyond that. I brought this up to my preceptor who I was glad helped point me to the JAMA Rational Clinical Exam article on clubbing. I was surprised to learn that there is no gold standard test for clubbing, and that the diagnosis is made mostly on clinical exam with techniques that are not very well established. Additionally, studies have shown that interobserver agreement is only fair to moderate. One of the most helpful measures is the phalangeal depth ratio between the distal phanalgeal depth (DPD) and the interphalangeal depth (IPD) which in disease free populations rarely exceeds 1.0. This is best measured with calipers - if there are no calipers reversal of the usual IPD>DPD to IPD<DPD can be useful. Another useful measure is the nail-fold angle, which rarely exceeds 180 degrees in disease free subjects. I learned that clubbing can be a manifestation of significant disease (including cardiac, pulmonary, and various malignancies) so despite the difficulties establishing definitive physical exam criteria it is an important finding to look for. I appreciated this opportunity to develop my physical exam skills and engage in point-of-care learning during this encounter in the clinic.

- MH

Alpha-1-antitrypsin deficiency

Today in the Airways and Asthma Clinic I had the opportunity to meet a number of patients with known or suspected alpha-1-antitrypsin deficiency - and with this, review some important patterns of inheritance relevant to these patients and their families. Unlike Gregor Mendel's peas, in which one allele (the dominant allele) dictates the phenotype, alpha-1-antitrypsin deficiency displays a pattern of co-dominance, in which both alleles are expressed simultaneously. In the case of alpha-1-antitrypsin deficiency, you can be unaffected (MM) (~98% of the population), a carrier (MZ), or an affected homozygote (ZZ). In patients with the PI**ZZ genotype, there is impairment in both genes responsible for producing the alpha-1-antitrypsin protein, a protein that is important in maintaining normal lung structure and function. As a result we often see early onset emphysema with little-no smoking history, and these patients are at a higher risk for cirrhosis of the liver (where the dysfunctional protein can accumulate). Patient who are carriers (MZ) have one functional allele and one mutant allele - therefore they make a little less of the alpha-1-antitrypsin protein. Today we met a patient who had an abnormal alpha-1-antitrypsin level, with no evidence of respiratory disease; for this reason and given her family history, we suspected she was an MZ genotype, or a carrier. Armed with this knowledge, we were able to advise her on implications for her own health, and provide counseling around approaching genetic testing for her family. I think my last experience providing genetic counseling was during a seminar in my second year of medical school (i.e. not a real clinical encounter), and I was so grateful to be able to step back with my attending staff and consider not only the genetics involved in this particular disorder, but also to appreciate the public perceptions around heritable disease, and approach counseling of this patient in a sensitive, and pragmatic fashion. I was also glad to have the opportunity to build on this counseling throughout the day, meeting other patients with carrier status, and provide insights about their lung and liver health in clear and simple terms. By taking the opportunity early in the day to sit down with my staff, and really understand this disorder, and model discussions around disease and inheritance with patients, I was able to bolster my own learning, and confidence in this particular clinical setting. 

-AS

Efficiency vs. Learning in the TB Clinic

In TB clinic this morning I saw several patients referred for abnormal tuberculin skin tests. During these visits I asked about all of the various risk factors that would make it more or less likely for them to truly have TB, given the positive results. The clinic is highly organized and has clearly worked on improving efficiency in patient flow. What made my morning easier was a prepared template of key questions. These questions helped me organize my history taking, physical exam, and considerations of investigations. I found it to be an excellent tool to help me be functional in the clinic and contribute without much experience. It is also a way to standardize patient encounters in a clinic where staff and learners rotate through. I ended up taking the template home as a study tool. Reflecting on the clinic I thought about the balance between efficiency and learning during medical training. Set templates clearly can help streamline clinical encounters, however I see how they might take the onus off of the student to learn for themselves. As I move forward in this clinic and beyond, I will strive to not use set encounter templates as crutches, rather to leverage them as tools in my own learning process. I have already seen how reviewing the template as a guide in my own studying, rather than a substitute for my own studying provides a much richer learning experience. 

