PBL Pearl Vol 2 (#16): Procrastination

Sent on behalf of Dr. M. Luterman

Procrastination is a complex psychological behavior that affects everyone to some degree or another. With some it can be a minor problem; with others it is a source of considerable stress and anxiety.

Procrastination is only remotely related to time management, (procrastinators often know exactly what they should be doing, even if they cannot do it), which is why very detailed schedules usually are no help.

The procrastinator is often remarkably optimistic about his ability to complete a task on a tight deadline; this is usually accompanied by expressions of reassurance that everything is under control.

(Therefore, there is no need to start.) For example, he may estimate that a paper will take only five days to write; he has fifteen days; there is plenty of time; no need to start. Lulled by a false sense of security, time passes. At some point, he crosses over an imaginary starting time and suddenly realizes, "Oh no! - I am not in control! There isn't enough time!”

At this point, considerable effort is directed towards completing the task, and work progresses. This sudden spurt of energy is the source of the erroneous feeling that “I only work well under pressure.” Actually, at this point you are making progress only because you haven't any choice. Your back is against the wall and there are no alternatives. Progress is being made, but you have lost your freedom.

Barely completed in time, the paper may actually earn a fairly good grade; whereupon the student experiences mixed feelings: pride of accomplishment (sort-of), scorn for the professor who cannot recognize substandard work, and guilt for getting an undeserved grade. But the net result is reinforcement: the procrastinator is rewarded positively for his poor behavior. (“Look what a decent grade I got after all!”) As a result, the counterproductive behavior is repeated over and over again.

Positive reinforcement for delay (a good grade) is a principal contributor to continued procrastination.

Other Characteristics:

Low Self-Confidence - The procrastinator may struggle with feelings of low self-confidence and low self-esteem. He may insist upon a high level of performance even though he may feel inadequate or incapable of actually achieving that level.

I'm Too Busy - Procrastination may be used to call attention to how busy he is. “Obviously I cannot do such and such because my affairs are so complicated and so demanding. That is why I am late, etc.” The procrastinator may even spend considerable time justifying his reasons, time that could be spent doing the work.

Stubbornness - Procrastination may be used as an expression of stubbornness or pride: “Don't think you can push me around. I will do it when I'm good and ready.”

Manipulation - Procrastination may be used to control or manipulate the behavior of others.

“They cannot start if I am not there.” Let's face it: deliberate delay drives others crazy. Coping with Pressures - Procrastination is often truly difficult to eradicate since the delay behavior has become a method of coping with day-to-day pressures and experiences. Obviously if one is cured, others will put new demands and expectations upon you. It's easier to have an excuse, to delay, to put off.

A Frustrated Victim - The procrastinator often feels like a victim: he cannot understand his behavior or why he cannot get work done like others. The whole thing is a frustrating mystery. The reasons for his behavior are hidden from him.


Bottom line....if you identify these behaviors in a student, talk to Karl or myself. After discussing it we may want to seek out some help if it is adversely affecting the student's performance.

Clinical Skills Pearl Vol 2 (#16): Adrenal Insufficiency Part 1

Sent on behalf of Dr. M. Luterman

Topic is Adrenal Insufficiency.
Who was Addisson?
What is his disease?
Which is more common primary or secondary disease?
What are the symptoms?

Dr Thomas Addison was a the British physician who first described the condition in his 1855 publication On the Constitutional and Local Effects of Disease of the Suprarenal Capsules. The adjective"Addisonian" is used for features of the condition, as well as patients with Addison's disease.

Adrenal insufficiency leads to a reduction in the output of adrenal hormones i.e. glucocorticoids and/or mineralocorticoids. There are two types of adrenal insufficiency:

1) Primary insufficiency - there is an inability of the adrenal glands to produce enough steroid hormones (Addison's disease is the name given to the autoimmune cause of this insufficiency). Glucocorticoid and often mineralocorticoid hormones are lost.

2) Secondary insufficiency - there is inadequate pituitary or hypothalamic stimulation of the adrenal glands.

Epidemiology

Primary insufficiency - rare 0.8 per 100,000; affects both sexes equally and can occur at any age.

Secondary insufficiency - relatively common compared to the primary type as exogenous steroid use is frequent leading to suppression of the hypothalamic-pituitary axis.

Presentation:
Note: Advanced adrenal insufficiency is more easier to diagnose but recognition of early cases is more difficult.

Presentation in part depends on the rapidity of adrenal hypofunction Acute - e.g. Waterhouse-Friderichsen syndrome (infarction secondary to septicaemia e.g. meningococcal); presents with collapse and shock 2 Chronic - symptoms develop insidiously and may be mild.

Symptoms
Fatigue and weakness
Anorexia
Nausea
Vomiting
Weight loss
Abdominal pain
Diarrhoea
Constipation
Syncope
Dizziness
Confusion
Personality change
Irritability
Amenorrhoea
Signs
Cutaneous and mucosal pigmentation - look at mucosa and in new scars
Hypotension
Postural hypotension

http://www.patient.co.uk/showdoc/40024894/

PBL Pearl Vol 2 (#15): Feedback Part 2 -- How to give it

Last week we discussed receiving feedback.....this week the tips are on how to give it....remember giving it incorrectly can be quite harmful as can not giving it....yin and yang.....some tips (from the University of Waterloo)....

Dr. Luterman

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Giving Effective Feedback:

• Prioritize your ideas. Limit your feedback to the most important issues. Consider the feedback’s potential value to the receiver and how you would respond – could you act on the feedback? As well, too much feedback provided at a single time can be overwhelming to the recipient.

• Concentrate on the behavior, not the person. One strategy is to open by stating the behavior in question, then describing how you feel about it, and ending with what you want. This model enables you to avoid sounding accusatory by using “I” and focusing on behaviors, instead of assumed interpretations.

Example: “I haven’t seen you in class in for a week. I’m worried that you are missing important information. Can we meet soon to discuss it?”

Instead of: “You obviously don’t care about this course!”

• Balance the content. Use the “sandwich approach.” Begin by providing comments on specific strengths. This provides reinforcement and identifies the things the recipient should keep doing. Then identify specific areas of improvement and ways to make changes.

Conclude with a positive comment. This model helps to bolster confidence and keep the weak areas in perspective.

Example: “Your presentation was great. You made good eye contact, and were well prepared. You were a little hard to hear at the back of the room, but with some practice you can overcome this. Keep up the good work!”

Instead of: “You didn’t speak loudly enough. However, the presentation went well.”

• Be specific. Avoid general comments that may be of limited use to the receiver. Try to include examples to illustrate your statement. As well, offering alternatives rather than just giving advice allows the receiver to decide what to do with your feedback.

• Be realistic. Feedback should focus on what can be changed. It is useless and frustrating for recipients to get comments on something over which they have no control. Also, remember to avoid using the words “always” and “never.” People’s behavior is rarely that consistent.

• Own the feedback. When offering evaluative comments, use the pronoun “I” rather than “they” or “one,” which would imply that your opinion is universally agreed on. Remember that feedback is merely your opinion.

• Be timely. Seek an appropriate time to communicate your feedback.

Being prompt is key since feedback loses its impact if delayed too long. Delayed feedback can also cause feelings of guilt and resentment in the recipient if the opportunity for improvement has passed. As well, if your feedback is primarily negative, take time to prepare what you will say or write.

• Offer continuing support. Feedback should be a continuous process, not a one-time event.

After offering feedback, make a conscious effort to follow up. Let recipients know you are available if they have questions, and, if appropriate, ask for another opportunity to provide more feedback in the future.

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Clinical Skills Pearl Vol 2 (#15): Thyroid Nodules

Sent on behalf of Dr. M. Luterman

The American Association of Clinical Endocrinologists (AACE) released medical guidelines for the diagnosis and management of thyroid nodules. The new guidelines were developed by a panel of experts who encompassdifferent disciplines, including endocrinology, nuclear medicine.

The guidelines emphasize the importance of thyroid nodules in clinical practice. Thyroid nodules are common in the general population and they are typically discovered by palpation in 3% to 7% and by ultrasound (US) examination in 20% to 75%. "Extra" nodules are detected by ultrasound in up to 50% of patients with a single palpable thyroid
nodule.

The estimated annual incidence rate of 0.1% translates into approximately 300,000 new nodules that will be discovered in the U.S. this year. The overall frequency of malignancy in thyroid nodules is approximately 5%, requiring careful selection of patients for surgical treatment.

