What Does the Evidence Say?

In yesterday’s “physical exam rounds” morning report, we learned about the JAMA rational clinical examination for ascites.  Our preceptor reviewed the definitions for positive and negative likelihood ratios as well as sensitivity and specificity to create a framework for the discussion.

In 1998, JAMA began creating their “The Rational Clinical Examination” series to evaluate how certain physical examination techniques can aid in our diagnoses.  The series focuses on high-yield topics that come up in common diagnostic dilemmas.  The chapters include an evidence-based approach to a particular examination based on meta-analyses of the literature.  (Garner, 2010). 

The concept of evidence-based medicine (EBM) is defined as the “integration of clinical expertise, patient’s values and best available evidence in [the] process of decision making related to patients’ health care.” (Masic et al., 2008) External clinical evidence does not replace your clinical expertise however, it informs and guides your decision-making.  In fact, you use your clinical expertise to decide if the external evidence applies to the patient in front of you. (Sackett et al., 1996)

These evidence-based rational clinical examinations provide a structure for a focused examination especially when you are in a busy setting such as the emergency department and triaging patients.  From yesterday’s lecture, I learned that one should start with the most sensitive tests when performing your physical exam and then move to more specific tests because the sensitive tests help you to rule out the diagnosis if negative.  For example, in the examination for ascites, the most sensitive findings to rule out the diagnosis are no history of ankle swelling or increased abdominal girth and the inability to demonstrate bulging flanks, flank dullness, or shifting dullness.  The most powerful findings for making the diagnosis of ascites are a positive fluid wave result, shifting dullness, or peripheral edema.  (Simel & Rennie, 2009)

It was brought up in rounds that in theory our pre-test probabilities would be based on epidemiological data and the likelihood of a disease occurring in a particular patient population.  However, in practice we base our pre-test probabilities on history-taking and physical examination.  This is why learning the questions on history or physical examination maneuvers that help you confidently rule in or rule out diagnoses will aid you the most in medical decision-making.  As the Garner article mentions, these physical examinations force us to become resource stewards as well.  Not only does certainty in our examination increase confidence in medical decisions, it also decreases the number of unnecessary tests that are ordered.

In the world of medical education, evidence-based medicine is weaved in throughout.  More than “physical exam rounds,” there are also “EBM rounds” each week where we learn to interpret and critically appraise primary research articles.   I am looking forward to next week’s sessions!

SH

Resources:

Garner, J. (2010). The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. Proc (Baylor University Medical Center Proceedings), 23(1): 87.

Sackett, D. L. et al. (1996). Evidence based medicine: what it is and what it isn’t. BMJ, 312: 71. doi: https://doi.org/10.1136/bmj.312.7023.71

Masic, I. et al. (2008) Evidence Based Medicine – New Approaches and Challenges. Acta Inform Med, 16(4): 219 – 225.

Simel, D. L. & D. Rennie.  (2009).  The Rational Clinical Examination: Evidence-Based Clinical Diagnosis.  JAMAevidence.  Retrieved from https://medicinainternaucv.files.wordpress.com/2013/02/jama-the-rational-clinical-examination.pdf  Accessed on February 10, 2018

Staying "a la mode" in medicine

One of the challenges in medicine includes staying up-to-date on new changes to practice.  Yesterday in Rapid clinic, my preceptor and I reviewed the new 2017 COPD guidelines which illustrated a shift from the FEV1-based classification criteria to one based on severity of symptoms and exacerbations/hospitalizations.  The pharmacologic treatment algorithms have also been altered with new escalation (de-escalation) strategies given that many COPD patients are already on treatment and still have symptoms or exacerbations.  We also reviewed an updated puffer chart which is a resource that is always very helpful to have in clinic.  Medicine is constantly evolving and keeping up with this is essential in order to provide effective patient care.  This can be especially difficult in the ambulatory setting if you are presented with a rarer condition and you have to balance this with seeing your patients in a timely fashion.

Learning in internal medicine encompasses a wide variety of shapes and forms.  It is important to not only find the learning style that works for you (auditory, visual, tactile) but also to explore different learning settings.  In our medical school training, we are exposed to: problem-based learning, virtual problem-based learning (online patient cases), lectures, clinical experiences, bedside teaching, informal teaching with staff/residents, and self-directed learning (SDL).

