Reflection on learning on ambulatory internal medicidine

March 6, 2020

Reflecting on my experiences on ambulatory internal medicine, I found it to be quite different from my clerkship experiences on the Clinical Teaching Unit (CTU). On CTU, I found that there was much more time to look up information to manage your patient compared to ambulatory clinics where the pace is much faster. I found that I had to accommodate for this by looking up patients ahead of time to prepare in order to feel comfortable in clinic. 

On CTU, there is also a sense of hierarchy as there are many different levels of learners and because of the larger team, I found it harder to be able to get one on one time with staff. I appreciated being able to work directly with my preceptors and felt that I had more supervision during my ambulatory clinics. This experience really allowed me to refine my skills in being able to take a history, physical, and coming up with my own management plans as I had could be directly observed and had time to discuss my thoughts on a case. 

I also found that I had more time to focus on the clinical aspects of patient care in ambulatory clinics compared to CTU where there are more administrative tasks to manage (e.g. consulting multiple specialties, arranging investigations, and liaising with allied health). It also allowed me to reflect on things like what happens when I discharge a patient from CTU or which patients should be sent to hypertension clinic. 

Another aspect that I enjoyed about my rotation was that my preceptors gave me opportunities to see my patients longitudinally. I had several patients that I worked up (e.g. palpitations, hypertension) and was able to see them in follow-up. This allowed me to see the impact of my management plans. I think this helps reinforce my clinical judgement and gives me the chance to recalibrate my plans for the future. 

Overall, the variety of ambulatory internal medicine and its subspecialty really gave me exposure to the breadth of internal medicine, which I think came at an appropriate time in my training to help me transition from being a medical student to a resident in the next few months. I am looking forward to continuing my training in Internal Medicine!

-JT-

Ambulatory Learning

March 6 2020

Before this selective, I had mostly experienced Internal Medicine through the Clinical Teaching Unit environment. Although the CTU setting offers a rich environment for learning and teaching, I knew the ambulatory setting had many unique opportunities for learning and wanted to experience this. After a month, this selective has not only shown me the valuable learning experiences that lie within ambulatory medicine, but has also allowed me to explore medical education research and practice my teaching skills. During these past weeks in clinic, I have been involved in cases I had never seen before, I have sharpened my ability to develop differentials, and also feel more confident in proposing management plans (even if I am wrong)!

The learning in the ambulatory setting is quite different compared to the inpatient service. On the wards, you often care for the same patients, get to know their medical history in depth, and often manage the same issues until they are safely discharged. In the clinic, you are seeing several patients in a day, who you may have never met before, often working up new issues, and following chronic issues. You need to be able to review their chart quickly and determine the reason they are being seen in clinic. In a short amount of time, you must decide if their clinical state is improved, worsened, or stable, and what your management plan will be. These assessments and decisions need to happen fairly rapidly to ensure all patients are seen in a timely manner.

This faster pace of patient care and learning was initially challenging for me. I often took a long time with patients, had difficulty expanding my differentials, and was unsure of my management plan. My preceptors allowed me to take my time and reassured me that ambulatory medicine is difficult even for Internal Medicine residents. Despite the challenges, this experience allowed me to become more comfortable in the ambulatory setting and showed me which areas I could improve on. I learned to focus on the most important issues for each patient and gained strategies to see patients more efficiently. For example, after reviewing the chart for a new patient, I would take a few minutes outside the room to think of my differential based on their referral and past medical history, and brainstorm which questions I would want to ask to help narrow my differential. Taking the time to do this allowed me to take more concise histories, focus my physical exam, and figure out which investigations I wanted.

All of my preceptors also fostered a positive learning environment and helped me get the most out of each patient encounter. They would push me to explain my reasoning, encourage me to formulate my differential in a systematic way, and help me review the most recent guidelines for my treatment plans. They would also provide their own clinical pearls and insight from their years of experience. This helped consolidate my knowledge and made me feel that my learning experience was valued.

This selective has further validated my decision to pursue my training in Internal Medicine. During clerkship, I had loved my experience on CTU, taking care of sick patients and building strong relationships with them. However, I had also really enjoyed seeing patients longitudinally in my Family Medicine rotation. This selective made me realize that a career in Internal Medicine can provide me with both aspects. I am grateful I was able to experience the ambulatory side of Internal Medicine and gain more exposure to medical education. I am eager to begin my residency in Internal Medicine and will definitely continue to seek involvement in medical education moving forward!

