Recently someone mentioned to me that medical school is a stressful experience to which I responded is the pope catholic, do bears poop in the woods....tell me something I don't know. Then I began to think of humor in the medical school curriculum. I love to laugh and if you google laughter and medicine there are thousands of responses. Without looking like I am losing it there is even laughter yoga that has become popular in North America. Now why do I bring this up? I think that as we fill these young brilliant minds in our school with myriads of facts and algorithms it’s important that they remember that there is an awful lot we don't know and we can't explain....here are some of the studies done on laughter....
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Although there are many clinical programs designed to bring humor into pediatric hospitals, there has been very little research with children or adolescents concerning the specific utility of humor for children undergoing stressful or painful procedures. Rx Laughter TM, a non-profit organization interested in the use of humor for healing, collaborated with UCLA to collect preliminary data on a sample of 18 children aged 7–16 years. Participants watched humorous video-tapes before, during and after a standardized pain task that involved placing a hand in cold water. Pain appraisal (ratings of pain severity) and pain tolerance (submersion time) were recorded and examined in relation to humor indicators (number of laughs/smiles during each video and child ratings of how funny the video was). Whereas humor indicators were not significantly associated with pain appraisal or tolerance, the group demonstrated significantly greater pain tolerance while viewing funny videos than when viewing the videos immediately before or after the cold-water task.
http://ecam.oxfordjournals.org/cgi/content/full/nem097?ijkey=vQVXkCN8QhDjDQe&keytype=ref%20
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In this study, researchers compared the humor responses of 300 people. Half of the participants had either suffered a heart attack or undergone coronary artery bypass surgery. The other 150 did not have heart disease. One questionnaire had a series of multiple-choice answers to find out how much or how little people laughed in certain situations, and the second one used true or false answers to measure anger and hostility. Miller said that the most significant study finding was that "people with heart disease responded less humorously to everyday life situations." They generally laughed less, even in positive situations, and they displayed more anger and hostility.
http://www.umm.edu/features/laughter.htm
Have a laughter filled day,
Maynard
Monday, January 18, 2010
Clinical Skills Pearl Vol 2 (#18): Diabetes
I have told the medical students that if you know nothing but diabetes and alcoholism you know more than most....this week is about diabetes....so here are the questions:
Is life expectancy altered by diabetes and by how much?
What is the prevelance of diabetes in the population?
Are all races at the same risk for diabetes?
What factors predispose for diabetes?
Diabetes Mellitus (DM) is a disease caused by deficiency or diminished effectiveness of endogenous insulin. It is characterized by hyperglycaemia, deranged metabolism and sequelae predominantly affecting the vasculature.
Life expectancy is reduced by 15 years in Type 1 diabetes; 5-7 years in Type 2 diabetes.
Prevalence models suggest the true prevalence is close to 5%. The incidence of diabetes is increasing in all age groups. Type 1 diabetes is increasing in children (especially <5 years), and type 2 diabetes is increasing particularly in black and minority ethnic groups.
People of South Asian, African and African-Caribbean and Middle-Eastern descent are at greater risk of type 2 diabetes, compared with the white population. People who are obese, are inactive or have a family history are also at increased risk of type 2 diabetes.
Other factors predisposing to DM, Gestational Diabetes and impaired glucose tolerance Drugs: steroids and thiazides
Pancreatic disease: acute and chronic pancreatitis (including surgery if 90% pancreas removed), haemochromatosis, cystic fibrosis. Endocrine disease: Cushing's, acromegaly, phaeochromocytoma, thyrotoxicosis.
Others: acanthosis nigricans, congenital lipodystrophy with insulin receptor antibodies, Wolfram syndrome (DIDMOAD),4 and glycogen storage diseases.
Reference:
http://www.patient.co.uk/showdoc/40000914/
Posted on behalf of Dr. M. Luterman
Is life expectancy altered by diabetes and by how much?
What is the prevelance of diabetes in the population?
Are all races at the same risk for diabetes?
What factors predispose for diabetes?
Diabetes Mellitus (DM) is a disease caused by deficiency or diminished effectiveness of endogenous insulin. It is characterized by hyperglycaemia, deranged metabolism and sequelae predominantly affecting the vasculature.
Life expectancy is reduced by 15 years in Type 1 diabetes; 5-7 years in Type 2 diabetes.
Prevalence models suggest the true prevalence is close to 5%. The incidence of diabetes is increasing in all age groups. Type 1 diabetes is increasing in children (especially <5 years), and type 2 diabetes is increasing particularly in black and minority ethnic groups.
People of South Asian, African and African-Caribbean and Middle-Eastern descent are at greater risk of type 2 diabetes, compared with the white population. People who are obese, are inactive or have a family history are also at increased risk of type 2 diabetes.
Other factors predisposing to DM, Gestational Diabetes and impaired glucose tolerance Drugs: steroids and thiazides
Pancreatic disease: acute and chronic pancreatitis (including surgery if 90% pancreas removed), haemochromatosis, cystic fibrosis. Endocrine disease: Cushing's, acromegaly, phaeochromocytoma, thyrotoxicosis.
Others: acanthosis nigricans, congenital lipodystrophy with insulin receptor antibodies, Wolfram syndrome (DIDMOAD),4 and glycogen storage diseases.