The panel agreed that all patients with palpable nodules should undergothyroid US examination and FNA. Ultrasound-guided FNA biopsy is suggested for a nodule yielding unsatisfactory aspirate on initial palpation-guided FNA; micronodules <1 cm; impalpable nodules; and for alcohol ablative therapy. The guidelines recommend that micronodules should be selected for biopsy primarily by history and ultrasound characteristics, rather than by size alone.

Click here for a link to the article (requires McMaster login).

PBL Pearl Vol 2 (#14): Receiving Feedback

We are continually receiving and giving feedback. Whether explicit through oral or written language, or implicit in gestures or tone of voice, feedback conveys information about behaviors and offers an evaluation of the quality of those behaviors. Feedback received from our students and feedback given to our students is important to a successful teaching experience. Here are some tips on receiving feedback and next week on giving it...

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Receiving Feedback Effectively

• Listen to the feedback given. This means not interrupting. Hear the person out, and listen to what they are really saying, not what you assume they will say. You can absorb more information if you are concentrating on listening and understanding rather than being defensive and focusing on your response.

• Be aware of your responses. Your body language and tone of voice often speak louder than words. Try to avoid putting up barriers. If you look distracted and bored, that sends a negative message as well. Attentiveness, on the other hand, indicates that you value what someone has to say and puts both of you at ease.

• Be open. This means being receptive to new ideas and different opinions. Often, there is more than one way of doing something and others may have a completely different viewpoint on a given topic. You may learn something worthwhile.

• Understand the message. Make sure you understand what is being said to you, especially before responding to the feedback. Ask questions for clarification if necessary. Listen actively by repeating key points so that you know you have interpreted the feedback correctly. In a group environment, ask for others’ feedback before responding. As well, when possible, be explicit as to what kind of feedback you are seeking beforehand so you are not taken by surprise.

• Reflect and decide what to do. Assess the value of the feedback, the consequences of using it or ignoring it, and then decide what to do because of it. Your response is your choice. If you disagree with the feedback, consider asking for a second opinion from someone else.

• Follow up. There are many ways to follow up on feedback. Sometimes, your follow-up will simply involve implementing the suggestions given to you. In other situations, you might want to set up another meeting to discuss the feedback or to re-submit the revised work.

http://www.cte.uwaterloo.ca/teaching_resources/teaching_tips/tips_challenges/receiving_and_giving_effective_feedback.pdf
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Clinical Skills Pearl Vol 2 (#14): Incidental brain findings on MRI c/o of Dr. Klimek

Why does CSF leak? (How does one measure CSF pressure?)

(Magnaes B. Body position and cerebrospinal fluid pressure. Part 2: Clinical studies on orthostatic pressure and the hydrostatic indifferent point .J. Neurosurg 1976;44:698-705)

There is conceptually a position in the body in which measured CSF pressure does not change during the transition from lateral decubitus to sitting upright.

Imagine that a person is lying down. The opening CSF pressure is the same along the entire length of the spinal canal. With tilting into a vertical posture the pressure of the column of CSF must (like a manometer tube) be proportional to the height of the column (greater at the bottom, less at the top).

In a control group of 72 normal patients, spinal taps were undertaken and the pressure measured as the patient was tilted from lying to sitting upright.

The normal lying CSF pressure measured ranged from 50 to 180 mm H2O. The CSF pressure in the sitting position ranged from 320 to 630 mm (H2O) with a mean of 490 mm. During continued sitting the CSF pressure rose 20 to 60 mm over one hour and returned to normal after lying for 5 minutes.

The occipital prominence is the palpable anatomical landmark beyond which 71 out of 72 normal patients had zero CSF pressure. In other words, maximal CSF pressure measured within 15 minutes of sitting was less than the height of the occipital prominence.

Thus, if one were to measure the opening pressure in the sitting position, it is not higher than the occipital prominence if measured before the increase pressure adaptation occurred.

Therefore a CSF leak above this level would not be accentuated by standing and walking about. However, the possibility of air entering the CSF would be a consideration.

PBL Pearl Vol 2 (#13): Giving Negative Feedback

Please click here for a webpage on giving negative feedback from the London Metropolitan University.

Remember you are not alone. If you have concerns about any of your students please ask me, Karl or Kathy....we are always available to help.

Maynard Luterman MD

Clinical Skills Pearl Vol 2 (#13): Dysphagia

Dysphagia, defined as difficulty in swallowing, can vary in severity, with symptoms ranging from mild throat discomfort to an inability to eat (Galvan, 2001). Perry (2001) described findings of dysphagia that included drooling, difficulty chewing, food pocketing, slow swallowing,coughing, choking, wet-sounding voice, food sticking in the throat,weight loss, heartburn, nasal regurgitation, and aspiration pneumonia.

Dysphagia is a condition that is associated with numerous neurological and neuromuscular diseases. Kayser-Jones and Pengilly (1999) identified stroke, Huntington's chorea, medications with anticholinergic effects (e.g., antidepressants and antihistamines), phenothiazines, and poor dentition as being associated with dysphagia. Myasthenia gravis, cerebral palsy, poliomyelitis, toxic or inflammatory encephalopathy, amyotrophic lateral sclerosis, injury from radiation or surgical procedures for head and neck cancer, and cleft palate also have been identified as contributing to dysphagia (Galvan, 2001). Alzheimer's disease, traumatic brain injury, Guillain- Barre syndrome, tonsillitis, dental caries, xerostomia, and chronic gastroesophageal reflux are other conditions that contribute to dysphagia (Perry, 2001).

It is difficult to comprehend the full extent of this major health problem. Doggett et al. (2001) estimated there are 300,000–600,000 new dysphagia cases each year. The reported mortality rates due to aspiration pneumonia are as high as 6% in the first year after a stroke. (Teasell, McRae, Marchuk, Hillel, & Finestone, 1996). This is a noteworthy finding, considering that nearly half of all stroke patients experience dysphagia (Smithard et al., 1996). According to Galvan (2001), 30%–60% of persons with stroke history have dysphagia. The incidence of dysphagia in Parkinson's disease may be as high as 50% (Galvan, 2001).

Nurses have an important role in identifying dysphagia patients. According to Travers (1999), nurses are the professionals who most often are present at the bedside, particularly at mealtime, and are the first members of the healthcare team to observe signs and symptoms of dysphagia. By recognizing dysphagia early, nurses can help to prevent complications and decrease the number of deaths associated with dysphagia in those who have had a stroke (Travers, 1999).

According to the Canadian Stroke Guidelines all patients diagnosed with a CVA should recieve a swallowing assessment before being fed.

Reference

PBL Pearl Vol 2 (#12): Instilling curiosity Part 2

Some practical tips to foster curiosity in learners . . . courtesy of Marilyn P. Arnone.

Most educators would agree that fostering the scholarly attribute of curiosity in learners is an important task. Providing students with adequate guidance while affording them the opportunities for exploration, however, is probably easier stated than accomplished. As mentioned earlier, not all students are highly curious and what might stimulate curiosity in some students might result in anxiety for others. It becomes the job of the educator and/or instructional designer to recognize these differences and control the classroom or other learning environment to accommodate all learners. With this caveat in mind, the following are ten instructional design strategies for fostering curiosity.

Strategy #1: Curiosity as a Hook
Use curiosity as a primary motivator at the beginning of a lesson by starting, for example, with a thought-provoking question or surprising statement (Small & Arnone, 2000).

Strategy #2: Conceptual Conflict
Introduce a conceptual conflict when possible. Learners will feel compelled to explore the conflict until it is resolved. When the student has resolved the conceptual conflict, he/she will sense a feeling of satisfaction.

Strategy #3: An Atmosphere for Questions
Create an atmosphere where students feel comfortable about raising questions and where they can test their own hypotheses through discussion and brainstorming. Not only does this foster curiosity but it also helps to build confidence.

Strategy #4: Time
Allow adequate time for exploration of a topic. If the teacher has been successful in stimulating curiosity, then learners will want to persist in that exploration.

Strategy #5: Choices
Give students the opportunity for choosing topics within a subject area. For example, in a writing class, the student can explore a topic of his/her interest while accomplishing the goals of the writing task. Being allowed to choose a topic that is intrinsically motivating will help sustain curiosity.

Strategy #6: Curiosity-Arousing Elements
Introduce one or more of the following elements into a lesson to arouse curiosity:
--Incongruity
--Contradictions
--Novelty
--Surprise
--Complexity
--Uncertainty
Learners will desire to explore the source of the incongruity, contradiction, novelty, uncertainty, etc., and the resulting information will satisfy their curiosity.

