Professor Brian Andrews NEJM Recommendations for Medical Students and
Tutors
Week of the 24th December 2015 (#22)
University of Notre Dame Australia
(Fremantle Campus)
Occasional Editorial
Comments
My Editorial comments are contained within the
context of the MUST READ section
MUST READ SECTION
CASE
RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case 40-2015 — A 40-Year-Old Homeless Woman
with Headache, Hypertension, and Psychosis
http://www.nejm.org/doi/full/10.1056/NEJMcpc1405204
The reason I have included this CPC
(clinic-pathological conference) as a MUST read article is that I was very
impressed by the sustained and caring management provided to a homeless,
psychotic (schizophrenic) patient by Dr. Travis Baggett in Boston,
Massachusetts.
The State of Massachusetts was the first and
only state in the Union to provide universal health care coverage to virtually
all of its citizens in 2006. This program formed the basis for the current
national Affordable Health Care Act
established by the Obama administration in spite of continued hostile attacks
overwhelmingly by House and Senate Republicans (with heavy funding from the
Insurance Health Care Industry).
We Australians must remain extremely vigilant
to protect our universal health care system against forces that want to
privatize this system. The erosion of universal health care is occurring now in
Scandinavian countries which, until recently, have been the shining example of
universal health care which should be the right of all citizens (refer to
previous series of articles in the Journal on International Health Care Systems, including Australia).
Apart from Dr. Baggett, this CPC gives an
excellent review of the causes of psychosis and discusses the problems of
homelessness.
One question I have is should this 40 year old
homeless patient with marked iron deficiency anaemia and significant
menorrhagia also have had a FOB test performed? Initially this would have been
impossible given the patient’s mental state and extreme difficulty establishing
rapport and continuing medical care. This may even be an exception to my rule
that all appropriate patients earn themselves a “good rectal exam.” But I
digress and my bias raises its head. There is a saying that older members of
the profession will be aware and which still applies today, “If you don’t put
your finger in it, you’ll put your foot in it.”
Perspective
Reducing Diagnostic Errors — Why Now?
http://www.nejm.org/doi/full/10.1056/NEJMp1508044
Perspective
Improving Diagnosis in Health Care — The Next
Imperative for Patient Safety
These are two
extremely important Perspectives that should be read by all and which follow
the publication of the report by The
Institute of Medicine in 2015 entitled
Improving diagnosis in health care.
In Australia making the correct diagnosis(es) will also become an increasing
challenge as will the cost of pharmaceuticals, which will be covered next week.
The time for focusing
on making the correct diagnosis in all patients is upon us.
In the US, data
indicate that between 1:10 and 1:20 of patients who attend a primary care
physician in the out-patient setting (references quoted) are diagnosed
incorrectly.
For the past 15 years,
the patient-safety movement has focused on treatment-related harms, which
include quality- and safety-improvement efforts and rectifying system failures.
Khullar et al suggest that the previous lack of attention
given to diagnostic errors may relate to:
i)
“Lack of
understanding of decision-making biases,
ii)
Cultural
attitudes discouraging discussion of misdiagnosis,
iii)
The
difficulty of defining and identifying such errors,
iv)
Assumptions
about the impracticality of potential process or outcome measures of diagnostic
quality, and
v)
The belief
that diagnostic errors are less amenable than other types of medical errors to
system-level solutions”
With the advent of
more sophisticated (and expensive) diagnostic procedures and laboratory tests
and the high cost of new drugs and hospital admissions, diagnostic errors are
clinically and financially more costly today than ever before. This applies
particularly to diseases that can be treated and/or cured. The most significant
cost in diagnostic errors involves the misdiagnosis and management of common
disorders, such as acute coronary syndromes, pulmonary embolic disease and
stroke.
What are some things UNDA might do as a medical
school in contributing to reducing diagnostic errors in the students we train
to ultimately practice medicine?
i)
Students and teachers should first recognise
that the problem exists (as it always has) and read carefully these two
Perspective articles,
ii)
The school should review the medical curriculum
(this is an ongoing process) to ensure that students receive the appropriate
updated and relevant knowledge (or know where to obtain it in a timely fashion)
to practice in the current health care system. This particularly applies to a
sound, current and practical knowledge in the basics sciences, which I believe
underpins the ability to derive the correct diagnosis and continues to make the
practice of medicine more intellectually stimulating.
iii)
In order for students and doctors to make the
correct diagnosis, the patient should have an appropriate and detailed history
and clinical examination performed. In this day and age of “time is money,”
many errors will result from poor history taking (not enough time, exhaustion,
lack of interest, not understanding the significance of a symptom), poor
physical examination and not taking the time to reflect on a differential
diagnosis (this should be an ongoing process during the history and
examination) and not formulating a provisional diagnosis(es), which can then be
proven or refuted.
iv)
Encourage students, and doctors, to hone their
skill of Clinical Reasoning. In most individuals this is not intuitive and must
be actively cultivated. Clinical reasoning is an ongoing process in everybody
that practices clinical medicine and incorporates the art of “long term learning”
which the School attempts to inculcate in its students.
