Teaching
PHYSICIAN
The
January 2011
Volume 10, Issue 1
For those who teach students and residents in family medicine
n
Teaching Points—A 2-minute Mini-lecture
Weight Loss
By John Brill, MD, MPH, University of Wisconsin
Editor’s Note: The process of the 2-minute mini-lecture is to get a commitment, probe for supporting evidence,
reinforce what was right, correct any
mistakes, and teach general rules. In
this scenario, Dr Brill (Dr B) works with
a third-year student (MS3).
M3: Dr B, this is a 69-year-old Vietnamese man who came in for a cough.
I thought it was just going to be a cold,
but his wife noted that he has lost 20
pounds during the last 4 months without trying. I’m worried that he might
have lung cancer.
n
Dr B: Lung cancer! Why are you thinking that?
M3: I didn’t really know where to start,
so I started—anatomically—with the
digestive system. He denied any trouble
with his teeth, swallowing, abdominal
pain, bloating, jaundice, diarrhea, or
change in stools.
Dr B: Good. Then what did you do after
that came up negative?
MS 3: I thought about the times in my
life when I lost weight and how those
might apply to him.
Dr B: Using your life experiences to
relate to a patient? Good.
MS 3: Just seemed like common sense.
So, during college I used to lose weight
when I was really stressed out. And
when I had mono, I lost 15 pounds. My
junior year I was totally broke and had
to live on ramen noodles for a month.
continued on page 2
Information Technology and Teaching in the Office
Working With Learners to Better Educate Our Patients
and Their Families
By Thomas Agresta, MD, MBI, University of Connecticut
Patient education and self-empowerment are some of the most important
tasks we take on as family physicians.
January 2011 | Volume 10, Issue 1
Clinical Guidelines..........................3
POEMs for the Teaching
Physician........................................6
FPIN HelpDesk Answers................7
We know, and often teach our learners,
that ultimately the patient and his/her
family determine adherence to treatment plans, monitoring of symptoms,
and taking on the challenging behavior
changes required for prevention and
treatment. Yet all too often, we shortchange the important task of helping
them truly understand the implications
of their disease, how to properly use
their medicines, what to expect in that
upcoming test or procedure, or when
to call us for changes in symptoms or
status. This is not purposeful but often
occurs nonetheless simply because we
do not have the time or knowledge of
how to use available resources to most
effectively facilitate this process. It is
often quoted that patients remember
only 20% of what we tell them (and
not necessarily the 20% we think they
should remember). This is true of complex communication that occurs in any
setting.
One helpful and effective strategy is to empower your learners to
directly demonstrate how to access
and use trusted on-line patient educacontinued on page 5
Teaching PHYSICIAN
The
Weight Loss
continued from page 1
Dr B: So you used those experiences
to ask him about . . .
MS 3: Depression or anxiety: negative.
Symptoms of infections: except for the
cough, nothing. Access to food seems
OK; his daughter cooks for him, and
there’s plenty. He doesn’t drink alcohol or use drugs. I also thought about
when I re-started running, and I lost
10 pounds, but he hasn’t changed his
activity.
Dr B: Excellent. How did you ask about
depression?
MS 3: I read that, to diagnose depression, you need at least one of the two
main criteria of feeling sad or not doing
things you usually enjoy, so I asked him
about those two things.
Dr B: One widely used screening test
for depression, the PHQ-2, asks about
those two things. Since the test is 95%
sensitive, a negative result can help rule
out depression. You mentioned weight
loss when you had mono; think he might
have that?
MS 3: Mono is pretty unlikely in a 69
year old, but infections like hepatitis
or TB could cause weight loss. Hep B
and TB are more common in Southeast
Asians, but he has tested negative for
both in the recent past.
sis Factor, that inhibit appetite. Where
might he have a cancer?
Dr B: In addition to thinking anatomically or remembering personal experience,
you might also think mechanistically.
When someone is low on something, be
it pounds or potassium, it means there’s
not enough coming in or being made;
too much going out or being used up;
or it’s going to the wrong place. Our
patient seems to be getting enough
calories in, not losing a lot of calories
externally, not doing more activity, so
we’re getting down to . . .
MS 3: The only complaint that he has
is the cough, and he used to be a big
smoker, so he could have a lung cancer.
MS 3: Something is making him burn
more calories. That’s why I thought of
cancer.