Strategy #7: The Right Amount of Stimulation
Be aware of the degree of stimulation that is being entered into the learning situation. Remember, there are individual differences when it comes to curiosity. Some learners will become anxious if the stimulus is too complex, too uncertain, too novel, etc. (Gorlitz, 1987). They may quickly leave what Day (1982) refers to as the Zone of Curiosity and enter the Zone of Anxiety.

Strategy # 8: Exploration
Encourage students to learn through active exploration.

Strategy #9: Rewards
Allow the exploration and discovery to be its own reward. "Exploration is self-rewarding (Day, 1982, p.19)." Use external rewards judiciously as some studies have shown that extrinsic rewards given for a task that a learner finds intrinsically motivating may dampen future interest in the activity.<

Strategy #10: Modeling
Model curiosity. Ask questions. Engage in specific exploration to resolve a question posed, and demonstrate enthusiasm.

Conclusion
To instill curiosity in students is to encourage their disposition to learn. To ignore its importance is to risk diminishing, if not losing, the endowment of curiosity conferred upon all at birth.

Dr. Maynard Luterman

Clinical Skills Pearl Vol 2 (#12): Should I order an amylase or a lipase?

What is a better test for diagnosing pancreatitis...lipase or amylase?

Lipase is produced primarily in the pancreas, with a small amount in the liver, intestine, tongue, and stomach. Amylase is derived primarily from the pancreas and salivary glands; it is also present in the ovaries, small and large intestine, and skeletal muscle. Serum amylase is the most commonly used lab test. Serum lipase is believed to be more specific and will stay elevated for a longer period of time, as hyperlipasemia persists for 7 days and amylase should normalize within 4 days. Becuase lipase stays higher longer it may be more sensitive. However it is agreed that patients should be followed on their clincial improvement not on an absolute value of amylase or lipase.

Normal serum amylase and lipase levels do not exclude acute pancreatitis. In one consecutive series, normal serum amylase was documented in 67 of 352 (19%) of contrast–enhanced CT-proven cases of acute pancreatitis.

What other entities could cause an elevated amylase or lipase?

Disease can occur in other organs that produce amylase/lipase. Transmural absorption in intestinal infarction and transperitoneal absorption with a perforated viscus and peritonitis probably explain the hyperamylasemia/hyperlipasemia in these conditions. There is decreased renal clearance in patients with renal failure. Macroamylasemia is a condition in which amylase is bound to a larger protein moiety that prevents renal excretion. Thus, serum amylase is elevated in absence of pancreatitis. Macroamylasemia is diagnosed by detecting a low renal amylase clearance. Increased amylase and lipase
in cholecystitis is probably due to subclinical or undiagnosed coexistent pancreatitis.

Amylase levels may also be significantly increased in patients with pancreatic duct obstruction, cancer of the pancreas, and gallbladder attacks. Urine and blood amylase levels may also be elevated with a variety of other conditions, such as ovarian cancer, lung cancer, tubal pregnancy, mumps, intestinal obstruction, or perforated ulcer, but amylase tests are not generally used to diagnose or monitor these disorders. Decreased blood and urine amylase levels may indicate permanent damage to the amylase-producing cells in the pancreas. Increased blood amylase levels with normal to low urine amylase levels
may indicate decreased kidney function or the presence of a macroamylase, a benign complex of amylase and other proteins that accumulates in the blood.

Dr. Maynard Luterman

Reference

Clinical Skills Pearl Vol 2 (#11): PSA for prostate screening

When the PSA first came out, I was taught it was the mammogram for men. But breast and prostate cancer are different and the bottom line is that treatment in prostate cancer may not equate to increased longevity. In 2008, Annals of Medicine published the article I have summarized below......

Dr. Luterman

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Prostate cancer is the most common non-skin cancer in men in the United States, and prostate cancer screening has increased in recent years. In 2002, the U.S. Preventive Services Task Force concluded that evidence was insufficient to recommend for or against screening for prostate cancer with prostate-specific antigen (PSA) testing.

Randomized, controlled trials and meta-analyses of PSA screening and cross-sectional and cohort studies of screening harms and of the natural history of screening-detected cancer were selected to answer the following questions: Does screening for prostate cancer with PSA, as a single-threshold test or as a function of multiple tests over time, decrease morbidity or mortality? What are the magnitude and nature of harms associated with prostate cancer screening, other than overtreatment? What is the natural history of PSA-detected, nonpalpable, localized prostate cancer? Few eligible studies were identified. Long-term adverse effects of false-positive PSA screening test results are unknown.

Conclusion: Prostate-specific antigen screening is associated with psychological harms, and its potential benefits remain uncertain.

Ann Intern Med. 2008 Aug 5;149(3):I37.

PBL Pearl Vol 2 (#11): Instilling curiosity in students

Educators and instructional designers recognize that instilling curiosity in students encourages their disposition to learn. When students are magnetized by a new idea or a new situation and are compelled to explore further, regardless of external rewards, they can be said to be truly motivated. In each new project, they discover seeds for a future project or a new question to examine. Curiosity is a heightened state of interest resulting in exploration and its importance in motivating scholarship cannot be ignored. Curiosity is also a critical component of creativity and fostering curiosity and creativity in today's learners is a challenge faced by educators and instructional designers alike.

Any discussion of curiosity must begin with Daniel Berlyne, considered to be the seminal mind in the study of curiosity. His neurophysiological view associated curiosity with exploratory behavior.

He identified two forms of exploratory behavior, diversive (e.g., seeking relief from boredom) and specific (e.g., uncertainty, conceptual conflict). It is specific curiosity that is of most interest to educators. Berlyne described specific exploration in the context of epistemic curiosity, that is, "the brand of arousal that motivates the quest for knowledge and is relieved when knowledge is procured" (1960, p. 274). It follows that epistemic curiosity results in specific exploration. This exploration ultimately resolves the uncertainty or conceptual conflict and returns the individual to a moderate, pleasurable tonus level. Although his work was cut short by his untimely death, his accomplishments paved the way for later investigations into the area of curiosity.

Berlyne's colleague, Day, extended the work, representing it graphically as a curvilinear relationship between level of arousal (or stimulation) and efficiency (1982). At the optimal level, a person enters the Zone of Curiosity characterized by exploration, excitement, and interest. Below the optimal level, the individual is unmotivated, disinterested, and inefficient. Beyond the optimal level, the individual enters a Zone of Anxiety with resulting behaviors including defensiveness, disinterest, avoidance, and inefficiency. This curvilinear explanation of curiosity was used in later studies including in an instructional design context exploring differences in young learners' curiosity and achievement in an electronic learning environment (Arnone & Grabowski, 1992, Arnone, Grabowski, & Rynd, 1994).

Whatever explanation one accepts, it cannot be dismissed that curiosity is a necessary ingredient for motivating scholarship. In his motivational design model for enhancing instruction, Keller (1987) acknowledges the important role that stimulating curiosity plays in gaining and sustaining learners' attention, the first component of his model. In fact, it has been argued that curiosity is an equally important factor in each of the other components - relevance, confidence, and satisfaction (Arnone & Small, 1995).

Next week: 10 tips to evoke curiosity in your students......

Taken from:

Using Instructional Design Strategies to Foster Curiosity
By Marilyn P. Arnone

Dr. Luterman

Clinical Skills Pearl Vol 2 (#10): Gallbladder - Part 2

Gallbladder Part B...

Dr. Maynard Luterman

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What is Murphy's sign? What is the best set of lab tests to order to diagnose cholecytitis? What's better CT or Ultrasound to make the diagnosis?

Murphy sign, which is specific but not sensitive for cholecystitis, is described as tenderness and an inspiratory pause elicited during palpation of the RUQ. A retrospective study by Singer attempted to determine a set of clinical and laboratory parameters that could be used to predict the outcome of hepatobiliary scintigraphy (HBS) in all patients with suspected acute cholecystitis. The results of the study showed that, in 40 patients with pathologically confirmed acute cholecystitis, fever and leukocytosis were absent at the time of presentation in 36 (90%) and 16 (40%) of the patients, respectively. The study also found that no combination of laboratory or clinical values was useful in identifying patients at high risk for a positive HBS finding. And by the way an elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis.

