We meet again, Harvey

On Friday we reviewed diastolic murmurs using Harvey.  Harvey is a life-sized cardiopulmonary simulator, developed in 1968 at the University of Miami, that can mimic a number of patient scenarios.  For each scenario, there are a number of findings in the precordial examination that can clue trainees into the diagnosis.

With our preceptor on Friday, we focused on aortic regurgitation and its salient features.  Our preceptor developed a simulated case of a man with a history of infective endocarditis presenting with shortness of breath.  The first step was reviewing the vital signs and his blood pressure was said to be “159/60” – we noted a wide pulse pressure and spoke about our differential for this.  The other vital signs were unremarkable.  After this, we discussed that for the physical examination we would inspect and palpate moving from peripheral to central.  We altered the scenario for a moment to consider other causes of aortic regurgitation, such as Marfan’s syndrome, so that we could discuss the manifestations we would see on exam such as pectus excavatum.  Throughout our scenario, we took a few minutes to review the characteristics of the JVP; this is a key component of any cardiovascular assessment even though it is not significantly affected in aortic regurgitation.  Although we cannot perform all of them on Harvey, we practiced other physical examination maneuvers that may be relevant to aortic regurgitation such as Quincke’s sign.  Before auscultation, much of the assessment was made from the information we had already gathered.  Interestingly, we also heard the Austin-Flint murmur that occurs in aortic regurgitation and this helped us to think about mitral stenosis as the Austin-Flint murmur occurs because of a functional mitral stenosis.

The richness in the discussion came from the synthesis of all of the information and putting together how the pieces of the puzzle would lead to a diagnosis.  Often times we are coloured by the more common “bread and butter” reasons for presentations but reviewing our cardiovascular examination emphasized the importance of thoroughness in order to not only identify the pathology but also to determine its etiology.

There was a meta-analysis done in 2013 by McKinney et al. of simulation-based medical education for health care professionals for the cardiac physical examination.  The authors suggested that hands-on practice with simulators increases the acquisition of cardiac skills because it lends itself to repetitive and deliberate practice.  The idea of repetition is important.  We have a Harvey simulator at a number of our teaching hospitals and I was introduced to this tool in my Art and Science of Clinical Medicine (ASCM) course in first year of medical school when we first learned about heart sounds and murmurs.  Throughout clerkship, we have re-visited Harvey with our attending physicians and a small group of students to enact various mock cases and discuss our approach and differential diagnosis for each.  As we move forward in our training, Harvey sessions have become an opportunity to consolidate knowledge from lectures and clinical experiences.  We are also able to continually improve and refine our technique for the same physical examination while tailoring it each time to the suspected diagnoses.

Until next time, Harv!

SH

Resources:

McKinney, J. et al. (2013). Simulation-Based Training for Cardiac Auscultation Skills: Systematic Review and Meta-Analysis. J Gen Intern Med, 28(2): 283 – 291. 

Why our patients are not compliant?

I had the pleasure of working in the GIM Rapid Referral Clinic yesterday. What I found unique and exciting about this clinic is that you can never predict what type of medical concerns are sitting in your exam room. Yesterday was a great example.

I saw Mr. J, a young gentleman following up with the GIM clinic for a follow-up appointment from a 24-hour ambulatory BP monitor. Mr. J’s ambulatory BP averaged an elevated mean, meeting a diagnosis of hypertension. However, he wanted to repeat the test because he claimed to be going through significant stress and felt that the values were not a fair representation of his usual blood pressure. He stated he had been non-compliant with an antihypertensive drug prescribed to him during the previous appointment for this reason.

After the repeat test also revealed an elevated mean, I broke the news to Mr. J that the results cemented a diagnosis of hypertension. I predicted frustration and disbelief. To my surprise, I was met with calm and acceptance throughout the discussion. He was also very receptive to my suggestions of increasing his weekly exercise and eating healthier meals. I proceeded to discuss pharmacological treatments and asked whether he had been taking his medications. He replied that he had been taking them regularly but recently ran out of them. I offered to increase his dose and caught a glimpse of hesitation flicker across his face. Probing further, he admitted he had completely non-adherent because he didn’t like how the medications made him feel. Initially, he wasn’t willing to elaborate. I repeatedly asked him what symptoms he was experiencing and after finally let out a long sigh, he said that he was primarily concerned about the drug cost.

