The New Building Blocks of Learning

Need to imbed the video, talking points, questions?

http://www.ted.com/talks/sugata_mitra_the_child_driven_education.html

1. Broadband

2. Collaboration

3. Encouragement

4. Challenge

Ptosis, Erythema, and Vision Loss - Case

Check out this cool ophtho case in JAMA 2013. I think the answer to the What would you do next? segment is the most important learning point.

Then, do these questions and review the answers. (Not posted here so as to not spoil the case).

Troponin Elevation DDx

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860726/

Excellence in Medicine through Rescue from Failure- Gawande

Below you will find excerpts from a commencement address given by Gawande re: excellence in medicine, from a perspective I had never heard before. 

"... the best surgeons I saw involved the ability to handle complexity and uncertainty. They had developed judgment, mastery of teamwork, and willingness to accept responsibility for the consequences of their choices.  

...I thought that the best places simply did a better job at controlling and minimizing risks—that they did a better job of preventing things from going wrong. But, to my surprise, they didn’t. Their complication rates after surgery were almost the same as others. Instead, what they proved to be really great at was rescuing people when they had a complication, preventing failures from becoming a catastrophe. 

....When things go wrong, there seem to be three main pitfalls to avoid, three ways to fail to rescue. You could choose a wrong plan, an inadequate plan, or no plan at all.  

...But recognizing that your expectations are proving wrong—accepting that you need a new plan—is commonly the hardest thing to do. We have this problem called confidence. To take a risk, you must have confidence in yourself. In surgery, you learn early how essential that is. You are imperfect. Your knowledge is never complete. The science is never certain. Your skills are never infallible. Yet you must act. You cannot let yourself become paralyzed by fear.  

Yet you cannot blind yourself to failure, either. Indeed, you must prepare for it. For, strangely enough, only then is success possible.  

...[The attending surgeon had] never seen a serious belly problem [after carotid artery surgery]. But the surgeon was humble enough to understand that he could.  

...So you will take risks, and you will have failures. But it’s what happens afterward that is defining. A failure often does not have to be a failure at all. However, you have to be ready for it—will you admit when things go wrong? Will you take steps to set them right?—because the difference between triumph and defeat, you’ll find, isn’t about willingness to take risks. It’s about mastery of rescue."

Choose a high risk clinical scenario and describe No plan, Inadequate plan, and Wrong plan scenarios. Then describe the Right plan. Try this exercise regularly and your patients and your hospital will benefit greatly from your preparedness. 

This connects to point #9 from our post on Clinical Reasoning - Progressive Problem Solving. Review that post to reinforce principles in Clinical Excellence. 

put in an example high risk case and connect to EN

Sinus Transillumination

A simple and practical physical exam maneuver to aid in the detection of sinusitis and other sinus space-occupying lesions.

Review these notes from the FPnotebook and these videos on frontal (one and two) and maxillary (one and two) sinus transillumination and practice on a number of "normals", include in your routine examination, and of course use in your focused ENT exams.

Include the sinusitis scoring criteria (Sapira's).

AAA Screening

Read this adapted from from UpToDate 2010 then answer the following questions from the AFP 2005:

M.G., a 70-year-old black man, requests refills for his medicines. His medications include lisinopril, atorvastatin, glipizide, and daily aspirin. He smoked heavily when he was younger but quit about 15 years ago. He also asks that you order “whatever tests should be done at my age.”

1. You review MG’s chart and find he is up to date on most age-appropriate immunizations and screening. You consider screening him for abdominal aortic aneurysm (AAA). Which of the following screening regimens reflects the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for AAA?
A. Screen men and women aged 65 to 75 years.
B. Screen men yearly between the ages of 65 and 75 years.
C. Do not screen men who quit smoking more than 10 years ago.
D. Screen men aged 65 to 75 years who have ever smoked.
E. Screen women aged 75 to 85 years who have ever smoked.

2. Which one of the following statements about AAA is correct?
A. Blacks and patients with diabetes are at increased risk for AAA.
B. There is a low risk for surgical complications from AAA repair.
C. Operative mortality for open surgical repair of an AAA is less than 1 percent.
D. Men generally die from AAA rupture at an older age than women.
E. An age of 65 or older, male sex, and a history of smoking are the major risk factors for AAA.

3. After you discuss the risks and benefits of AAA screening with MG, he decides to proceed with screening. Which of the following statements about screening for AAA is/are are correct?
A. Ultrasonography is the screening test of choice.
B. An estimated 500 men aged 65 to 74 years who have ever smoked would need to be screened to prevent one AAA-related death over five years.
C. Screening and surgical repair of large AAAs in older men decreases all-cause mortality.
D. Abdominal palpation is an adequate screening alternative.

Answers

Gout Review

This one-pager on gout was adapted from this In The Clinic review from Annals 2010. Review the article and answer the MKSAP questions at the end.

Answers

Surgical Site Infections Prophylaxis

After reviewing this 2011 review article from the AFP, you should be able to answer the following questions:

1. What are the six Surgical Care Improvement Project (SCIP) performance measures?

2. In the recent study referenced in the article, approximately what percentage of surgical patients received prophylactic antibiotics within the appropriate time frame?