Ultrasonography provides greater than 95% sensitivity and specificity for the diagnosis of gallstones more than 2 mm in diameter. Ultrasonography is 90-95% sensitive for cholecystitis and is 78-80% specific.Studies indicate that emergency clinicians require minimal training in order to use right upper quadrant ultrasonography in their practice. The sensitivity and specificity of CT scan and MRI for predicting acute cholecystitis have been reported to be greater than 95%. Spiral CT scan and MRI (unlike endoscopic retrograde cholangiopancreatography [ERCP]) have the advantage of being noninvasive, but they have no therapeutic potential and are most appropriate in cases where stones are unlikely.

PBL Pearl Vol 2 (#10): The Quiet Student

What do you do with the quiet student? Here are some strategies......

Dr. Maynard Luterman

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Use verbal and non-verbal cues to encourage participation.

Do not rely on the same volunteers to answer every question. Respond to frequent volunteers in a way that indicates that you appreciate their responses, but want to hear from others as well. Move to a part of the room where quiet students are sitting; smile at and make eye contact with these students to encourage them to speak up. By the same token, when frequent volunteers speak, look around the room rather than only at them to encourage others to respond (see below).

Reduce students’ anxieties by creating an atmosphere in which they feel comfortable “thinking out-loud,” taking intellectual risks, asking questions, and admitting when they do not know something; one of the best ways to do this is to model these behaviors yourself.

Listen fully to your students’ questions and answers; avoid interrupting.

Resist the urge to interrupt when you think you know what the student is going to say or ask. Often, well-meaning and enthusiastic instructors make incorrect assumptions and leave their students’ actual questions unanswered or misrepresent what the students had planned to say.

Provide specific, encouraging, varied responses.

Point out what is helpful or interesting about student contributions.

Pick up on comments that were made but not discussed. Do not use the=2 0 same, standard praise to respond to every comment. When students hear “good point” again and again, they start to lose motivation. Ask follow-up questions to prompt students to clarify, refine, and support their ideas. When a student gives an incorrect or ill-conceived answer, respond in way that challenges the student to think more deeply or to reconsider the evidence. The best way to shut down participation, and learning, is to embarrass a student.

Place the emphasis on student ideas.

Encourage students to share their ideas and use those ideas (with attribution) whenever you can. Referring back to a comment made by a student in an earlier class demonstrates that you have thought about and appreciated what your students have to say.

http://teachingcenter.wustl.edu/increasing-student-participation

Clinical Skills Pearl Vol 2 (#9): Gallbladder

The next two clinical skills muses are devoted to your gallbladder.

Dr. Luterman

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How common is acute cholecytitis? Guess what surgical procedure is the most common in the USA? Which gender gets gallstones more commonly? True or false: acalculous cholecytitis is worse than regular cholecytitis.

Next week we will talk about some of the diagnostic modalities......

Acute calculous cholecystitis is caused by obstruction of the cystic duct, leading to distention of the gallbladder. As the gallbladder becomes distended, blood flow and lymphatic drainage are compromised, leading to mucosal ischemia and necrosis. An estimated 10-20% of Americans have gallstones, and as many as one third of these people develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most common major surgical procedure performed by general surgeons, resulting in approximately 500,000 operations annually. Gallstones are 2-3 times more frequent in females than in males, resulting in a higher incidence of calculous cholecystitis in females. Acalculous cholecystitis is observed more often in elderly men. Patients with acalculous cholecystitis have a mortality rate ranging from 10-50%, which far exceeds the expected 4% mortality rate observed in patients with calculous cholecystitis. Emphysematous cholecystitis has a mortality rate approaching 15%.

Gladden et al.

PBL Pearl Vol 2 (#9): Communication Skills

What are some of the intangibles with PBL? We have talked about learning and how PBL seems to promote this learning. What about communication skills and malpractice? I found this article online.....PBL improves communication skills and improves patient satisfaction...after all isn't that what we strive for....to satisfy our patients?

Some excerpts from the article:

"It is well accepted that it is not quality of care, medical negligence or chart documentation that are the critical factors in whether or not patients complain, but patient dissatisfaction. The combination of a bad outcome and patient dissatisfaction means that the patient is much more likely to complain. The largest factor in patient dissatisfaction is communication breakdown."

"One USA study 23 noted that, in a general practice setting, GPs that had no malpractice claims used more statements of orientation (informing patients about what to expect and the flow of the visit), laughed and used humor more often, and used more facilitation skills (soliciting patient opinion, checking understating, and encouraging patients to talk). Their routine consultations were longer (18.3 vs 15 minutes) when compared to GPs who had received patient complaints."

Dr. Maynard Luterman

PBL Pearl Vol 2 (#8): The experience of a first time tutor

This week’s pearl is care of Dr. Bruce Rosenberg....he writes about his experience as a first time tutor.....well worth the read....

Dr. Maynard Luterman

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Maynard,

We are doing much better after implementing Mike's feedback. Our objectives for Ted Mitchell, the drunk (which might not sound PC but apparently is. As I was recently informed by someone: "I'm a drunk. Alcoholics want treatment.") prior to digesting Mike's comments were boring things like: Anat and Phys of Liver, What is CAGE, etc. We had a pre-case meeting and went to the much more interesting: Why is his belly swollen? Wazzup with the yellow? What should we do to find out where the hematemesis is coming from and once we know, why/how (which led to a great discussion of portal HiBP and varices).

So anat/phys has now become what we refer to as the ante. If you don't have that, you can't even play. Come with enough to be in the game and some days you will be the big guy (with lots of knowledge about the case) and other times you might not be The Guy, but on that day someone else probably will be loaded with knowledge and either way, the game will be exciting and interesting.

We begin answers to our questions with a basic overview of the underlying anat/phys or whatever basic knowledge everyone should have to offer a quick check for everyone that they understand the fundamentals. Since we all agreed to at least do this, the review is very efficient. Then the person who gave the quick overview can either try to answer the question (like Wazzup with the yellow?) or they can ask someone else in the group for their opinion. Mike was right that this stimulates a much more interesting discussion which creates some depth in the otherwise relatively thin layer of general knowledge they have. I have been reassuring them that, over time, they will create more areas of depth in their knowledge veneer and at some point, they will know quite a bit about the whole topic. For now, knowing a little about the whole and a lot about one area (as defined by the case), is what PBL seems to be about. Other than occasional straying (about liver regenesis), we were very focused and all agreed that the process felt a lot better. There was hardly any yawning and only one 5 minute break, which I take as positive signs.

Finally, to emphasize the importance of THIS CASE, we have agreed that, in contrast, each student will identify 3-5 other problems that could be this case but aren't. For example, we are doing the celiac case today. We expect that, when someone looks at Malabsorption Syndrome, there will be 85 differentials. We decided that they should read about differentials as part of their study, but since they can't digest all the information, instead try to pick out a few other problems that could give a young man weight loss and diarrhea over a 1 year period. Clustering of differentials will give them a reference point (Dr Cork) to remember similar conditions, rather than acute or other diarrheas that are not reasonable differential considerations. We are only going to spend a few minutes on this, but it will add some clinical flavor as well as provide a guideline when confronted with voluminous differential choices (find ones like the case and try to learn a tiny bit about them, then broaden your knowledge over the years from that starting point which, if we do the in depth case study properly, will be a well anchored point).

So, that's my report. Whether we are or not, we believe that we are 'getting it' and moving along a better track. Our previous track was more a series of mini-lectures from various students, although in fairness, the 2 failure to thrive cases are less conducive to our improved approach than Ted and subsequent cases.

We have a makeup session tonight and I think everyone is keen to see if we can repeat our positive experience of yesterday. Please thank Mike for me and let him know that his comments did not fall upon deaf ears. Maybe he will be able to attend a later session where we will be able to give him the ole Mac follow up/feedback so that he can fine tune his criticism of later groups (but in fairness, his comments obviously rang clear and we have modified our ways). Anyway, thanks Mike, but I don't have his email address.

In closing, I'm happy to report that my students are still med students at heart, already priming me for some of the answers they gave on their CAE's that I have not yet received for marking. I'm glad that the obsessive nature you and I had to gain admission has not been taken out of the future generation. I'll keep you posted.

Bruce

Clinical Skills Pearl Vol 2 (#8): Detecting alcohol abuse

A teacher once told me if I understood the physiological manifestations of diabetes and alcoholism I would be a very smart doctor....so here is an interesting article I just read on detecting alcohol abuse.

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Screening for unhealthy alcohol use is not regularly performed in many clinician offices. In a study by Friedmann and colleagues, which was published in the February 2000 issue of the Journal of General Internal Medicine, while 88% of 853 clinicians reported regularly asking about alcohol consumption when interviewing new outpatients, only 13% of clinicians reported using formal alcohol screening tools.