Mr. J told me that he didn’t have any drug coverage and paid about $90 every few months for his BP medication. He was worried that increasing the dose would add to what he was paying already. After comparing different medication prices, I switched him to another drug that was a fraction of the cost of his current pills. Both the patient and my preceptor were satisfied with my recommendation and Mr. J agreed to follow up with us in 3 weeks to reassess his blood pressure.

All it took for me to help Mr. J was a quick search of an online drug formulary and a call to a local pharmacy. This case taught me that treating our patients often requires us to understand them holistically. Physicians can order a plethora of investigations and prescribe a multitude of medications but if we don’t have a solid grasp of a patient’s social determinants of health, we will never be able to deliver patient-centered care.
- AX

Procedural Teaching

Yesterday afternoon I was in the catheterization lab with the interventional cardiologists and fellows.  It was an exciting experience in which we visualized the coronary circulation of patients who had a number of different reasons for referral.  These included: NSTEMI, troponin elevations, or positive stress testing.  It was neat to be able to review the decision-making that went into delineating which patients needed stenting versus those who were more fit for medical management.  The attending I was working with would perform the catheterization for diagnosis and if angioplasty was needed, another interventionalist would join us to complete the procedure.

For example, one of the cases was a patient who presented because of a syncopal episode in the context of a past history of coronary artery disease.  He did have a troponin elevation but also when admitted he was noted to have a significant drop in hemoglobin from his last hospitalization and an upper endoscopy showed ulceration.  After his coronary catheterization, although one of his smaller arteries did show disease, the judgement call was that his troponitis was likely due to demand from gastrointestinal bleeding rather than acute coronary syndrome.  We could have intervened yesterday, but the safer option given that we would have to keep him anticoagulated was to treat his gastrointestinal bleeding (which likely explains his vasovagal episode and troponitis) and then he would return for intervention at a later date.  This was an important teaching point.  My staff highlighted to me that when in a sub-specialty that is procedural, it is important to know as a clinician whether or not to intervene.  In cardiology, this relies on a number of factors including: the vessel that is affected, the clinical context of the patient, anticoagulation, and other risks and benefits.

It made me reflect on the concept of how we teach procedures overall in Internal Medicine.   I was watching the cases on the fluoroscopy camera and my attending was explaining to me his steps and thought process.  Even before the afternoon started, he reviewed the anatomy and procedural technique with me including how to set-up, anesthetize, gain access, and the risks and benefits of using radial versus femoral arteries for access.  This was incredibly useful so that I could follow along during the procedures.

In terms of bedside procedures, I have had the opportunity to perform a few during my core rotation and electives under the supervision of my residents and attending physicians.  Before doing any procedures, I have reviewed the NEJM Videos in Clinical Medicine (http://www.nejm.org/multimedia/medical-videos) which guide trainees through the equipment needed, how to set up, and how to actually perform the procedure.  Afterwards, it has been very helpful when I have debriefed with my residents to review positive aspects and items to improve for next time.

An article by Fincher in 2000 highlighted that competency in performing procedures is a salient aspect of internal medicine training and that it has to be delineated what procedures internists are expected to perform.  Another topic that has been brought up is how to ensure that senior trainees feel comfortable before supervising more junior trainees.  (Mourad et al., 2010) Mourad’s study surveyed 7 teaching institutions in the Medical Education Research Network (MERN) of California.  They found that three-fourths of residents reported feeling comfortable (reaching a comfort threshold) with paracenteses, lumbar punctures, and femoral CVC’s after 3 to 4 times of having performed them, thoracentesis after 5 to 6 times, and IJ and subclavian CVC’s after 7 to 9 times.  The number of procedures performed was strongly associated with meeting the comfort threshold. (Mourad et al., 2010)

Over the years, the way in which schools have addressed this is by implementing procedural teaching in Academic Half-Days and making use of simulation centres.  (Sacks et al., 2017) It has been said that objectivity can be important when determining whether trainees are competent in a specific procedure. (Tariq et al., 2015) The biggest change moving forward is that as we move into a competency-based era, every resident will have to be deemed competent in a set of procedures before formally completing the program.  These benchmarks help to ensure that residents’ academic advisors are following their progress in procedural skills and this evaluation serves as an impetus for the resident to learn the skills.