Dr B: How does cancer make someone
lose weight?
MS 3: I’m not sure, but I have this picture of an evil cancer growing inside of
him, and stealing all his calories, like
a thief.
Dr B: Quite an imagination you have.
Well, you are partly right. Malignant
neoplasms tend to be more metabolically active than other tissues. That’s
really the basis for chemo and radiation
therapy: cells that are replicating faster
will be destroyed first.
In addition, many cancers also produce hormones, such as Tumor Necro-
Dr B: Very possible; lung cancer is
the fourth most common cancer in US
males, after skin, prostate, and colon.
And, because of its higher mortality,
it’s the leading cause of cancer death.
Let’s summarize what we learned
here today.
MS 3: (1) Two ways to think about undifferentiated complaints like cough are
anatomically and mechanistically. (2) An
effective way to screen for depression
in primary care is with a two-question
screen asking about depressed mood
or anhedonia. (3) A good history can
usually take you to a correct diagnosis. (4) Cancers can cause weight loss
through hormonal appetite suppression
or increased metabolism. (5) Lung cancer is the leading cause of cancer death
in the United States.
Dr B: Superb! Now let’s go see him and
talk with him about next steps.
Alec Chessman, MD, Medical University of South Carolina, Editor
Helping You Teach Better—The STFM Resource Library
Teaching Chronic Disease Management............................................................................... www.fmdrl.org/2853
Lifestyle changes are needed for patients to manage chronic disease. This presentation will help you learn to evaluate residents’
ability to be successful at motivational interviewing and eliciting behavior change in patients while precepting.
Improving the Pelvic Exam: Reducing Iatrogenic Effects, Decreasing
Distress, and Enhancing the Doctor-Patient Relationship.......................................................... www.fmdrl.org/3017
This presentation reviews the potential iatrogenic effects of speculum exams and techniques to improve the exams,
reduce iatrogenic effects, and improve the doctor-patient relationship.
Using the Practice Huddle to Teach Systems-based Practice and Teamwork......................... www.fmdrl.org/2890
The UC-Davis FPR Clinic implemented a Practice Huddle as part of becoming a PCMH. This presentation describes the rationale,
steps, challenges, and outcomes of using a Huddle to teach systems-based practice and teamwork.
2
January 2011 | Volume 10, Issue 1
n
Clinical Guidelines That Can Improve Your Care
University of Michigan Health System:
Acute Low Back Pain
By Diana L. Heiman, MD, University of Connecticut
With the snowy weather that just hit
the entire mid-section of the country,
there’s no doubt that many patients will
present with acute low back pain (LBP).
Even with my sports medicine training,
it’s still the bane of my existence; I’m
sure you are no different.
The University of Michigan has an
excellent set of evidence-based guidelines and this one on Acute Low Back
Pain was revised at the beginning of
2010. (All of the University of Michigan guidelines are available for free
at http://cme.med.umich.edu/iCME/
default.asp, and there is associated
free CME available as well.) Although
this guideline did not evaluate cost effectiveness, the recommendations can
aid in performing an appropriate history
and physical as well as further testing
only as warranted by those findings.
Patient education hand-outs are also
available on the University of Michigan
Web site at www.med.umich.edu/1libr/
guides/lowback.htm.
Acute LBP is defined for guideline
purposes as being of <6 weeks duration
and occurring in patients over the age
of 18. Subacute LBP falls in the 6 weeks
to <3 months period, and chronic back
pain is >3 months duration. Finally,
recurrent LBP occurs in a patient who
has had previous episodes of LBP in a
similar location who is asymptomatic
between episodes; 60%–80% of patients will experience recurrence within
2 years of initial episode of LBP. The
guideline primarily addresses acute
LBP but also addresses risk factors for
developing chronic LBP and things to
look for to identify malingering (Waddel’s five signs).
Two of the more helpful tables are
reproduced below: Table 1 breaks
down the “red flags” into likely etiologies, and Table 2 lists the risk factors for
chronic disability. These are probably
the two areas we worry about most in
evaluating patients and should be the
focus of the initial visit. If risk factors for
chronic disability are identified, aggressive management to prevent disability
should be undertaken. Also important
is realizing the fact that 90+% of patients with nonradiating LBP will have
complete symptom resolution within
6 weeks, whereas 50% of patients
with associated radicular symptoms
will have resolution within the same
time period. The remaining 50% will
generally have continued improvement
to resolution of pain, but the small
percent with disabling pain remaining
at 3 months have <50% chance of full
recovery, and 10% of those remaining
out of work at 1 year have <10% chance
of returning to full work capacity ever
without treatment.