A simpler screening instrument might increase the rates of screening and detection of unhealthy alcohol use. The current study examines the usefulness of a single-question screening tool in the primary care setting.

Adult English-speaking patients recruited from primary care waiting rooms were asked, "How many times in the past year have you had X or more drinks in a day?" (X = 5 for men and 4 for women). A positive response to this single-question screen was defined as more than 1. Patients were considered to have unhealthy alcohol use if a standardized diagnostic interview revealed the presence of an alcohol use disorder or if a validated 30-day calendar method showed risky consumption.

The interview was completed by 286 (73%) of 394 eligible primary care patients. For identification of unhealthy alcohol use, the single-question screen was 81.8% sensitive (95% confidence interval [CI], 72.5% - 88.5%) and 79.3% specific (95% CI, 73.1% - 84.4%). For identification of a current alcohol use disorder, the single-question screen was slightly more sensitive (87.9%; 95% CI, 72.7% - 95.2%) but was less specific (66.8%; 95% CI, 60.8% - 72.3%).

Test characteristics of the single-question screen resembled those of a commonly used 3-item screen. Subject demographics affected diagnostic performance of the single-question screen only minimally.

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So, "how many times in the last year have you had more than 5/4 drinks in a day" seems to be a simple question we can ask to screen.

Maynard Luterman MD

http://cme.medscape.com/viewarticle/589706?src=cmenews

PBL pearl Vol 2 (#7): How can we be better facilitators?

This week I thought I would put out as a point of discussion how we can be better facilitators. This is based on a lot of reading I am doing of late and many conversations with previous tutors. The general consensus is the facilitator should always try to step back and observe the group function. By this I mean look at how group members reason, engage in their critical thinking and process information, and
how they interact with each other. We should avoid teaching and instead act as a resource trying to take students to the end of their knowledge, helping them realize when they are not focused. The biggest task is to assist the group to be self aware and self correcting and most importantly modeling good group behavior. As any facilitator we must give timely (i.e., prompt) and effective feedback.....and we should
not let things build. Most important we need to be flexible, these are smart souls. Last but not least life is short so have fun.

A teacher's purpose is not to create students in his own image, but to develop students who can create their own image. ~Author Unknown


I like a teacher who gives you something to take home to think about besides homework. ~Lily Tomlin as "Edith Ann"

Maynard

Clinical Skills Pearl Vol 2 (#7): How helpful is physical examination in assessing liver size?

Click here for a review (from the University of Washington) of the evidence base around performing physical examination of the liver.

PBL Pearl Vol 2 (#6): The First Group Session

Keeping in mind that PBL is as much about the process as the content, this week's topic is about starting the group. In my group session days we would call this "building the container" -- a metaphor for the vessel you will use to move with the group. I am interested in everyone's feedback so please wade in . . .

The First Group Session

Be sure you have the necessary information: Bring your manual to the session, the names of the students in your group and something to keep notes on.

Seating arrangements: Be sure that conversation can flow easily, and be sure that everyone can establish eye contact with everyone else in the group.

Tutor introductions: Tutors will introduce themselves by telling the group something about their field and personal interests. Tutors may want to identify how they wish to be addressed (e.g., "Please call me Barry in these group sessions and Dr. Smith in the clinical setting").

Student introductions: Students will be asked to introduce themselves to the group. Ask the students to tell about themselves, their interests, and background etc.

Review the objectives of PBL and the evaluation process: Briefly go over the process and the objectives of PBL and review the evaluation process. It may help to discuss your understanding of the objectives expectations and ask the students what their understanding and expectations are. It is especially useful if the members of the group discuss their own experience in previous PBL groups - what worked, what didn't. This should lead to a consensus as to how to proceed in the current sessions. It also serves to prevent some problems before they arise.

Starting the case: After the introductions and discussions are completed, the tutor should identify the case to be discussed and the process begins with the students reading it out loud. Based on their current level of knowledge the students then discuss the key information presented, formulate hypotheses as to the nature of the
problem, discuss what information may be needed to test their hypotheses, and, finally, generate a list of learning issues. Your task is to facilitate not lead this process.

Adapted from a document from the Fiji School of Medicine.

Dr. Maynard Luterman

Clinical Skills Pearl Vol 2 (#6): Video Clips of Physical Exam

Our students have access to a number of resources for learning the physical exam. One of these resources is the video clip. This paper (click here) shows these video clips to be a good resource for medical students. While I don't think its a replacement for good clinical instruction, it may be something to keep in mind as a resource to point them towards . . .

Dr. Maynard Luterman

Clinical Skills and PBL Pearl Vol 2 (#5): Generation Me

Students today (Generation Me) differ from those in the past. They score higher on assertiveness, self-liking, narcissistic traits, high expectations, and some measures of stress, anxiety and poor mental health, and lower on self-reliance, suggests Jean Twenge (Medical Education 2009: 43; 398-405). Today’s students would benefit from a more structured but also a more interactive learning experience. Also, over-confidence of students may need to be tempered. Staff should give very specific instructions and frequent feedback and should explain the relevance of the material. Instruction should be arranged in shorter segments and incorporate more material delivered in media such as videos and interactive format.

Courtesy of Dr. K. Stobbe

PBL Pearl Vol 2(#4): Emotional Intelligence and Choice of Specialty

We often assume certain personality types go along with certain specialties. When students are making choices, we may try to guide them into specialties that suit their personality. Is there really a “surgical personality”? A “type of person who would make a good family doctor”?

This paper looks at 3 independent studies of “emotional intelligence” in medical students and linked this to their choice of specialty. Emotional intelligence refers to empathy and emotional connectedness, and there exist a number of validated measurement tools.

Across all 3 studies, using different measurement tools, in different medical schools, and dividing specialty choice in different w ays (primary care vs. specialty and technical-surgical specialties vs. others) no significant differences were found in emotional intelligence between students and their choice of specialty.

Bottom line for me: I’ll stop using student personality as a factor in coaching them toward certain specialties.

Borges, Stratton, Wagner, Elam in Medical Education 2009; 43: 565-572.

Dr. Karl Stobbe

Clinical Skills Pearl Vol 2 (#4): What’s the best way to teach suturing and other procedural skills?

This "pearl" (previously known as a "muse") was contributed by Dr. K. Stobbe. It comes from Brydges, Carnahan, Safir and Dubrowski in Medical Education 2009, 43: 507-515. NOTE: this approach is meant for early learners – those with very little or no experience.
___________

We want our students to learn efficiently – i.e. the most learning in the least amount of time. We also want them to learn in a way that will stick – to retain their skills over time. The literature cites factors which can optimize the students’ learning, for both efficiency and retention. Self-guided learning and the setting of performance goals by students are more efficient and result in greater skill retention than traditional teaching.

What exactly is self-guided learning? Students first observe an expert performing the procedure, then are able to practice on their own, while being able to refer back to the expert performance when they wish (e.g. using a video). This is efficient – they learn the skill more quickly than traditional skills instruction.

Students who set their own goals retain their skills longer than those whose learning goals are set by the teacher. However they need guidance in setting goals, such as a list of what constitutes good performance. There are 2 general types of goals: outcome goals and process goals. It turns out that students who set process goals show greater skill retention than those who set outcome goals.

Here’s an example. When teaching suturing, outcome and process goals would look something like this:

• Outcome goals: Complete each interrupted suture and knot tie in a timely manner. Be sure to equally space the sutures, evert the skin edges, and ensure that every knot is square.

• Process goals: Needle is loaded on the driver 2/3 along the length and enters tissue perpendicular to the skin. Concentrate on hand pronation and supination when passing the needle through the tissue. Take the same size bite on each side of the wound. Ensure each throw is down square, either by having the sutures crossed, or by crossing your hands. Maintain appropriate tension on the tie.

How will this information affect my teaching of procedures for inexperienced students?

1. If a student has never seen the procedure performed, I’ll demonstrate it once, or tell them to view a video on-line.
2. Self-guided: I’ll ask the student what they want to focus on this time. I’ll restrict my feedback to the element the student’s interested in, unless they’re compromising patient care.
3. I’ll restrict my teaching comments to how they’re doing the procedure rather than the end result.

Dr. Karl Stobbe

Clinical skills and PBL Muse Vol 2 (#3): Listening Skills

A major complaint that patients have with doctors is that they do not listen. Efficiency in listening skills however, has attracted little attention in the medical curriculum. How can this skill best be inculcated in medical students?