3. When should repeat antibiotic administration be done?

4. What is the go-to prophylactic antibiotic for most clean-contaminated surgeries?

5. When should vancomycin be used prophylactically?

6. When should metronidazole be added to the prophylactic regimen?

Answers

Derm Terms

See the powerpoint for a review of dermatology terminology and analysis of a case of a HIV+ patient with fever and a generalized rash.

See the following resources for derm education and cases to practice:

Derm Atlas (atlas, cases, & quizzes)
Dermatology Glossary (terms with images)
AAD Med Student Core Curriculum (modules)

Excellence in Clinical Reasoning

Adapted from Dhaliwal's 2011 article in JAMA & his 2012 article in Academic Medicine

1. Build rapport with your patient. For example, delve into the social history before getting into the clinical questions. E.g. occupation, family, home life, immigration history, travel history, etc. Have a positive demeanor. All this makes eliciting a complete history and performing a thorough physical exam much easier. Further, these social details might be the key to the diagnosis!

2. Allow the differential to guide investigations from the start. Develop a broad differential from the chief complaint and narrow the possibilities by asking pertinent questions and performing physical exam maneuvers that address these entities. This makes history taking and physical exam a more of an intellectual challenge, instead of just rote checklists. (Not to undermine checklists. Checklists support safety and quality. Checklists should serve as a back-up of "things not to forget" rather than the principle method of evaluating a case.)

3. Base of knowledge and experience guides evaluation. Without a large base of knowledge and experience, one cannot generate the "pertinents" of a case. Emphasize the importance of study of cases and clinical opportunities. This allows the clinician to develop "illness scripts" - pattern recognition of clinical entities - and the knowledge that allows accurate clinical reasoning when the presentation does not promptly lead to a clear diagnosis. You need to know the disease to detect the disease.

4. Problem representation. AKA the one-liner or the "Assessment". Synthesis of the pertinent details into a meaningful representation of the case that allows the clinician to connect the case to their database of illness scripts and clinical encounters, or appropriately reference their knowledge base to evaluate other possibilities.

5. Utilizing both pattern recognition and analytical reasoning. Familiarity with many different clinical presentations, illness scripts, frequently allows the clinician to steer their investigations to quickly confirm the most likely culprits, but when complex or unclear situations arise, the expert can use analytical reasoning supported by a broad knowledge of the field to guide the investigation.

6. Prioritize. A knowledgable and experienced clinician should be able to use the relevant details of the case to prioritize what conditions are most likely and what cannot-miss diagnoses must be considered.

7. Second opinion. Especially for complex cases, discuss the case and the clinical reasoning with others. One may find there are other ways to categorize the possibilities, other diagnostic algorithms  or new evidence that should be integrated into the work up.

8. Feedback. Follow up the case to its definitive conclusion. This follow up will provide feedback that allows the clinician to refine their clinical reasoning processes and build up their knowledge and experience base to help them in future encounters. Follow up outcomes, treatment responses, lab results, pathology, encounters with other providers, etc. This feedback will hone your judgement.

9. Progressive Problem Solving. Learn from every case, even the "easy" ones. Find a way to reformulate the case in such a way that you consider related challenges, such as potential complications, rare diagnoses, common mistakes, contingency planning, medication side-effects, treatment failures, etc.

10. Simulate. Advance your cognitive skills through case simulation. Review published cases, case-quizzes, and interactive/virtual cases.

11. Deliberate Practice. Select specific competencies that need improvement. Focus on the skill, seek out guidance, study the relevant literature, and repeatedly practice until habitual mastery is achieved.

12. Defend against Cognitive Errors. Of course you cannot defend against cognitive error if you are not aware of the types of cognitive errors that clinicians are susceptible to. This is a whole other topic that will be discussed in the future.

13. Model these behaviors for the benefit of other learners & yourself.

Expect to see more cases, differential building, illness scripts, analytical reasoning, and cognitive errors discussed on this blog.

Cirrhosis Treatment Nuggets

Nuggets taken from AFP review paper on treatment in cirrhosis/chronic liver failure

Link to paper:  Liver Failure Treatment

1) In a patient with ascites, list the Grade A treatment recs.  (hint: 3 types)

2) What percentage of patients with ascites have cirrhosis as its etiology?

3) List causes of ascites that have SAAG <1.1 (hint: 1 malignant, 1 infectious, 1 endocrine/exocrine)

4) If propranolol is contraindicated for variceal bleeding prophylaxis, what's the next drug you can use?

Child-Pugh criteria mnemonic

HAPI BAbi

-hepatic encephalopathy
-ascites
-PT/INR

-Bili
-Albumin

Diagnostic Criteria for SLE

In keeping with our series on mnemonics for rheumatology diagnositic criteria: One on Lupus-

Article from AFP 2003 on Dx of SLE

How many criteria are there?
How many do you need?
What are the criteria?
Know a good mnemonic to remember?

Answers