-MB-

Proposal to improve wellness

March 5, 2020

           
          After reviewing the literature on physician burnout, I spent some time trying to figure out what type of intervention I could implement to improve wellness in the internal medicine residency training program. One of the ideas that I thought of was to turn one of the weekly academic half day into monthly wellness and resiliency sessions. During my CaRMS tour, I remember some of the residents talking about how much they enjoyed having weekly "Ice Cream Rounds" during their academic half days because they were able to debrief with their peers about some of the stresses they have been experiencing. This gave them an opportunity to really connect with their fellow colleagues. I can see how this would greatly contribute to a feeling of wellness because these dedicated sessions normalizes the process of sharing concerns and allows for peer support. I do understand that it will be challenging to dedicate academic half days to wellness and resiliency due to limited curriculum time but I would argue that being able to take of one self in order to care for others is also part the Professionalism role of CanMEDS. Furthermore, I think we should be allowed to have self-compassion and follow our own recommendations that we give our patients because we are all human beings at the end of the day.


-JT-

Cutaneous tuberculosis

March 5 2020

I spent the day in the Dermatology Clinic today and saw a wide variety of common and interesting dermatologic cases! In the morning, we saw a patient that had been referred by the Tuberculosis Clinic for possibility of cutaneous manifestations of TB. Cutaneous lesions are a relatively uncommon manifestation of TB, occurring in only 1-2 % of infected patients. Therefore our staff spent some time discussing the various dermatologic presentations seen in TB.

The clinical variants of cutaneous TB are divided into: infectious acquired through exogenous inoculation, infectious that result from contiguous spread from nearby structures, infectious related to hematogenous dissemination, and the tuberculids, which are thought to be hypersensitivity reactions to M. tuberculosis.

Exogenous inoculation:

• Primary inoculation TB (tuberculous chancre): results from direct entry of organism into the skin or mucosa of someone previously not sensitized to M. tuberculosis. Lesions appear as red-brown papules or nodules that evolve into painless, shallow ulcers. The face and extremities are most commonly affected.
• Tuberculosis verrucosa cutis: occurs after direct inoculation of mycobacteria into the skin of previously  sensitized host. Lesions are usually painless, violaceous, indurated plaques, appearing on the fingers and dorsum of hands.

Contiguous spread:

• Scrofuloderma (tuberculosis colliquativa cutis): results from extension of the infection from a deep structure (eg lymph node) into the skin. Lesions appear as firm, painless, subcutaneous, red-brown nodules. The neck, axillae and groin are often involved.
• Tuberculosis cutis orificialis: develops in individuals with advanced TB of the GI tract, lungs, GU tract and impaired cell-medicated immunity. Lesions occur in the nasal mucosa, oral mucosa or anogenital skin/mucosa and appear as red-yellow nodules that break down to form painful, punched-out, friable ulcers.
• Lupus vulgaris (tuberculosis lupus): represents reactivation of TB infection and is a chronic and progressive form of cutaneous TB. It can result from either direct extension from an underlying focus or via lymphatic or hematogenous spread. It appears as collection of discrete, red-brown papules that coalesce to form an indolent plaque.

Hematogenous spread:

• Metastatic tuberculous abscesses (tuberculous gummas): occurs from the spread of mycobacteria to subcutaneous tissues. Patients present with a single or multiple, nontender, fluctuant, subcutaneous nodules, which eventually penetrate the skin and form ulcers.
• Acute miliary tuberculosis: results from the hematogenous dissemination of mycobacteria from a focus of infection. Cutaneous manifestations are rare but can present as pinpoint red-blue or purpuric papules with overlying tiny vesicles that then become umbilicated and crusted.
• Lupus vulgaris

Tuberculids:

• Papulonecrotic tuberculid: presents as firm, dark red or purple papules that are symmetric and often recurring. They subsequently become pustular and necrotic. Lesions occur on the face, ears, extensor surfaces and buttocks.
• Lichen scrofulosorum: collection of firm, yellow-red to red-brown papules that are follicular and often found on the trunk.
• Erythema induratum of Bazin (nodular vasculitis): presents as mildly tender, dull red, subcutaneous nodules on the lower legs. Nodules can break down and form deep, draining ulcers.

In our case, the patient did not end up having any cutaneous manifestations of tuberculosis. However, this case allowed me to learn about the various dermatologic presentations that can be seen in TB patients. Overall, the day was a fantastic opportunity to gain more exposure to dermatologic presentations and to review the many cutaneous manifestations seen in systemic diseases!

-MB-

References:

1. Handog EB, Macarayo MJE, Rosen T (Ed.). Cutaneous manifestations of tuberculosis. UpToDate. Accessed on March 5 2020 from: https://www-uptodate-com/cutaneous-manifestations-of-tuberculosis.