Preparing medical students to be attentive listeners is the subject of a paper by Boudreau and colleagues in Medical Teacher (2009; 31: 22-29). The authors developed a set of eight core principals of attentive listening. These were then used to design specific teaching modules in the context of curriculum renewal at the Faculty of Medicine, McGill University.

Attentive listening . . .

• is a perceptual, cognitive and social act.
• is an active process.
• is triadic: the speaker, the utterance, and the listener.
• involves focusing on word choice, paralanguage and non verbal cues and signs.
• requires receptiveness, an understanding of how spoken language works, and the ability to move between open-mindedness and an awareness of inference.
• can accomplish the following: reveal the personhood and concerns of the speaker (i.e. the patient); produce diagnostically relevant data; assist in healing.
• is not a neutral act – it can have a positive and negative impact on the patient, physician and their relationship.
• necessitates the formation of new habits.

In their paper the authors provide a sample of activities and tasks that are designed to teach these core principals to first year medical students.

Medical Teacher; Volume 31. Number 6 – June 2009 (2009; 31: 563-568)

PBL Muse Vol 2 (#2): Your role as tutors

The particular way in which students are asked to learn has a strong influence on how well they will be able to recall and apply what they have learned in the real clinical world outside of  medical school. The basic aim of the PBL curriculum is to have our students:

1) Reason their way through patient problems.

2)  Recall and apply what they have been taught to the care of their patients.

3) Recognize when their skills and knowledge are not adequate to the clinical task they are confronting.

4) Acquire new information and skills as they need it, and, as medical research moves ahead, keeping contemporary in their knowledge and skills.

5) Work independently and yet support a team approach, a task so important to the practice of medicine today.

Your role as tutors is to support this way of learning.

Dr. Maynard Luterman

Clinical Skills Muse Vol 2 (#2): The Six Habits of Highly Respectful Physicians

Here is an article from the New York Times describing six steps to promoting "etiquette-based medicine".

Clinical Skills and PBL Muse Volume 2 #1: Improving the performance of students

From Medical Teacher 2009; 31:675-676

What 7 principles of good undergraduate teaching improve the academic performance of students?

1) Level of contact between students and teachers
2) Reciprocity and co-operation among students
3) Active learning
4) Prompt feedback
5) Awareness of the time needed to be spent on the task
6) High expectations
7) Respecting diverse talents and ways of learning

These were identified in 1991 by Chickering and Gamson. Subsequently adopted in 2008 Lowis and Castley (Innovations in Education and Teaching International 2008; 45:333-343) in the development of an inventory for predicting student progression and achievement. This was tested on remedial students and shown to improve their performance.

Summarized by Dr. K. Stobbe

Clinical Skills and PBL Muse #27: Going on vacation

Going on vacation may be more than just a pleasure. It may actually be good for all aspects of your health . . .

Dr. Maynard Luterman

Clinical Skills Muse #26: Breast cancer detection

Click here for a 2004 position statement from the National Breast Cancer Centre on early detection of breast cancer, courtesy of Dr. Luterman.

PBL Muse #26: What makes a good teacher?

Click here for a two-page commentary on important principles of good teaching.

Clinical Skills Muse #25: Transfusions Part 2 -- Clinical Signs

So last week we talked about the different types of transfusion reactions...this week can you describe what the patient will complain of (history) and what physical findings you may find if the patient is having a reaction (physical findings)?

Click here for the original article.

History

In hemolytic transfusion reactions, symptoms usually occur after a small amount of blood has been transfused and almost always before the unit is transfused completely. These reactions are associated with the following:
-Fever
-Chills
-Flushing
-Nausea
-Burning at the intravenous (IV) line site
-Chest tightness
-Restlessness
-Apprehension
-Joint pain
-Back pain

Nonhemolytic febrile reactions do not occur as rapidly as acute hemolytic reactions. They occur between 1 and 6 hours of transfusions and are associated with the nonspecific symptoms of fever, chills, and malaise. Some patients may complain of dyspnea. These nonspecific symptoms also occur with a hemolytic transfusion reaction.

In anaphylactic reaction, symptoms usually occur with less than 10 mL of blood transfused and only rarely occur more insidiously. These reactions are associated with rapid development of the following:
-Chills
-Abdominal cramps
-Dyspnea
-Vomiting
-Diarrhea

Minor allergic reactions are associated with urticaria.

Extravascular hemolytic reactions are associated with fever and chills. Symptoms often occur after several hours and sometimes may be observed several days after transfusion.

Symptoms of transfusion-related acute lung injury start suddenly while the blood products are being transfused or shortly thereafter. Dyspnea is the primary presenting symptom.

Graft-versus-host disease often presents within the first week following transfusion, although it may be delayed up to several weeks following transfusion. Symptoms include the following:
-Fever
-Abdominal pain
-Nausea
-Vomiting
-Diarrhea, often copious
-Anorexia

Hypocalcemia from multiple transfusions may present with circumoral tingling and tremors of the skeletal muscles.

Physical

Hemolytic transfusion reactions are associated with the following signs, which usually occur after a small amount of blood has been transfused and almost always before the unit is transfused completely:
-Tachycardia
-Tachypnea
-In severe cases, hypotension, oozing from the IV site, diffuse bleeding, hemoglobinuria, and shock
-Oliguria may be seen in renal failure.

(IMPORTANT) In unconscious or obtunded patients, the diagnosis of hemolysis is suggested by development of the following:
-Hypotension
-Dark urine
-Oozing from an IV or other puncture sites

Nonhemolytic febrile reactions are associated with a fever.

Anaphylactic reactions are associated with the following:
-Tachycardia
-Flushing
-Urticaria
-In more severe cases, wheezing, laryngeal edema, and hypotension

Minor allergic reactions are associated with urticaria.

Extravascular hemolytic reactions are associated with fever. Only rarely are signs of shock and renal failure noted. Clinical signs may occur several days later.

Patients with transfusion-related acute lung injury will present with the following signs:
-Fever
-Tachycardia
-Tachypnea
-Rales

Graft-versus-host disease often presents with the following signs:
-Erythematous, maculopapular rash, which may progress to toxic epidermal necrolysis Right upper quadrant tenderness
-Hepatomegaly

Again, here is the full article.

Maynard

PBL Muse #25: Habits of Highly Effective Teachers

This week’s PBL muse is about the 7 traits that highly effective teachers should have.....truth is, the reviews on the Niagara Campus teachers by our students has been superlative....keep up the great work....we are shaping some brilliant new medical minds.

Click here for the list of traits.

Maynard

PBL Muse #24: What students remember about teachers

Today’s PBL muse is on what students remember about their teachers. Amazingly it’s not their ties although I have seen some I won't forget in my lifetime. Click here.

Maynard

Clinical Skills Muse #24: Transfusions Part 1

Patients with acute blood loss or symptomatic anemia frequently require blood replacement therapy. SO TODAY'S QUESTIONS ARE 1) CAN YOU DESCRIBE THE PATHOPHYSIOLOGY OF 5 DIFFERENT TRANSFUSION REACTIONS 2) WHICH IS THE MOST COMMON?

As a clerk, one of the things you will be called to assess (or were called to assess!) are adverse blood transfusions reactions . . . if you suspect a reaction, the first treatment is to stop the transfusion. So what are some of the adverse effects of a blood transfusion?

1) Hemolytic transfusion reactions are the result of antibodies in the recipient's plasma directed against antigens on the donor's erythrocytes. This results in rapid intravascular hemolysis of the donor red blood cells. ABO incompatibility due to clerical error is the most frequent cause. This results in hemoglobinemia, hemoglobinuria, disseminated intravascular coagulation (DIC), renal failure, and complement-mediated cardiovascular collapse.

2) Nonhemolytic febrile reactions are thought to stem from the formation of cytokines during the storage of the blood. These reactions seldom proceed to hypotension or respiratory distress.

3) Infectious diseases also may be transmitted through transfusion. (Hep B and Hep C, bacteria, viruses etc)

4) Transfusion-related acute lung injury may be caused by transfusing any plasma-containing blood product. It is caused by the interaction between the recipient's leukocytes and preexisting donor antileukocyte antibodies. This results in complement activation and increased pulmonary vascular permeability. In addition, mediators of inflammation that form while the blood is in storage are also felt to be contributory.

5) Massive transfusion is defined as the replacement of more than one-half of the blood volume within a 24-hour period or the replacement of 10 units of blood over the course of a few hours. Complications of massive transfusion include the following: -Coagulopathy is caused by a dilutional effect on the host's clotting factors and platelets, as well as the lack of platelets and clotting factors in packed red blood cells.
-Volume overload
-Hypothermia
-Hyperkalemia may be caused by lysis of stored red cells and is increased in irradiated red blood cells.
-Metabolic alkalosis and hypokalemia may be caused by the transfusion of a large amount of citrated cells.
-Hypocalcemia due to citrate toxicity may occur in those with hepatic failure, congestive heart failure (CHF), or other low-output states.