- MH

Aortic Stenosis

In Rapid Referral Clinic this week we had a patient presenting with worsening pedal edema, our differential diagnosis including her short-course of prednisone (following an asthma exacerbation), and a possible mild exacerbation of her congestive heart failure. 

Of note in her past medical history, she also had moderate aortic stenosis, for which she was followed by a Cardiologist. 

During my focused assessment, I spent most of the time characterizing her present symptoms in relation to her heart failure, and conducting a complete volume assessment. When listening to her heart, I noted her Grade 3/6 systolic ejection murmur, loudest over the right sternal border.  Upon completion of the exam, I reviewed the case with my staff, and we returned to the clinic room to meet with the patient. My staff introduced himself and asked a few questions, and then pulled out his stethoscope, placing it gently over the patient's right clavicle. As he moved to her carotid artery, distant memories of exam maneuvers floated into my mind. I took out my own stethoscope, to listen once again over her upper sternal borders, and followed my staff in placing my hands over her brachial and radial arteries, closing my eyes and holding my breath to hone in on the subtle delay between the pulses.   

After the appointment, we sat down together to review the clinical approach to aortic stenosis, an approach I've worked through a few times in the last two years, but often have to return to to recall the specific exam maneuvers (and the significance of each). When it comes to aortic stenosis (and valve diseases generally), I feel confident in my ability to think through the pathophysiology and symptomatology of the disease (i.e. ideas about forward flow and perfusion, and back flow, remodeling, and ultimate congestion); over this past year I've worked to try and relate these processes to physical exam findings, and even more so, discern which exam findings are the most pertinent in evaluation (which has necessitated continued review on my part as a trainee). 

Etchells et al. (1998) provide a straightforward approach to evaluating suspected aortic stenosis on history and exam; for the exam, they ask a few questions:

1. Does the patient have a systolic ejection murmur that radiates to the right clavicle?

If no, chances are this patient does not have moderate-severe aortic stenosis (LR 0.1).

If yes, we look for a few other pertinent findings: 

- Is the murmur heard loudest over the right upper sternal border?
- Is the second heart sound diminished?
- Is the carotid pulse weaker than expected?
- Is the carotid upstroke delayed?

3-4 positive findings yield a likelihood ratio of 40, for a diagnosis of moderate-severe aortic stenosis.
0-2 findings = indeterminate (LR 1.76). 

In my most recent review of the clinical exam guidelines, I found it particularly helpful to understand the details of how to perform specific maneuvers; for instance, listening for murmurs over the clavicle, with practical tips on how to alter your approach for different patients (i.e. in thinner patients, using the bell instead of the diaphragm, etc.)   

I was glad to have this opportunity to review the clinical examination for aortic stenosis, and also prompt further reading on how best to follow our patients, reduce risk and prescribe appropriately given different clinical stages, and when to consider surgical management.  

-AS

Link to publication (Etchells et al. 1998): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1500900/ 
  

Reflections on Narrative Medicine

This past week my classmates and I had the opportunity to join a second-year Portfolio session (a recurring group session focused on reflective practice), focused on preparing for clerkship and beyond. My role as a fourth-year student was to share my own reflections on clerkship (and residency applications), considering what I would write in a letter to my first or second year self. This concept of narrative medicine has been on my mind a lot lately, especially in the context of reflecting on my experiences (constantly!) as I applied to residency. In addition to helping with residency preparation and decision-making, Portfolio has often served as a vehicle for discussing challenging situations throughout medical school, particularly through group discussion (more so than the written reflection we are asked to provide, in my experience). These sessions also create a space to engage in shared reflection with classmates, and hopefully develop some insights for practice. At a more basic level, Portfolio lets you catch up with friends. Commiserate about the challenges of a particular rotation. Feel good about each other's moments of inspiration and clarity, after a long day.  Portfolio serves a lot of roles - but what do we know about its role in clinical practice? And what does reflecting really mean? And what is the use of formulaic structure in these reflections (a challenge I faced during the last year)?