In general, at the first visit (regardless of whether pain is localized or
radicular—pain below the knee) the
evaluation includes a focused history
and examination paying particular attention to the “red flags” in Table 1,
risk for chronic disability in Table 2,
and strength and reflexes on physical
examination. If no red flags are present,
all diagnostic testing is deferred unless
the pain has been present for at least
3–6 weeks. Initial treatment involves:
heat, stretching, analgesics, and muscle relaxants. Acetaminophen, NSAIDs,
and COX-2 inhibitors can be beneficial
in reducing pain and are appropriate to
use and should be dosed around the
clock (not prn) unless the pain is very
minor. Muscle relaxants can also be
beneficial, but have no proved additive
effect when used with NSAID’s. Opiate
pain medications are not indicated for
non-radicular LBP and should be only
used with extreme caution in radicular
Teaching PHYSICIAN
The
The Teaching Physician is published by the
Society of Teachers of Family Medicine,
11400 Tomahawk Creek Parkway, Suite
540, Leawood, KS 66211
800-274-7928, ext. 5420
Fax: 913-906-6096
tnolte@stfm.org
STFM Web site: www.stfm.org
Managing Publisher:
Traci S. Nolte, tnolte@stfm.org
Editorial Assistant:
Jan Cartwright, fmjournal@stfm.org
Subscriptions Coordinator:
Jean Schuler, jschuler@stfm.org
The Teaching Physician is published
electronically on a quarterly basis (July,
October, January, and April). To submit
articles, ideas, or comments regarding
The Teaching Physician, contact the
appropriate editor.
Clinical Guidelines That Can Improve
Your Care
Caryl Heaton, DO, editor
heaton@umdnj.edu
Diana Heiman, MD, coeditor
dheiman@stfranciscare.org
Family Physicians Inquiries Network
(FPIN) HelpDesk
Jon Neher, MD, editor
ebpeditor@fpin.org
Information Technology
and Teaching in the Office
Richard Usatine, MD, editor
usatine@uthscsa.edu
Thomas Agresta, MD, coeditor
Agresta@nso1.uchc.edu
POEMs for the Teaching Family
Physician
Mark Ebell, MD, MS, editor
ebell@msu.edu
Teaching Points—A 2-minute Minilecture
Alec Chessman, MD, editor
chessmaw@musc.edu
continued on page 4
January 2011 | Volume 10, Issue 1
3
Teaching PHYSICIAN
The
Acute Low Back Pain
continued from page 3
LBP. Their early use is associated with
increased disability, even when controlling for severity.
Activity should be prescribed as tolerated. Bed rest is bad! Especially for
non-radicular LBP. Minor work restrictions and avoiding long spans of driving
may need to be prescribed depending
on the level of physicality of the job, but
in general, activity is good as long as it
doesn’t exacerbate the pain.
Follow-up visits should occur weekly,
unless the patient is initially kept out
of work, in which case they should be
seen in 2–3 days to reassess need to
remain out of work. At each follow-up
visit, improvement or deterioration in
symptoms should be assessed as well
as progression or regression of physical
exam findings, specifically strength and
reflexes. If pain is not improved at 1–2
weeks, formal physical therapy should
be considered including manual therapy (manipulation) for non-radicular pain
and McKenzie (extension) exercises for
radicular pain. If radicular pain persists
at 3 weeks, MRI can be considered.
X-rays are not likely to show much. If
the MRI is not diagnostic, an EMG can
then be done to show the area of nerve
root impingement.
For patients at risk for chronic disability at any point, early referral to a
multi-disciplinary back pain program,
if available in your area, can be helpful
in decreasing the likelihood of chronic
disability. Also, referral to a back pain
Table 1
“Red Flags” for Serious Disease
Cauda
Equina
specialist can help in cases where
pathology cannot be demonstrated
objectively on MRI/EMG.
Hopefully, this will help in managing
the very challenging patients that undoubtedly will walk though your door
in the near future.