SDL is a part of adult education in which “an individual is to assume the primary responsibility for planning, initiating, and conducting the learning project.”  (Manning et al., 2007) A study by Sawatsky et al. in 2017 analyzed the Internal Medicine Residency Program at Mayo Clinic and using a focus group, developed a theoretical model for how residents engage in SDL.  Their model suggested that this is the process by which SDL happens: building a knowledge framework, having triggers (external events such as patient cases that stimulate questions), uncovering knowledge (identifying weaknesses), formulating learning objectives, using resources, applying knowledge, and finally evaluating learning.  The paper discussed personal factors that inspire the practice of SDL, such as: motivations, individual characteristics, and changes over time.  An example of the latter is the way in which our questions change as we move through clinical training, something that all trainees can identify with.  They also commented on contextual factors that influence the pursuit of SDL: the need for external guidance, the residency program culture/structure, and the presence of contextual barriers. 

Finding the right information sources for your independent learning depends on several features of the source such as: efficiency, integration with the workflow, familiarity, optimization for the clinical question, and others.  (Cook et al., 2013) This morning before my afternoon hypertension clinic I reviewed the 2017 CHEP guidelines on diagnosis and treatment of hypertension.  I used the CMA website to access the guidelines (https://www.cma.ca/En/Pages/clinical-practice-guidelines.aspx).  In clinic, when I need to review doses or drug-interactions, I will use UpToDate and for a quick reference, I always have my Pocket Medicine (The Massachussets General Hospital Handbook of Internal Medicine) on me.  To read in more detail outside of the clinical setting, Approach to Internal Medicine and Toronto Notes are my go-to!

I’m curious to see what resources my colleagues like!

SH

Resources:

Sawatsky et al.  (2017).  A model of self-directed learning in internal medicine residency: a qualitative study using grounded theory.  BMC Medical Education, 17(31): https://doi.org/10.1186/s12909-017-0869-4.

Manning. (2007).  Self-Directed Learning: A Key Component of Adult Learning Theory. Journal of the Washington Institute of China Studies, 2(2): 104 – 115.

Cook et al. (2013). Features of Effective Medical Knowledge Resources to Support Point of Care Learning: A Focus Group Study.  PLOS ONE, 8(11):  e80318. https://doi.org/10.1371/journal.pone.0080318

Longitudinal, Vertical, Diagonal: How Do We Learn Best?

Today I had my first clinic of the CEEP selective – it was called GIM Longitudinal.  I spent lots of time on CTU’s and consult teams during my electives, but it has been a while since I’ve been in an outpatient clinic.  The term “longitudinal” resonated with me today for a number of reasons.

Hirsh et al. highlighted that continuity in the learning environment extends across three spheres: continuity of care, continuity of curriculum, and continuity of supervision. Let’s distill these points.

• Continuity of care – Much of the satisfaction we derive in internal medicine stems directly from the therapeutic alliance we have with our patients. Patients derive benefit from seeing the same trainees and physicians in clinic, and trainees and physicians derive fulfillment from this too.  A study by Butler et al. from the Department of Medicine in Kettering Medical Center, Ohio articulated that in a model whereby a team of residents was responsible for a cohort of patients, rather than patients seeing a different resident each visit, a couple of things improved.  First, patients were seen consistently by the same subset of residents and second, communication between providers improved.  For example, in clinic today we reviewed a patient who was seen for cutaneous lesions that had been worsening for over a decade.  I had the opportunity to review the previous notes from physicians in the internal medicine team at TWH and simultaneously, the patient herself felt we had a good grasp of her story.
• Continuity of curriculum – In internal medicine we are afforded the unique opportunity to see patients both acutely in the inpatient setting and emergency department but also as outpatients.  We see different manifestations of the same chronic diseases, requiring us to synthesize the information we learn across a number of spheres.  For example, the management of a hypertensive emergency/urgency in an acute setting differs from the way you will manage and follow hypertension in clinic.  Fazio et al. described that ambulatory clinics create a balanced learning experience.  Nontraditional settings such as community health centers or inner-city clinics provide trainees with diversity.  Furthermore, these experiences provide us with the opportunity to explore the needs and demands of different patient populations.
• Continuity of supervision – Today I had the opportunity to work with one of my attending physicians from my core CTU rotation and today it was in the GIM Longitudinal clinic.  From my CTU rotation, I’ll never forget one of the bedside teaching exercises we went through in the emergency room when reviewing a patient with decompensated aortic stenosis.  She asked our team of medical students and residents to take turns listing up to 10 things we noticed in the room purely with visual inspection before examining the patient.  We came up with a lot which highlighted the importance of that bedside technique.  Today in clinic we reviewed how to counsel patients when discharging from clinic and the things to discuss with them so that they are aware of when to return.  Continuity of supervision is important because, as Hirsh et al. pointed out, it forms a strong learning community.  Students are encouraged to take intellectual risks in their learning but are also open to coaching and feedback.