Frequency
1) Hemolytic transfusion reactions occur in 1 per 40,000 transfused units of packed RBCs.
2) (MOST COMMON) Nonhemolytic febrile reactions and minor allergic reactions are the most common transfusion reactions, each occurring in 3-4% of all transfusions.
3) Nonhemolytic febrile reactions and extravascular hemolysis are observed more commonly in patients who have developed antibodies from prior transfusions.
4) Anaphylactic reactions occur in 1 per 20,000 transfused units.
5) Due to improved preventative measures, the incidence of GVH disease is less than 0.15%.
6) Transfusion-related acute lung injury complicates 0.1-0.2% of all transfusions.
7) Risk of transfusion-related hepatitis B is 1 per 50,000 units transfused. Risk for hepatitis C is 1 per 3000-4000 units transfused. Risk of transfusion-related HIV infection is 1 per 150,000 units transfused.

Posted on behalf of M. Luterman

Clinical Muse #23: UTI's and Cranberries

Cranberries for preventing urinary tract infections.......something patients in your office always ask about......and now you can buy cranberry tablets.....I sometimes where a cranberry colored thong if my prostrate is bothering me (only kidding)....anyways I came across this article and like everything you will hear, without good evidence it’s at best anecdotal and so someone looked at cranberries and UTI's.....Maynard

Here is the link to the review.

PBL Muse #23: Disciplinary Action by Medical Boards and Prior Behavior in Medical School

Here is a summary of a paper form the NEJM on professional behavior and why it is so important we identify and correct any aberrations early on. Maynard.

Clinical Muse #22: Dialysis

Working in the Welland ER, I see a lot of renal patients.....thought this data was interesting on dialysis...

DIALYSIS SURVIVAL

Summary:

• The survival of all dialysis patients starting dialysis in 1993 to 2002 was 90%, 73%, 60% and 39% at one year, 3 years, 5 years and 10 years respectively.

• CAPD patients had a 74% higher risk of death compared to haemodialysis patients.

• Survival of dialysis patients in recent vintage was lower than in earlier vintage. Compared to the 1997-1998 cohort the mortality risk of 1999-2000 and 2001-2002 cohorts were increased by 21% and 27% respectively.

• Diabetics on dialysis had 2.1 times higher risk of death compared to non-diabetics.

• Low serum albumin concentration, low body mass index and low serum cholesterol level were independent risk factors for mortality.

• There was a U-shaped relationship between diastolic blood pressure and risk of mortality.

• The haemoglobin level associated with the lowest risk of mortality was 110-120.

• Hyperphosphataemia, hypercalcaemia and low calcium phosphate product were associated with increased risk of death.

• Hepatitis B or Hepatitis C status did not affect patient survival.

Maynard Luterman

PBL Muse #22: Medical Student Professionalism

Today’s muse asks the question: is there a relationship between medical student professionalism and lapses in professionalism when they become physicians?

Professional behavior is considered essential to the practice of medicine, and is increasingly emphasized in medical school curricula. However, several obstacles limit the effectiveness of professionalism education in medical training. Medical educators struggle to define and measure professionalism, which, in fact, is usually identified in terms of its absence-when unprofessional behavior is observed in trainees. Instruments to assess professionalism reflect this struggle for consistency and credibility. There is also skepticism as to whether professionalism is a learnable skill or an inborn character trait. Student peers and teachers are often reluctant to report negative behaviors, either because they do not directly observe such behaviors, or feel personally uncomfortable with (or fear) the confrontation that arises in making such reports. Finally, faculty typically encounter such behaviors as isolated events, and may be hesitant to generalize about what are seen as solitary behaviors in individual students.

Click here for the abstract of a research study on this topic.

Maynard Luterman

Clinical Skills Muse #21 - Microscopic Hematuria

This week is about microscopic hematuria.....and these answers are based on the Canadian Urological Association Guidelines.....so here are the questions....

1) What is microscopic hematuria? 2) Who do you workup? 3) What do you do with the negative workups?

Click here for the answers.

Maynard Luterman

PBL Muse # 21 - Death and Dying

This study is interesting, and important for our students, many of whom will encounter death and dying for the first time during med school.

How does McMaster handle the issue? This is part of the Professional Competencies (Procomp) curriculum, which runs every Tuesday morning. Our students are divided into 2 groups which stay together for their entire preclerkship. Each group has 2 "Longitudinal Facilitators" - one is a physician and one a non-physician; in our case this year the non-docs are a nurse and a psychologist. The Procomp curriculum is quite comprehensive and covers all the non-scientific elements of being a doctor: professionalism, ethics, legal issues, communication, and more. End of-life is part of the Procomp curriculum. There's quite an intense focus on this, I've seen students quite shaken after some sessions.

There's focus on both appropriate professional behavior as well as the students' own feelings and how to deal with them. Students' intense feelings during these particular Procomp sessions sometimes affect them later - they might be 'out of sorts' during tutorial or clinical skill sessions on those days.

Maybe not clearly a PBL topic but as the PBL Tutors see and hear from our students in a short period more than anyone else on our faculty I thought I would talk about death and dying. Students by this point are doing horizontal electives and are seeing real events in real time. I came across this study and after reading it I thought it’s a good intro to the topic. One of the things I have had trouble remembering about my medical school experience was how I felt. Truth is at McGill in the 1980's I don't think anybody ever asked. I found the conclusions of this study most interesting.

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Background: Medical schools require time for end-of-life topic. However, there is very little medical literature that directly addresses how medical students and residents are to behave, manage emotion, and confront their own grieving process when patients die.

Objective: The purpose of this study was to understand how preclinical medical students describe feelings toward the death of a hypothetical patient in order to affect curricular change at our institution.

Design: Qualitative methods using narrative analysis of student papers to identify patterns, core constructs, and themes related to student's projected feelings on patient death.

Setting/subjects: Federal medical school with volunteer medical students from the class of 2005.

Results: Two thirds of the students (108/162) volunteered to participate. Five significant themes emerged including: (1) affective responses (guilt, fear, blame, and impotence) (2) personal experience with death, (3) survivorship and professionalism, (4) the meaning of death, and (5) the affects of religion and spirituality. Many feared facing families and responding to grief. An active belief in an afterlife was mentioned as a coping strategy by 40% of the students.

Conclusions: End-of-life curriculum is more than teaching about the clinical care of the patient and support of family. These medical students overwhelmingly identified the need for coping strategies when confronting the dying patient. Teaching students these coping strategies should be an integral part of an end-of-life curriculum.

Writing exercises cannot only help students recognize and reflect upon their emotions and feelings, but also allow educators a window into curricular elements that need to be added to death and dying education.

To cite this paper:

Cynthia M. Williams, Cindy C. Wilson, Cara H. Olsen. Journal of Palliative Medicine. April 1, 2005, 8(2): 372-381.

Maynard Luterman

Clinical Skill Muse #20: Chvostek Sign and Trousseau Sign

Unfortunately there will never be a Luterman sign....so here's the question: what are these signs, when were they discovered and who were the docs who discovered them? Bonus question..which is more sensitive? And how reliable are they?

The Chvostek sign (also Weiss sign) is one of the signs of tetany seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw, the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcaemia (ie from hypoparathyroidism, pseudohypoparathyroidism, hypovitaminosis D) with resultant hyperexcitability of nerves.

Frantisek Chvostek (1835–1884) was an Austrian surgeon who was born in Moravia, Czech Republic. Chvostek investigated the pathology and treatment of neurologic illnesses, including the use of electrotherapy, and described the sign that was to bear his name in 1876.

Trousseau sign of latent tetany is a medical sign observed in patients with low calcium. This sign may become positive before other gross manifestations of hypocalcemia such as hyperreflexia and tetany, but is generally believed to be more sensitive than the Chvostek sign for hypocalcemia.

To elicit the sign, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct. The sign is also known as main d'accoucheur (French for "hand of the obstetrician") because it supposedly resembles the position of an obstetrician's hand in delivering a baby.