Reference Material
University of Michigan Health System. Acute low
back pain. Ann Arbor, MI: University of Michigan
Health System, 2010 Jan. 14 p. [11 references]
Available online at www.med.umich.edu/1info/
fhp/practiceguides/back/back.pdf.
Caryl Heaton, DO, UMDNJ-New Jersey Medical School, Editor
Diana Heiman, MD, University of
Connecticut, Coeditor
Table 2
Risks for Chronic Disability
Clinical Factors
Fracture
Cancer
Infection
• Previous episodes of back pain
Progressive neurologic deficit
X
Recent bowel or bladder dysfunction
X
• Multiple previous musculoskeletal
complaints
Saddle anesthesia
X
• Psychiatric history
Traumatic injury/onset,
cumulative trauma
X
Steroid use history
X
Women age >50
X
Pain Experience
Men age >50
Male with diffuse osteoporosis or
compression fracture
Cancer history
• Alcohol, drugs, cigarettes
X
X
X
• Rate pain as severe
X
• Maladaptive pain beliefs (eg, pain will not
get better, invasive treatment is required)
X
• Legal issues or compensation
Premorbid Factors
X
Diabetes Mellitus
• Rate job as physically demanding
X
• Believe they will not be working
in 6 months
Insidious onset
X
X
No relief at bedtime or worsens
when supine
X
X
• Don’t get along with supervisors or
coworkers
Constitutional symptoms (eg, fever,
weight loss)
X
X
• Near to retirement
• Family history of depression
History UTI/other infection
X
• Enabling spouse
IV drug use
X
HIV
X
• Are unmarried or have been
married multiple times
Immune suppression
X
• Low socioeconomic status
Previous surgery
X
• Troubled childhood (abuse, parental death,
alcohol, difficult divorce)
4
January 2011 | Volume 10, Issue 1
Teaching PHYSICIAN
The
Working With Learners
continued from page 1
tion resources to patients and family
members. Giving them this important
task can have many direct benefits for
them as learners, as well as improving
the quality, effectiveness, and overall
satisfaction of your patient care. Many
recent studies show that while patients
increasingly use Internet resources for
health information, they still believe
that their primary care physicians are
the most reliable and trusted source of
information. Yet patients are increasingly asking their doctors to guide them
in accessing quality online information.1
So how can you make it easy to have
learners take on this task while in your
office?
• Have a predefined handout for
patients that lists your trusted patient
education sites.
• Have the URLs for favorite patient
education sites bookmarked on office
computers and within your EMR system
to enable quick and easy access during
a patient encounter.
• Post your preferred Patient Education Sites on your own Web site or
patient portal.
• Show the learner (student or resident) by example how you would like
them to use the tool and watch them
introduce a few patients or families to
Web sites for the first time
• Have them become familiar with
sites as part of a homework assignment
in between patient sessions, then ask
them to teach you more about what is
available.
• Try and incorporate the demonstration of patient education sites into the
“wait time” patients experience (waiting
for a flu shot, an EKG, or bloodwork)
• Give them guidelines and feedback
about how much time to spend on a
topic; often it is only necessary to show
a patient where a resource is, talk about
what it has within it, and then give them
the URL for viewing on their own.
• Have learners be responsible for
creating a “Patient Education Prescription” as part of the health care plan
and put that within their write up of the
encounter.
Having learners take on a substantive role in patient education while they
rotate through your office will help
them better understand the potential
resources, see more clearly the common barriers that patients and their
families face in adhering to our recommendations, and greatly increase the
value that patients themselves place
on learning more about their own health
conditions. It can also be a means by
which we help transition and empower
our staff to take a greater role in this
important task as we try to move our
practices closer to Patient-centered
Medical Homes. I would encourage
you to give this a try—it has greatly
enhanced my own teaching experience
and has been highly valued by students
empowered to take on this fun and
exciting role.
Reference
1. Iverson S, Howard BA, Penny B. Impact of
Internet use on health-related behaviors and
the patient-physician relationship: a surveybased study and review. J Am Osteopath
Assoc 2008;108:699-711.
