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