v)
Encourage students and doctors to ask if they
are unsure of the diagnosis and obtain second opinions early if the diagnosis
is unclear. In the practice of medicine, where possible and if there were diagnostic
uncertainty, I tried to avoid not necessarily obtaining second opinions from a
previous teacher or close friend, as many times they will provide you with the
diagnosis you wanted to hear. Consider asking a respected, knowledgeable
colleague who may not necessarily agree with you on occasions and is not a
close friend. Patients will love you, talk about you to friends and remain
loyal to you if you say “I’m not sure what the diagnosis is and would like to
get a second opinion”
vi)
Be aware of your diagnostic biases and keep an
open mind. You may think you have the correct diagnosis based on early symptoms
you may obtain and fail to focus on other aspects of the history and
examination
vii)
Encourage students to seek help if they are
having difficulties in diagnostic reasoning and encourage tutors to spend more
time in exploring this valuable area
viii)
In CD groups, if a student has witnessed a
significant diagnostic error by a clinician, the CD environment should be such
that this error can be discussed by the group while maintaining the
confidentiality of the doctor (students frequently make mistakes and do not
necessarily have the whole story). If the student is unsure, they should first
discuss this with the CD tutor before presenting. If real diagnostic problems
are unable to be discussed, diagnostic errors will continue
Articles Recommended for Medical Students
REVIEW
ARTICLE
Comfort Care for Patients Dying in the Hospital
http://www.nejm.org/doi/full/10.1056/NEJMra1411746
This is an extremely well
written article dealing with the care of the dying patient who is very close to
death, what the authors describe as Comfort
Care, which is in fact a small component of Palliative Care. The article focuses predominantly of relieving
symptoms present in the patient close to death and dying in hospital. The
authors indicate that in the US, but also in Australia, most patients dying in
hospital do not see a palliative care physician, in part due to the shortage of
physicians trained in this area. In a US study in 2010 quoted by the authors,
29% of patients die in hospital with an average duration of admission of 7.9
days.
I found this to be a very
informative, evidence-based and practical article, primarily involving
pharmacological agents for various terminal symptoms. This is written for
generalists and non-palliative care specialists.
Recommended
learning: Palliative care in the
patient close to death
IMAGES
IN CLINICAL MEDICINE
Polychondritis with Auricular and Ocular
Involvement
Not everybody who
presents to the ED with a painful swollen ear suffers from a bacterial
infection, is a pugilist or suffers from child abuse.
IMAGES
IN CLINICAL MEDICINE
A Lousy Diagnosis
A scary video and an
itchy groin. Another use for permethrin apart from scabies. Consider the
populations at risk.
Important Articles Related to Mechanisms of Disease and
Translational Research
CLINICAL
IMPLICATIONS OF BASIC RESEARCH
Environmental Microbial Exposure and Protection
against Asthma
http://www.nejm.org/doi/full/10.1056/NEJMcibr1511291
This article was
precipitated by a recent study in Science by Schuijs el al 2015 and an earlier Northern European epidemiological
observational study that found that children born into traditional
dairy-farming households (exposed to microbe-rich animal-barn dust containing
high levels of bacterial lipopolysaccharide - LPS) developed a natural
resistance to asthma (especially household dust mites - HDM) and allergy. In
the Science study, the authors demonstrated a molecular mechanism underlying
the barn-dust effect. The immunological basis for their results is illustrated
in Figure 1. Both LPS and HDM allergen bind to toll like receptor 4 (TLR4) on
the surface of airway epithelial cells. If LPS exposure occurs prior to or even
at the same time as first exposure to the HDM allergen, the effect of NF-kB is
attenuated due to increased synthesis of A20 (coded for by the gene TNFAIP3) by
the cell. They also note that in airway epithelial cells from patients with
asthma, compared with non-asthmatic controls, that there was a relative
reduction in the production of LPS-induced A20-specific mRNA and, further in
another study, that some patients with asthma demonstrated a polymorphism in
the gene TNFAIP3 presumably leading to reduced A20 production.
What are the potential
therapeutic implications of this study?
Recommended learning: Review the pathology including advances in
immunology and basic science, causes, differential diagnosis and management of
asthma
Other areas which should be of interest to medical students
EDITORIAL
Second Cancers after Treatment for Hodgkin’s
Lymphoma — Continuing Cause for Concern
ORIGINAL
ARTICLE
Second Cancer Risk Up to 40 Years after
Treatment for Hodgkin’s Lymphoma
This study and the
accompanying Editorial found that the risk of a second cancer continues for up
to 40 years after treatment for Hodgkin’s lymphoma. When data was analysed for
various time periods between 1989 and 2000, the pre-study expectation was that
with less aggressive curative therapy being used that the risk for the
development of a second solid cancer would be reduced. This was not seen in the
study.
However, it was found
that:
i)
The risk
for breast cancer development was significantly reduced if the field of
supradiaphragmatic radiotherapy did not include the axilla, and
ii)
While a
higher dose of procarbazine (an alkylating agent) protected against breast
cancer, there was an increased risk of gastrointestinal malignancy
ORIGINAL
ARTICLE
Azithromycin versus Doxycycline for Urogenital Chlamydia
trachomatis Infection
EDITORIAL
Treatment for Chlamydia Infection — Doxycycline
versus Azithromycin
http://www.nejm.org/doi/full/10.1056/NEJMe1513001
This article address
the question as to whether azithromycin is inferior to doxycycline in the
treatment of Chlamydia trachomatis
urogenital infection. The answer to the question is NO, both appearing to be
equally effective. The caveats are that azithromycin is administered as a
single dose (optimal compliance) whereas doxycycline is administered as a twice
daily dose for seven days. This is a randomized trial but carried out among
adolescents in youth correctional facilities where all administered doses are
closely observed increasing the compliance rate for doxycycline. Therefore
azithromycin appears to win overall.
Recommended learning: Causes of sexually transmitted diseases and
diagnosis and management of pelvic inflammatory disease