Medical education research

March 4, 2020


          Part of the CEEP selective involves exploring an aspect of medical education research. This was something that I was also very excited about as I had relatively recently become interested in medical education after working on a project to improve our advocacy curriculum. Something that has crossed my mind in the past few years is the topic of physician burnout. During clerkship, burnout seemed to be prevalent no matter where I went. Sadly, it seems that there is no real intervention in place to help with this. The topic of resiliency came up a lot during these conversations, often accompanied by some measure of contempt. As a medical student who will be entering residency training soon, I became concerned about how I would personally manage burnout but also how could we improve the system to support wellness in the future.

          As I delved into the literature, there has been a huge number of studies studying physician burnout. Burnout is a widespread phenomenon that affects approximately 30-50% of physicians, and is particularly prevalent during residency training (1,2). Burnout is a response from exposure to chronic stress that results in a syndrome involving exhaustion, depersonalization, and a sense of low personal accomplishment (3). This has been linked to medical errors, unprofessional conduct, and decreased altruism, which can be detrimental to patient care as well as compromising the physicians’ own well-being and safety associated with substance use and suicide (4). Unfortunately, there continues to be stigma and normalization associated with burnout that makes burnout challenging to address (5). Given that professionalism is one of the core competencies of the CanMEDS Physician Competency Framework, which includes a “responsibility to self, including personal care, in order to serve others,” tackling burnout is important to ensuring both physician and patient safety (6).

There are many factors that contribute to burnout, including: long hours, heavy workloads, sleep deprivation, exposure to intense emotional experiences, poor control over scheduling, changing work environments, and a high burden of administrative tasks (7). Additionally, the culture of medicine itself has been found to be a barrier to physician wellness as there is a strong expectation to be a “superhuman” and to prioritize work over personal time and self-care (5).

            Many studies investigating ways to manage physician burnout focus on improving resiliency training (8). Resiliency can be described in many ways but essentially allows one to thrive in the face of adversity. In order to implement resiliency strategies, there needs to be self-awareness to recognize the need for self-care. Formalized resiliency curriculum involves skill-building workshops on topics such as meditation, mindfulness, and managing expectations (9).

            A randomized clinical trial of 74 practicing physicians found that participation in biweekly facilitated discussion groups incorporating elements of mindfulness, reflection, shared experience, and small-group learning during 1 hour of protected time resulted in significantly improved empowerment and engagement at work, decreased depersonalization, emotional exhaustion and overall burnout (10). Another study found that a resiliency curriculum with sessions on setting realistic goals, managing expectations, letting go of medical errors, and finding gratitude was considered very valuable to interns to mitigate stress (11).

The discourse around well-being focuses on training individuals to have the skills in resiliency to combat adversity. However, there has been criticism to this approach as it places a strong responsibility on individuals to manage their burnout as if this was a result of a personal deficiency in resiliency rather than external barriers to wellness such as systemic organizational issues. Although addressing systemic issues is a daunting task, it can be guided based on the six categories of work stress by Maslach and Leiter: 1) workload, 2) control, 3) balance between effort and reward, 4) community, 5) fairness, and 6) values (12,13).

-JT-

References:

1.        Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81(1):82–5.

2.        Thomas NK. Resident burnout. Vol. 292, Journal of the American Medical Association. American Medical Association; 2004. p. 2880–9.

3.        Maslach C, Leiter MP. Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry. 2016 Jun 1;15(2):103–11.

4.        Dyrbye LN, Massie FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA - J Am Med Assoc. 2010 Sep 15;304(11):1173–80.

5.        Ironside K, Becker D, Chen I, Daniyan A, Kian A, Saheba N, et al. Resident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study. Perm J. 2019;23.

6.        The Royal College of Physicians and Surgeons of Canada :: CanMEDS Role: Professional [Internet]. [cited 2020 Mar 1]. Available from: http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-professional-e

7.        Edmondson EK, Kumar AA, Smith SM. Creating a Culture of Wellness in Residency. Acad Med [Internet]. 2018 Jul 1 [cited 2020 Mar 1];93(7):966–8. Available from: http://insights.ovid.com/crossref?an=00001888-201807000-00010

8.        West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016 Nov 5;388(10057):2272–81.

9.        Bird A, Pincavage A. A Curriculum to Foster Resident Resilience. MedEdPORTAL Publ. 2016;12(12).

10.      West CP, Dyrbye LN, Rabatin JT, Call TG, Davidson JH, Multari A, et al. Intervention to promote physician well-being, job satisfaction, and professionalism a randomized clinical trial. JAMA Intern Med. 2014 Apr 1;174(4):527–33.