Reference:
http://www.patient.co.uk/showdoc/40000914/
Posted on behalf of Dr. M. Luterman
Monday, January 11, 2010
PBL Pearl Vol 2 (#17): Traits of successful teachers
What makes a good teacher? A study was done at the San Diego School of Pharmacy to identify faculty characteristics and teaching methods that initiate and maintain student attention and engagement throughout the classroom experience.
Current 3rd and 4th professional year Doctor of Pharmacy students were invited to complete a web-based survey regarding their perceptions of faculty attributes and teaching techniques that maintain or enhance engagement. Each questionnaire consisted of 23 multiple choice questions using a 1-4 rating scale from strongly disagree to strongly agree and 5 open ended questions. Preferences of teacher characteristics, active learning techniques and lecture structure were examined.
Ninety eight questionnaires were completed (48%). Students strongly agreed that enthusiasm (73%), genuine interest in student learning (71%) and preparation/organization (69%) were engaging faculty attributes. Strong agreement was also observed for techniques including multiple examples/patient cases per subject (71%) and end of class summaries (72%).
Reference:
http://www.allacademic.com/meta/p_mla_apa_research_citation/1/1/8/2/0/p118208_index.html
Posted on behalf of Dr. M. Luterman
Current 3rd and 4th professional year Doctor of Pharmacy students were invited to complete a web-based survey regarding their perceptions of faculty attributes and teaching techniques that maintain or enhance engagement. Each questionnaire consisted of 23 multiple choice questions using a 1-4 rating scale from strongly disagree to strongly agree and 5 open ended questions. Preferences of teacher characteristics, active learning techniques and lecture structure were examined.
Ninety eight questionnaires were completed (48%). Students strongly agreed that enthusiasm (73%), genuine interest in student learning (71%) and preparation/organization (69%) were engaging faculty attributes. Strong agreement was also observed for techniques including multiple examples/patient cases per subject (71%) and end of class summaries (72%).
Reference:
http://www.allacademic.com/meta/p_mla_apa_research_citation/1/1/8/2/0/p118208_index.html
Posted on behalf of Dr. M. Luterman
Clinical Skills Pearl Vol 2 (#17): Adrenal Insufficiency Part 2
Part 2.....how much of the adrenal gland needs to be destroyed for you to become Addisonian? Here's a dandy...what happens to the following blood tests..Na, Cl, Bicarb, K, Urea, Glucose,LFTs, Ca,Hb, WBC diff,
BONUS TIME>>>>test to distinguish primary from secondary Addison disease?
Pathogenesis:
Addison disease is characterized by progressive destruction of the adrenal glands. This is usually autoimmune based and most likely the result of cytotoxic T lymphocytes, although 50% of patients have circulating adrenal antibodies. Clinical and biochemical insufficiency only occurs once >90% of the gland is destructed.
In the early period of adrenal insufficiency, investigations may be normal however, patients have no reserve when faced with stress.
Laboratory abnormalities in adrenal insufficiency:
Sodium - reduced
Chloride - reduced
Bicarbonate - reduced
Potassium - increased
Uraemia
Hypoglycaemia
Abnormal liver function tests
Calcium - increased in 10-20%
Normocytic anaemia
Lymphocytosis
Moderate eosinophilia
Distinguish between primary and secondary insufficiency by measuring the ACTH level
Primary insufficiency - ACTH increased; Secondary insufficiency - ACTH decreased.
Reference:
http://www.patient.co.uk/showdoc/40024894/
Posted on behalf of Dr. M. Luterman
BONUS TIME>>>>test to distinguish primary from secondary Addison disease?
Pathogenesis:
Addison disease is characterized by progressive destruction of the adrenal glands. This is usually autoimmune based and most likely the result of cytotoxic T lymphocytes, although 50% of patients have circulating adrenal antibodies. Clinical and biochemical insufficiency only occurs once >90% of the gland is destructed.
In the early period of adrenal insufficiency, investigations may be normal however, patients have no reserve when faced with stress.
Laboratory abnormalities in adrenal insufficiency:
Sodium - reduced
Chloride - reduced
Bicarbonate - reduced
Potassium - increased
Uraemia
Hypoglycaemia
Abnormal liver function tests
Calcium - increased in 10-20%
Normocytic anaemia
Lymphocytosis
Moderate eosinophilia
Distinguish between primary and secondary insufficiency by measuring the ACTH level
Primary insufficiency - ACTH increased; Secondary insufficiency - ACTH decreased.
Reference:
http://www.patient.co.uk/showdoc/40024894/
Posted on behalf of Dr. M. Luterman
Monday, December 14, 2009
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.
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/
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/
Monday, December 7, 2009
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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Dr. Luterman
*******************************************************
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.
*******************************************************
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).
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).
Monday, November 30, 2009
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
*****************************************
*****************************************
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.
(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.
Tuesday, November 24, 2009
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
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
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
Monday, November 16, 2009
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
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
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
Monday, November 9, 2009
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
**********************************************************************
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.
Dr. Luterman
**********************************************************************
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......
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:
Dr. Luterman
Monday, November 2, 2009
Clinical Skills Pearl Vol 2 (#10): Gallbladder - Part 2
Gallbladder Part B...
Dr. Maynard Luterman
***************************************************************************************************
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.
Dr. Maynard Luterman
***************************************************************************************************
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
*********************************************************************************
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).
Dr. Maynard Luterman
*********************************************************************************
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.
Monday, October 26, 2009
Clinical Skills Pearl Vol 2 (#9): Gallbladder
The next two clinical skills muses are devoted to your gallbladder.
Dr. Luterman
**********************************************************************************
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.
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
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
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