In a brief review of the literature, a few conclusions have been made regarding reflective practice in medicine. A review by Mann et al. (2009) suggests reflective practice may be most useful as a learning strategy, with some correlations between iterative reflections, and deeper learning and understanding of clinical knowledge and skills. Other studies in their review supported the practice of group reflection, with strengths in offering multiple perspectives from which to view clinical dilemmas, and brainstorm solutions; this collaborative model is something we've employed during each portfolio session over the last few years, with similar positive results. Regarding the hypothesis that reflective practice increases overall competence in care, the authors found no evidence; however, they were encouraging of future research into this area, given the existence of work suggesting benefits in learning (for instance) (which may indirectly effect overall competence).

Regarding assessment of learners in reflective practice, Wald et al. (2012) built a rubric ("REFLECT") to guide review and feedback for written reflections from trainees; interestingly, the authors made clear recommendations against employment of this rubric for summative evaluation, for fear of inadvertently encouraging a formulaic approach to reflection, and diminished reflective capacity.  However, this idea of assessment, and perceived value in trainees adhering to specific guidelines and outputs in their reflection has been discussed elsewhere in the literature, and in our own curriculum. Reflecting on these studies, and in my own experiences struggling with balancing my own expression of experience and learning (while also adhering to the prescribed goals and aims of the practice), it is evident that it may not be clear at present how to best approach evaluation, and more broadly, how to best support trainees in conducting a process of thorough and meaningful reflection in clerkship and in residency.  

This quick review answered some (but not all) of my questions about narrative medicine and reflective practice; I'm looking forward to spending the next few weeks reading more, and discussing these ideas with my colleagues and staff (and looking ahead on how I aim to build these strategies into my practice as a future resident).

(1) K. Mann, J. Gordon, and A. MacLeod. (2009) Reflection and reflective practice in health professions education: a systematic review. Adv in Health Sci Educ, 14:595–621. DOI 10.1007/s10459-007-9090-2

(2) H. Wald, J. Borkan, J. Taylor, D. Anthony, and S. Reis. (2012) Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for Assessing Reflective Writing. Acad Med, 2012;87:41–50. DOI 10.1097/ACM.0b013e31823b55fa

-AS

Kerion in the Dermatology Clinic

I had the opportunity to work in a dermatology clinic the other day. We saw a young patient presenting with scalp swelling. She had no hair loss but described a lot of scalp discomfort with occasional purulent discharge. On physical exam I saw something I had never seen before. Her entire scalp was boggy and tender. Notably she had a history as a child of a similar issue that doctors told them was due to mold. With no inkling as to a differential diagnosis I presented to my supervisor. I rested on first principles and simply described what I had seen. My supervisor was able to quickly identify the likelihood of this being a kerion, a fungal abscess. We prescribed the patient some oral antifungals and reassured her that this would most likely fully treat the condition. This experience taught me the value of solid fundamentals in physical exam skills and how to describe them. These allowed me to properly convey the salient information to my supervisor even though I didn't have a unifying diagnosis in mind at the time.