Another example of this movement is that undergraduate medical education structure is changing. For example, the new Foundations Curriculum has weaved various longitudinal themes into the components that are being delivered to students.

Educational continuity has many benefits as described above and I am grateful to have experienced these today!

Until tomorrow,

SH

Resources:

Fazio, S. B. et al. (2017). The Challenges of Teaching Ambulatory Internal Medicine: Faculty Recruitment, Retention, and Development: An AAIM/SGIM Position Paper. The American Journal of Medicine, 130(1): 105 – 110. DOI: https://doi.org/10.1016/j.amjmed.2016.09.004

Hirsh, D. A. et al. (2007).  “Continuity” as an Organizing Principle for Clinical Education Reform.  The New England Journal of Medicine, 356(8): 858 – 866.

Butler, M. et al.  (2017).  Improved continuity of care in a resident clinic.  The Clinical Teacher, 14(1): 45 – 48. doi: 10.1111/tct.12489. Epub 2016 Jan 8. 

Entry 2

Today was an eventful day. It was a mixture of clinical exposure and teaching.

In the morning, I saw a few patients in the TB clinic. The staff and admin assistants were very kind in orienting me to the clinic. Not surprisingly, I felt quite nervous before knocking on the door of the room of my first patient. I mentally prayed that what I’d read last night would prove useful in just a few moments… I needn’t have worried. My patient was very pleasant, and I found myself rattling off questions about TB risk factors and clinical features with ease. When reviewing the case with my staff, I had formulated an assessment which included a false positive Mantoux at the top of my differential. My staff agreed with my assessment, boosting my confidence further and bringing a smile to my face as I headed to noon rounds.

The topic at rounds was a sharp deviation from the usual clinical scenario. It was evidence-based medicine and one of the staff presented a new controversial paper examining non-inferiority of edoxaban to LMWH’s in preventing and treating VTE among cancer patients. My first instinct was disbelief. After all, hadn’t I been taught in medical school that LMWH’s showed well-established mortality in precisely this population? Surprisingly, the study did show non-inferiority of the NOACs compared to LMWH’s for VTE treatment at roughly the 90-day mark. After this period, the results diverged. Concurrently, the incidents of major bleeding in the NOACs arm was higher than the LMWH arm right from the beginning. However, due to the ambiguity in some of the design details, it leaves the rationale why open to interpretation. I left rounds thinking to myself that as a future physician, I want the paper's results to be further verified to ensure patient safety and better care quality. Yet, if I were a cancer patient, would I not prefer to take a pill once a day rather than having to stab my abdomen with a needle? I reasoned that the study outcomes would have to be replicated and the standard knowledge-translation window would have to elapse before this commonplace practice changed. Until then, cancer patients would have to continue to endure daily painful injections. It was food for thought.
- AX.

First day back - deja vu

On the first day of ambulatory GIM selective, I was nervous, relieved, and excited.

Having just survived my CaRMS tour and not been around the GIM environment since clerkship, I definitely felt some pressure. I remember being constantly in awe of the Internists' vast knowledge and feeling "inadequate" in comparison. This feeling had accompanied me for nearly all of my core rotation. A year later, I wondered if my experience this time would be different. One thing I did not find nostalgic on my first day was the lengthy orientation and online training modules. It took roughly 3 hours and a trip back and forth between TWH and TGH to get everything settled.

The last task on our agenda today was to attend rounds at lunch. We walked in a bit late and only caught a glimpse of the topic: bacteremia in the context of compromised skin barrier/erythroderma. While trying to chew my food as quietly as possible, I quickly glanced at the differentials outlined on the board and found myself able to come up with most of the diagnoses discussed by the group. Furthermore, I was able to answer a majority of the questions thrown out by the attending staff. Hearing the residents contribute helped round out some of the clear gaps in my knowledge. I thoroughly enjoyed today's teaching rounds. Overall, I found the topic to be extremely relevant to my current stage of training and the knowledge to be very practical. The familiarity of the learning environment gave me some peace of mind, and I remembered why I loved IM in the first place. The multitude of complex medical concerns could be challenging, but there's always support from a team of clerks, residents, and staff. The rare and unique pathology within GIM offers constant clinical challenges but endless learning opportunities also.

I'm excited about what this rotation has to offer. I'm certain my adventures during the next 4 weeks will help shape my future career in medicine.
- AX