Richard Usatine, MD, University of
Texas Health Science Center at San
Antonio, Editor
Thomas Agresta, MD, University of
Connecticut, Coeditor
Examples of Trusted Patient Education Sites
Web Site
URL
Comments
Medline Plus
http://medlineplus.gov/
Multi-media Web site maintained by National Library of
Medicine—most sites
Family Doctor.Org
http://familydoctor.org/
Maintained by American Academy of Family Physicians
KidHealth
http://kidshealth.org/
Maintained by Nemours—sections for parents, teens, and kids.
Interactive games and homework helper included.
January 2011 | Volume 10, Issue 1
5
Teaching PHYSICIAN
The
n
POEMs for the Teaching Physician
ARBs and ACE Inhibitors Prevent
AFib
Clinical Question: Can angiotensin
receptor blockers or angiotensinconverting enzyme inhibitors prevent
atrial fibrillation in susceptible people?
Study Design: Meta-analysis (randomized controlled trials)
Funding: Self-funded or unfunded
Setting: Various (meta-analysis)
Synopsis: First, some plausibility: The
renin-angiotensin-aldosterone system
seems to be involved in structural—and
electrical—remodeling of the atrium;
blocking this effect might prevent
atrial fibrillation. We’re beyond theory,
though, and these authors searched
three databases, including the Cochrane Controlled Trials Register, to
identify 26 randomized controlled trials
evaluating the effect of ARBs or ACEIs
on the prevention of atrial fibrillation. All
trials compared one drug with placebo
or with conventional treatment for at
least 6 months. Eleven of the studies
enrolled patients without atrial fibrillation, 12 enrolled patients with atrial
fibrillation, and three enrolled patients
with or without atrial fibrillation. In other
words, the authors of this meta-analysis
combined all studies, regardless of
baseline risk. Most of the studies were
not specifically designed to evaluate
the effect on atrial fibrillation, and only
some of the studies (n=12) specifically
tested for atrial fibrillation, and these
only tested symptomatic patients. The
quality of the studies was not formally
assessed. There was no evidence of
publication bias. Overall, the use of an
ARB or ACEI significantly lowered the
risk of atrial fibrillation. The study results
were heterogeneous and analysis of
specific subgroups of patients showed
prevention was more pronounced in patients with recurrent as compared with
new-onset atrial fibrillation and was
greatest in patients also treated with
amiodarone (odds ratio = 0.35; 95% CI,
0.25–.048). The effect of prevention in
patients with heart failure was not clear.
Bottom Line: Treatment with an angiotensin receptor blocker (ARB) or
angiotensin-converting enzyme in-
hibitor (ACEI) decreases patients’ risk of
developing atrial fibrillation, especially
patients with recurrent atrial fibrillation
and those who are receiving treatment
with amiodarone (Cordarone) to prevent
fibrillation. The clinical application of
this information is unclear, though it
makes sense to use one of these classes of drugs in patients with recurrent
atrial fibrillation who also have another
indication for its use. (LOE = 1a-)
Source article: Zhang Y, Zhang P, Mu Y, et al.
The role of renin-angiotensin system blockade
therapy in the prevention of atrial fibrillation: a
meta-analysis of randomized controlled trials. Clin
Pharmacol Ther 2010;88(4):521-31.
LOE—level of evidence. This is on a scale of 1a
(best) to 5 (worst). 1b for an article about treatmen is a well-designed randomized controlled
trial with a narrow confidence interval.
Mark Ebell, MD, MS, Michigan State
University, Editor
POEMS are provided by
InfoPOEMs Inc
(www.infopoems.com)
Copyright 2011
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January 2011 | Volume 10, Issue 1
Teaching PHYSICIAN
The
From the “Evidence-Based Practice” HelpDesk
Answers Published by Family Physicians Inquiries
Network (FPIN)
n
What Is the Best Treatment for Chlamydia
in Pregnancy?
By Umera Ghouse, MBBS, and Anne M. Proulx, Wright State University
FMR, Dayton, OH
Evidence-based Answer
For treatment of chlamydia in pregnancy, azithromycin 1 g taken orally as
a single dose has similar effectiveness,
better patient adherence, and fewer
adverse effects than a 7-day course of
either amoxicillin or erythromycin. (SOR
A, based on a meta-analysis.) Amoxicillin and erythromycin, however, are less
expensive.