Armand Trousseau (October 14, 1801 — June 27, 1867) was a French internist. His contributions to medicine include Trousseau sign of malignancy, Trousseau sign of latent tetany, Trousseau-Lallemand bodies (an archaic synonym for Bence Jones cylinders), and the truism, "use new drugs quickly, while they still work." Trousseau was instrumental in creating new modes of treatment of croup, emphysema, pleurisy, goiter, and malaria. He received the prize of the French Academy of Medicine for his classic essay on laryngology which originally appeared in 1837. He was the first in France to perform a tracheotomy, and he wrote a monograph on this as well as intubation in 1851. His textbooks on clinical medicine and therapeutics were both extremely popular and translated into English. Trousseau coined the terms aphasia and forme fruste and popularized eponyms in disease description such as Addison's
disease and Hodgkin's lymphoma.

Trousseau was considered an outstanding teacher. Numerous students of his achieved fame in their own right, including Puerto Rican pro-independence leader, surgeon and Légion d'honneur laureate, Ramón Emeterio Betances. Trousseau’s grandson was the distinguished ophthalmologist Armand Trousseau (1856-1910).

As previously mentioned, Chvostek’s sign is a classic signification of hypocalcemia. However, some studies have demonstrated that hypocalcemia is not the only condition in which a positive Chvostek’s sign may be seen. Other conditions that have produced Chvostek’s sign include rickets, diphtheria, measles, scarlet fever, whooping cough, and myxedema. The sign has also been positive in persons without any known disease. One study demonstrated a positive Chvostek’s sign in nearly 25% of healthy individuals. Another study showed that 29% of patients with laboratory- confirmed hypocalcemia had a negative Chvostek’s sign. In turn, the medical community considers Chvostek’s sign as only a crude indicator of neuromuscular irritability and an unreliable indicator of hypocalcemia.

Click here and here for references.

Maynard

PBL Muse #20: Students in academic difficulty

One of the biggest myths in the medical school process is that once you get into medical school, it is relatively easy to STAY in medical school. Each year, approximately 5% of those who enter fail one or more courses or fail out of medical school entirely. (These numbers are an average and are lower at McMaster) Why does this happen after being subjected to a selection process that is very stringent?

The biggest reason for students failing a course or failing out of medical school is an inability to put in the study time that a very competitive medical school curriculum demands. A sizable proportion of first year medical students may have been able to get through their undergraduate studies by the “last minute knowledge cram” method, only to find that they are in deep trouble fast.

Most of these students will adjust their time management skills and do well enough to pass their coursework but some are not able to make the transition from undergraduate to medical school. These folks find themselves behind their class very quickly and fail to catch up enough to learn the core knowledge required.

Another small proportion of students will have too many personal demands to keep up with their studies. They may be parents or spouses or they may have personal illness that actually prevents them from the mastery of their work. In these cases, a wise Dean of Students will offer a Leave of Absence before the student finds himself/herself in academic difficulty. It pays to alert Karl, Maynard or Kathy Swayze at the first sign of personal trouble. Often the Dean can alleviate the problem and get the student back on track. Again, sometimes the problem is so pervasive, that only a Leave of Absence will allow the student to take care of personal matters and return to academics without penalty.

Few medical students are intellectually unable to master the curriculum. While the amount of information to be mastered is massive, the difficulty of the material is fairly average. This means that the key to keeping yourself academically sound is disciplined study habits that enable you to digest this large body of information in a short period of time. Most students study daily and keep a rigorous study schedule even on weekends.

Many students will become caught in the “no one else is struggling so I must be stupid” trap. Every medical student from time to time will struggle with something. Most students figure out what they need, ask for help and get the task accomplished. Some students will become depressed and procrastinate. Procrastination is the enemy of good scholarship and leads to more depression. Again, chatting with a few classmates or the Dean of Students can often put your problems into perspective and give you new ideas that get you on your way.

Key message is if you see someone struggling please tell Karl, Kathy or myself as soon as possible.

Maynard

Clinical Skills Muse #19: Appendicitis and CT

Acute appendicitis represents the most common specific identifiable cause of an acute abdomen worldwide. Accurate diagnosis of acute appendicitis is often difficult clinically. Although there is some continuing controversy in the surgical and clinical literature, a consensus is emerging regarding the utility of routine CT for most, if not all, adult patients with suspected acute appendicitis. Increasing evidence suggests that even young adult men should routinely undergo CT rather than initial surgical exploration, and there is no convincing evidence-based data that the routine use of CT increases the perforation rate. CT, regardless of the protocol used, permits diagnosis or exclusion of appendicitis and alternative diagnoses accurately compared with the historical 20% negative appendectomy rate.

Furthermore, CT establishes the severity of appendicitis. The paradox is that the increased use of CT may have made accurate diagnosis more difficult in some patients, especially those in the earlier stages of appendicitis. Because patients are being scanned earlier, and because findings may therefore be more subtle or false-negative on unenhanced CT or on CT with oral/rectal contrast only, IV contrast should be considered routinely for imaging all patients with suspected appendicitis. Thin cuts, cine review of images on a monitor, and careful review of the right lower quadrant anatomy, as well as routine scanning of the entire abdomen and pelvis, should be performed in all cases. Radiologists need to appreciate the overlap of normal and abnormal appendiceal sizes, and should use all the CT findings present to make or exclude the diagnosis of appendicitis.

Click here for more information.

Maynard Luterman

PBL Muse #19: So you think you're smart

So here's this week’s question......how well does IQ equate to doing well in school?

Correlations of this magnitude tell us that IQ tests, on their best days, predict 40-50% of school achievement (Applied Psychometrics 101 – square the correlations and multiply by 100 to get the percent of variance explained). This is very good. Yet…50-60% of a person’s school achievement is still related to factors “beyond IQ!”

Today, IQ testing is one of the most common tools in the school system for assessing cognitive ability, classroom placement, need for accommodations and cognitive expectations. But good gracious, 50-60% achievement is beyond IQ! Rather than using IQ to tell us about our limitations, we should look for strengths that tell us what to build on.

What are some of the other predictors? Organization, will, desire, interest, are but a few. So while being smart is a good start its not the end all and be all.

Click here for more information.

Maynard Luterman

Clinical Skills Muse #18: Diabetes Part 2 - DKA

As an ER Doc the lowest pH I have seen in a living human was 6.83....DKA patients are quite sick when they present....today's questions are about DKA....
1) What is the incidence of DKA?
2) What is the pathophysiology of DKA?
3) What are the precipitating conditions of DKA?
4) What's the differential?

For more information, click here.

Maynard

PBL Muse #18: Concentration

Karl and I met with the students. The feedback was very positive. The students recognized everyone's keen interest in making our campus successful and they were very grateful for the interest everyone is showing. We want to express thanks to each of you who have participated thus far and who will be participating in the future. 

Today’s topic is concentration. As we all know our ability to concentrate changes from day to day. Some days it’s easier to focus than others. 

There are many reasons why your mind might wander in class or during homework. Some of the most common factors are non-medical and simple, and they can be treated by making small changes in our routines. Click here to see the article.

Bottom line....sleep, eat, exercise and share your feelings.....

Maynard 

New events in the calendar

Hi all. I've posted links in the calendar to all of the upcoming CME sessions that are happening through the NHS. These are the events organized by Rick Horne. His contact information is listed in the links to the flyers for the events.

It's clear there is a lot happening in the Region when it comes to CME!

Regarding Faculty Development, we are organizing a session for PBL tutors and clinical skills preceptors that will likely happen in May. If you belong to one of these groups, stay tuned.

The next large group faculty development session will be held on Wednesday, June 24th.

We also hope to hold several small group teaching sessions with a focus on skills development. There is a teaching series on Medical Education that is based on the successful "Problem-Based Small Group" Learning Program developed by the Foundation for Medical Practice Education. Follow the link and take a look at the available modules (we have all of them). If you or your group are interested in using any, you could let me know by e-mail. You could also express interest by commenting on this post -- there may be others who are also interested that you did not know about!

Welcome!

Welcome to this website designed for the Faculty of the Niagara Regional Campus. 

Take a look at the sidebar -- we've provided links to a number of websites that we think will be useful to you -- to do your clinical work more effectively and also to be a better teacher. If there are any other links you would like added, please let us know!

The calendar will be updated regularly with local Faculty Development events as they are planned, events in Hamilton, medical education conferences, and local CME events.

We hope that this website will be useful enough to you that you set it as your "homepage" on your internet browsers. If you're checking the blog regularly, then it becomes an effective way to communicate. Browsers have slightly different ways to set a homepage -- on a Mac, click the browser name (e.g., Firefox, Safari) then click "preferences"; on a PC, click "tools" then "internet options".