Exciting times ahead!

SH

Resources:

Fincher, R. E. (2000).  Procedural Competence of Internal Medicine Residents. J Gen Intern Med, 15(6): 432 – 433.

Mourad, M. et al. (2010). Supervising the Supervisors – Procedural Training and Supervision in Internal Medicine Residency. Journal of Internal Medicine, 25(4): 351 – 356.

Tariq, M. et al. (2015). Optimum number of procedures required to achieve procedural skills competency in internal medicine residents. BMC Medical Education, 15: 179. DOI 10.1186/s12909-015-0457-4

Sacks CA, Alba GA, Miloslavsky EM. The Evolution of Procedural Competency in Internal Medicine Training. JAMA Intern Med. 2017;177(12):1713–1714. doi:10.1001/jamainternmed.2017.5014

Think outside of the box

Another Monday, another new week! Today I was working in the General Respirology clinic, which I initially thought was going to be a repetitive day of asthma/COPD patients. Surprisingly, I saw everything BUT the ordinary! I had a memorable case, which questioned a long-standing diagnosis because my preceptor challenged me to think outside of the box.

I had the pleasure of seeing an elderly gentleman with a 20+ year history of “asthma” who was accompanied by his family to get a “fourth opinion”. He was diagnosed with asthma in the early 90s and had been in and out of hospitals for more than 20 times due to “atypical asthma attacks”. Despite trying many different asthma medications, he continued to struggle with symptoms. He had been referred to specialists in the past who hadn’t made any significant difference in his care. Today’s appointment was his third Respirology consultation. I could sense both the patient and his family were quite disheartened at this point. Based on his history, he had never really responded to bronchodilators. Although there were findings suggestive of an underlying immunologic component to his illness, this alone didn’t explain the severity or frequency of his attacks. Even PFTs didn’t exhibit the classic reactive-obstructive airway. There had been some speculation about his underlying condition is a result of his tracheal anatomy or vocal cord dysfunction, but those ideas were never seriously explored. Finally, the patient also had a history of GERD and UPPP that left him with some swallowing difficulty.

Instead of tackling this patient’s individual medical concerns and trying to find out one explanation for his atypical asthma, my preceptor considered the entire clinical picture and lay out the pieces separately. First, my preceptor told the patient that asthma was unlikely based on the clinical picture. However, his episodes of dyspnea might be a combination of vocal cord dysfunction exacerbated by his GERD as well as UPPP-dysphagia. Based on this explanation, my preceptor referred him to an ENT specialist with a particular interest in studying vocal cord dysfunction. Both the patient and family were extremely satisfied with the certainty and clarity of my preceptor’s explanation. They were grateful that after struggling with a questionable diagnosis for more than three decades, someone was finally offering to look at an old problem with a new perspective.

When we often think of specialists, we believe that they have their specific set of knowledge and are only able to address issues within their scope of expertise. My preceptor showed me today that eliciting and making sense of a patient’s history is not just a job for the generalist. Regardless of where our niche is in a healthcare system, it’s crucial that we consider patients as a whole to help us reach the correct diagnosis.
-AX

TB or not TB? A Multidisciplinary Approach

Today was one of my two half-days in the tuberculosis (TB) clinic.  In clinic today, the team was comprised of a physician (today an Infectious Diseases specialist, other times a Respirologist), a nurse practitioner, a nurse from Public Health, a respiratory therapist who joined us for sputum inductions, and myself.  There is a social worker who is a member of the team here as well.   The TB clinic started in the year 2000 and they focus on diagnosing and managing both active TB disease and latent TB infection. 