A 2007 meta-analysis pooled eight
randomized controlled trials (RCTs)
conducted from 1991 to 2006 with 587
patients to determine which treatment
strategy for chlamydia in pregnancy
was best. All patients had microbiologically confirmed Chlamydia trachomatis infections. Two RCTs compared
azithromycin with amoxicillin, whereas
six RCTs compared azithromycin with
erythromycin. No difference was noted
in treatment success of azithromycin
compared with amoxicillin and erythromycin (six RCTs with 374 subjects; odds
ratio [OR] 1.45; 95% confidence interval
[CI], 0.82–2.57). Patients taking azithromycin reported fewer gastrointestinal
(GI) side effects than patients taking
amoxicillin and erythromycin (seven
RCTs with 412 patients; OR 0.16; 95%
CI, 0.06–0.4). Total adverse events were
also fewer with azithromycin than with
both comparators (six RCTs with 325
subjects; OR 0.13; 95% CI, 0.08–0.21).
Patients treated with azithromycin also
showed better adherence (seven RCTs
with 413 patients; OR 21.96; 95% CI,
9.05–53.3).1
Limitations of this meta-analysis
include differences in gestational age
at time of screening and differences in
timing of posttreatment cervical cultures for test of cure. Reinfection rates
may be decreased with more advanced
gestational age because of decreased
sexual intercourse rates. Later gestational age at detection may also reduce
pregnancy-related GI symptoms and
affect perception of medication side
effects. Another limitation is the grouping of GI side effects and total adverse
effects of amoxicillin with erythromycin,
instead of evaluating each separately.1
The 2006 updated Centers for Disease Control and Prevention guideline
for the treatment of chlamydia in preg-
nancy advocates the use of azithromycin 1 g in a single dose or amoxicillin
500 mg three times a day for 1 week.2
Treatment costs differ significantly:
Azithromycin was priced at $29 versus
amoxicillin for $14 and erythromycin
for $17 from a major online pharmacy
(http:// www.drugstore.com, accessed
September 16, 2009).
References
1. Pitsouni E, Iavazzo C, Athanasiou S, Falagas ME. Single-dose azithromycin versus
erythromycin or amoxicillin for Chlamydia
trachomatis infection during pregnancy: a
meta-analysis of randomised controlled trials.
Int J Antimicrob Agents 2007;30(3):213–21.
[LOE 1a]
2. Centers for Disease Control and Prevention,
Workowski KA, Berman SM. Diseases characterized by urethritis and cervicitis. Sexually
transmitted diseases treatment guidelines
2006 [published errata appear in MMWR Morb
Mortal Wkly Rep 2006;55(36):997]. MMWR
Recomm Rep 2006;55(RR-11):35-49. http://
www.cdc.gov/mmwr/PDF/rr/rr5511.pdf. Accessed December 16, 2009. [LOE 5]
SOR—strength of recommendation
LOE—level of evidence
Jon O. Neher, MD, University of
Washington, Editor
HelpDesk Answers are provided by
Evidence-based Practice, a monthly
publication of the Family Practice
Inquiries Network (www.fpin.org).
STFM Annual Spring Conference
Register now at www.stfm.org/annual
April 27–May 1, 2011, New Orleans
The Annual Spring Conference
offers presentations focusing on best practices,
new teaching technologies, emerging research, and public policy issues.
7
January 2011 | Volume 10, Issue 1
Know someone outstanding?
Nominate him or her for the 2011 Pfizer Teacher Development
Awards, honoring outstanding community-based family
physicians who are part-time teachers of family medicine.
Each recipient receives $2,000 in scholarship funds, $500 stipend
for a recognition event, and a framed certificate.
Eligibility requirements:
• Member of the American Academy of Family Physicians
• Recent graduate of an ACGME-approved family medicine residency
program (2004-2010)
• Community-based family physician who also teaches as a preceptor
or as an educator of family medicine residents and students
• Practices in community settings or clinics (not in educational institutions
or practices funded or sponsored by an educational institution)
• Teaches on average no less than four and no more than 32 hours
per month
• Teaches voluntarily or receives no more than $18,000 annually
for educational time
To nominate yourself or someone else, go to
www.aafpfoundation.org/ptda and download an
application packet. Submit your completed application
by April 29, 2011.
Questions? Contact (800) 274-2237, Ext. 4457, or
sgoodman@aafp.org.
Support made possible by the AAFP Foundation through
a grant from Pfizer Inc.
January 2011 | Volume 10, Issue 1
8