11.      Bird A-N, Martinchek M, Pincavage AT. A Curriculum to Enhance Resilience in Internal Medicine Interns. [cited 2020 Mar 1]; Available from: http://dx.doi.org/10.4300/JGME-D-16-00554.1

12.      Jennings ML, Slavin SJ. Resident Wellness Matters. Acad Med [Internet]. 2015 Sep 1 [cited 2020 Mar 1];90(9):1246–50. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00001888-201509000-00024

13.      The Truth About Burnout: How Organizations Cause Personal Stress and What to ... - Christina Maslach, Michael P. Leiter - Google Books [Internet]. [cited 2020 Mar 1].

Too low for comfort

March 2 2020

We saw a patient today who had been initially followed for management of his hypertension, but had subsequently developed severe orthostatic hypotension. Despite treatment, his hypotension was ongoing and significantly affecting his life. In medicine, we often manage patients with difficult-to-treat hypertension, however we less often encounter persistent orthostatic hypotension. I took this opportunity to learn more about the management strategies for orthostatic hypotension in the ambulatory setting.

Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within 3 minutes of standing when compared with the blood pressure in the sitting or supine position. It can be asymptomatic or symptomatic, causing light-headedness, dizziness, fatigue, palpitations or syncope. Goals of treatment involve improving hypotension without excessive supine hypertension and symptomatic relief for the patient. There are many non-pharmacologic and pharmacologic options available.

Non-pharmacologic options: These are an important first-line for neurogenic orthostatic hypotension (ie caused by autonomic dysfunction).

• Discontinue offending medications: this commonly includes diuretics, antihypertensive agents (primarily sympathetic blockers), nitrates, alpha-adrenergic antagonists,  antidepressants.
• Modification of daily activities and patient education: this includes strategies such as getting up slowly, avoiding straining or violent coughing, ensuring adequate hydration and avoiding overheating, raising the head of the bed, and exercise in some cases.
• Compression stockings and abdominal binders: may be helpful in patients who are able to tolerate them.
• Certain physical maneuvers: tensing the legs by crossing them while actively standing on both legs was found to increase blood pressure by 13%.
• Increased salt and water intake: target daily water ingestion of 1.5 - 3 L per day and encourage high sodium foods or prescribe salt tabs.

Pharmacotherapy options: Non-pharmacologic measures should always be maximized prior to starting pharmacotherapy and must be continued after initiating medications. A stepwise approach should always be used with pharmacotherapy, with frequent monitoring.

• Midodrine: is a peripheral selective alpha-1-adrenergic agonist causing both arterial and venous constriction. The dose should be titrated from 2.5 to 10 mg three times a day, with a maximum dose of 40 mg a day. It should not be used in patients with severe heart disease, uncontrolled hypertension or urinary retention. Side effects include: supine hypertension, pilomotor reactions, GI complaints, pruritus and urinary retention.
• Droxidopa: is a norepinephrine (NE) precursor which is converted to NE after ingestion. Dosing starts at 100 mg and can be titrated up to 600 mg three times a day. It is approved for treatment of symptomatic neurogenic orthostatic hypotension associated with Parkinson's, multiple system atrophy, and autonomic neuropathy. Again supine hypertension is a side effect.
• Fludrocortisone: is a synthetic mineralocorticoid which acts by increasing blood volume. Treatment is initiated at a dose of 0.1 mg per day (in the morning) which can be increased to 0.3 mg/day. Side effects include: development of edema, worsening seated or supine hypertension, and hypokalemia (potassium supplementation is usually required).
• Other agents (such as caffeine, erythropoietin, pyridostigmine) have been used in small trials but there is limited evidence to support their use. 

This case allowed me to learn more about the different management options for patients with orthostatic hypotension. Although I was previously familiar with a few of the non-pharmacologic methods, I did not know much about the various pharmacologic options. Through this case, I was able to learn more about the medications available, their mechanism of action, indication for their use, dosing protocol, and their side effects! 

-MB-

References:

1. Kaufmann H, Aminoff MJ (Ed.), Kowey P (Ed.). Treatment of orthostatic and postprandial hypotension. UpToDate. Accessed on March 2 2020 from: https://www-uptodate-com/treatment-of-orthostatic-and-postprandial-hypotension.
2. Lanier JB, Mote MB, Clay EC. Evaluation and Management of Orthostatic Hypotension. Am Fam Physician. 2011 Sep 1; 84(5):527-536.