One of the new patients I saw was referred because of an abnormal chest X-ray finding on immigration into Canada from another country.  Upon completion of the interview, it appeared that the patient had been completely asymptomatic and otherwise healthy.  What do we do in these cases?  We contacted the respiratory therapist and in between her other tasks, she came to clinic to help us obtain an induced sputum so that we could test for acid-fast bacilli (AFB).  If negative, the plan in this case would be to follow-up with sputum cultures every 6 months for 2 years.  If positive, this would warrant treatment.  Outside of clinic hours, the nurse practitioners also serve as a contact point for these patients to notify them of abnormal results and help to coordinate their follow-up.  The Public Health nurse pointed out to me that as a part of her work with Public Health, she often accompanies her patients to their TB appointments.  Many of the patients that she works with may live in marginalized areas or are on social assistance and she encourages them to follow-up and ensures that they feel supported.  It was fascinating to learn about the scope of my colleagues’ roles in management of this complex disease.

A study from the University of California, San Francisco demonstrated that designing an Interprofessional Patient Aligned Care Team (iPACT) to provide interprofessional education (IPE) for internal medicine residents had positive feedback from residents and interns.  It was found that this collaboration created a mutual understanding of the roles of the team members and was better for patient care and safety. (Lo et al., 2017)

In a pilot curriculum study between the medical school and pharmacy school at Marshall University, third year students attended between two to four sessions during their rotations focusing on IPE topics.  Students’ perception towards IPE had a statistically significant improvement from this.  (Gilkerson et al., 2017) These early experiences in such settings have an impact on medical students’ appreciation of IPE teams.  From my time in the outpatient TB clinic, this multidisciplinary environment facilitated excellent patient care and was an enriching learning experience.  I’ll be back in TB clinic on Thursday!

Bonne nuit,

SH

Resources:

http://www.uhn.ca/PatientsFamilies/Health_Information/Health_Topics/Documents/TWH_Tuberculosis_Clinic.pdf

Lo, D. et al. (2017). Changing Spaces and Learning Environments to Improve Inpatient Interprofessional Education for Internal Medicine Residents. Journal of Graduate Medical Education, DOI: http://dx.doi.org/10.4300/JGME-D-16-00771.1

Gilkerson, C. L. et al. (2017). The Development of a Novel Interprofessional Education Curriculum for third year medical students and pharmacy students. Marshall Journal of Medicine, 3(1): 80 – 89. DOI: http://dx.doi.org/10.18590/mjm.2017.vol3.iss1.13

Health care: caution or cure?

In yesterday’s TB clinic I saw mostly follow-up appointments after initiating TB therapy. One particular encounter left a distinct impression on me. It illustrated the pivotal impact of social determinants of health on patient outcomes.
The patient was a young student who had recently been diagnosed with latent TB from a positive TST but otherwise normal CXRs. She returned to the clinic yesterday for her first follow-up appointment since she started her TB medications one month ago. On presentation, she appeared to be doing well and not experiencing any medication side effects. I inquired a little bit of her background history of how she was diagnosed with latent TB. On review of systems, I couldn’t identify any specific risk factors for contracting TB. I probed further and asked which TB test had confirmed her diagnosis of latent TB. To my surprise, the patient replied that she had never had additional testing beyond her positive TST.
After reviewing the case with my preceptor, we both agreed that the patient should have been offered a confirmatory TB test. However, this test was not covered by OHIP and would cost $90 out of pocket. The patient was clearly at a loss. She was unsure whether she should choose a definitive TB test (with a hefty price tag) or continue to take her 9 months of TB treatment (at no cost). For a student living with overwhelming loans, she clearly struggled to make a decision. In the end, she took the test requisition and agreed to think about it further.

This unique case highlights how social determinants of health directly impact health outcomes. By continuing therapy without confirming her TB diagnosis, we were exposing this young lady to potentially unnecessary TB drug toxicity. Yet because of her difficult financial status, she could not afford to proceed with a confirmatory test. How ironic that our health care system is willing to dole out a pound of cure instead of an ounce of caution.
- AX