- MH

Progressive Bilateral Leg Swelling

I had the opportunity to work in the rapid assessment GIM clinic yesterday. This is a clinic for patients being discharged from the ED who are too well to stay in hospital, but unwell enough that they would benefit from prompt internal medicine follow up. I saw a gentleman who had progressive bilateral lower limb swelling that had been getting worse for several years. He had no history of heart disease and only medical comorbidities/risk factors were hypertension and dyslipidemia. His limb swelling had begun to affect his ability to walk and was generally a big burden in his life. He had been tried on Lasix with little benefit. On physical exam I found severe bilateral leg swelling with significant skin induration. The physical exam was otherwise benign, notably he did not appear volume overloaded (the JVP was not elevated), and there was no evidence of hepatomegaly or ascites. I proceeded to work through an approach I had developed for bilateral leg edema. I generally think about 3 systems: the heart, liver, and kidneys. I recommended an echocardiogram to assess for any CHF, albumin to check for liver function and as a screen for nephrotic syndrome, and a urinalysis for protein. While my staff agreed with my approach, he brought something up that had not crossed my mind: the patient had a peripheral eosinophilia and had lived in South America. He brought up the possibility of parasitic infection, specific Lymphatic Filariasis. I did some reading about this condition and it seemed like a great hypothesis and we referred the patient to the tropical diseases clinic. I was happy with my initial thought process but this experience taught me that I have a lot left to learn in developing my approach. I will appreciate having an experienced staff fill in the gaps in my learning as I move through training. This experience also reinforced the value of case based learning. Lymphatic Filariasis is not a common condition and even if the patient turns out to have something else, I will remember the entity and be motivated to study it having had to work through it with this case.

- MH

Small vessels (and big opportunities for collaboration and learning)

This morning in Dermatology clinic I witnessed a great breadth of presentations, from basal cell carcinomas quickly remedied by in-office removal, to following the regression of silvery scales of psoriasis after optimization of a patient's treatment plan. I also saw two cases of suspected vasculitis, one of which turned out to be IgA nephropathy, now requiring careful thought and continuation of management post-discharge.

To me, the vasculitides have come to epitomize those diagnoses in medicine that bring together teams of clinicians and care providers, all trying to offer their expertise in fitting together the pieces of a diagnostic puzzle, and offer insights into best practices in management and patient care. And it is in these experiences in collaborative care, that I've found opportunities for truly rich learning.

Today for instance, I sat with the senior Dermatology resident, poring over the patient's chart and work-up. We reviewed investigations initiated by the in-hospital GIM service, which were complemented by a tissue sample procured by the on-call Dermatology team, and analyzed by Pathology. In interpreting the patient's testing we reminded ourselves of the nuances of Hepatitis B serologies, discussed the merits of inflammatory markers like ESR and CRP, and learned from one of the Family Medicine residents about updates to preferred antibiotic coverage for the patient's foot wounds. We also discussed next steps, including referrals to Rheumatology and Wound Care.

This clinic experience not only gave me a (much needed) chance to substantiate my approach to vasculitides, but lent me insight into the complementary roles and insights we provide as members of distinct, but inter-related care teams. I think back to my experiences as a CC3 in a Rheumatology clinic, my weeks on General Internal Medicine, bedside teaching from a Podiatrist, and today, in the Dermatology clinic, and the skills and insights gained from looking at the same clinical entities in slightly different ways. I'm excited to take these opportunities over the next month (and as I move into residency) to better understand the pearls and priorities from various teams, to inform my own practice as a clinician.

-AS

Cardiology Clinic

I was working in a cardiology clinic this morning. We saw a patient with asymmetric septal thickening concerning for hypertrophic cardiomyopathy (HCM). I was surprised at how common this condition is. The patient was awaiting genetic testing and thankfully had minimal symptoms. I enjoyed thinking about the interesting physiologic principles relevant to the condition. For instance, the concern of outflow tract obstruction and how it can be precipitated with reductions in preload or afterload. My preceptor and I talked about the value of the physical exam to screen for this. We thought about different murmurs that can be clues. For instance a murmur of mitral regurgitation due to systolic anterior motion of the valve and/or papillary muscle displacement. Should there be outflow tract obstruction we went through the systolic murmur that could result and some maneuvers that would be clues to HOCM: improvement lifting legs when supine and improvement with clenching fists. During my physical exam I thought I heard an S4 sound (another feature consistent with HCM), I was thankful for the opportunity to have my preceptor repeat the physical exam as she agreed with me. It was the first true S4 sound I had heard and having an experienced clinician confirm the finding was critical to my learning. I will have greater confidence in my physical exam skills moving forward because of this encounter. It is a strong argument for the value of observed clinical encounters and bedside teaching.

- MH