Professor
Brian Andrews NEJM Recommendations for Medical Students and Tutors
Week
of the 25th February 2016 (#31)
University
of Notre Dame Australia
(Fremantle
Campus)
Occasional Editorial Comment
Editorial comments are in Surgical Training and Duty Hours
review.
Once again I must emphasize that the editorial comments
are mine alone and do not reflect the opinions of the University of Notre Dame
Australia, Fremantle Campus, or the School of Medicine. As such, I reserve the
rights to reflect my own opinions and anecdotes as a member of the academic
faculty of a learned institution. You may agree with me, disagree or have no
opinion (hopefully this may change by reading this blog) but as long as my
editorial comments engender an academic discussion, I believe I have fulfilled
my role.
The practice of good medicine is also the practice of
politics and ultimately the delivery of health care dollars to the system.
Australia has one of the best and most desired health care systems in the world
and we must all be vigilant in order to protect the current system from
self-interested politicians who control health care dollars and who attempt to
balance their budget using health care dollars.
But more on this next week when I discuss the
Uberization (frequently referred to as “The Sharing Economy”) of the medical
system.
Must Read Articles
None
Articles Recommended for Medical Students
Perspective
Dealing
with Racist Patients
A
patient's refusal of care based on the physician's race or ethnic background
can raise thorny ethical, legal, and clinical issues — and can be painful and
confusing for physicians. Sound decision making in this context turns on five
ethical and practical factors
Although most medical students read this Perspective, perhaps
because of the catchy term, “racist”, the majority were not as impressed as
several PBL tutors who felt this to be a very informative article. I would
regard the medical students’ attitude from a positive point of view, namely
that the students are more aware of the problems of interacting with racist
patients and they also have experienced the strong focus on various aspects of
communication, awareness of indigenous culture, ethical training and professionalism
which we seek to imbue at Notre Dame. All agreed with the outlined algorithm
and believed this to be “obvious”. Students as a group believed they could cope
with a single racist comment directed towards them (most as yet had not
experienced this), but felt that if this experience became a repetitive
experience that it could affect their ability to deliver effective patient
care. In this circumstance, however,
they also felt they would need to reflect on their own attitudes to determine
if they were in part responsible for these interactions.
Recommended
learning:
Communication with Aboriginal and Torres Strait
Islander and immigrant patients and understanding how social and cultural norms
may differ.
ORIGINAL ARTICLE
Stopping vs. Continuing Aspirin before Coronary Artery
Surgery
In
a randomized trial involving 2100 patients undergoing coronary artery surgery,
the risk of bleeding within 30 days after surgery was not higher with aspirin
than with placebo, nor was the risk of death or thrombosis within 30 days after
surgery lower with aspirin than with placebo
The question about stopping aspirin 5-7 days before any
elective surgery has revolved around the risk of perioperative bleeding (which
should ideally be limited by careful surgical haemostasis) versus the risk of a
thrombotic event for which the aspirin has been used prophylactically (prevention
of stroke, myocardial infarction or death) or as in this study to limit
thrombosis in the grafted tissue (vein or internal mammary artery).
The results of this Australian study out of Melbourne
and Adelaide, but also Devon and Quebec City, appear to answer this question in
this 2-by-2 factorial trial design. Tranexamic
acid was also employed in addition to aspirin at the second level (see Figure
1). There are many aspects of anticoagulation in this study (see Table 3), but in
spite of the complex nature and careful design of the study, the results
indicate that for patients given 100 mg aspirin preoperatively compared with
those where aspirin was stopped 5-7 days prior to surgery in this multicentre
study, there was no significant difference between the groups regarding outcome
parameters. This appears to answer the question regarding safety of preoperative
aspirin use (1-2 hours) in patients undergoing coronary artery surgery in this
carefully monitored study using dedicated surgeons interested in participating
in the trial. However, the question
remains, can these results be translated to aspirin use prior to all elective
surgeries? Students believed that aspirin should definitely not be given prior
to neurosurgery or in patients with known bleeding disorders.
An interesting subgroup analysis would have been to
perform bleeding times on all patients within 15 minutes of anaesthesia to see
if there were any differences in outcomes between the groups.
I was reacquainted with the use of tranexamic acid (a
synthetic ant-fibrinolytic agent containing lysine analogues which binds
reversibly to 4-5 active lysine residues in plasminogen and plasmin reducing
their abilities to cleave fibrin) in major trauma, severe dysfunctional uterine
bleeding (MED300 students have witnessed this in their O&G rotation), and
some bleeding disorders.
How will the general surgeons regard this paper in
their numerous predicted discussions?
REVIEW ARTICLE
Challenges
in the Elimination of Pediatric HIV-1 Infection
Preventing
mother-to-child transmission of HIV-1 requires a series of steps in the care of
women and their infants during pregnancy, delivery, and the postpartum period.
This review outlines the steps and summarizes progress in resource-limited
countries and elsewhere
This is an important article as it illustrates the
periods during pregnancy, delivery and breast feeding where HIV transmission
occurs and how management and transmission in developed countries and
“resource-limited countries” (90% in sub-Saharan Africa) differs.
All of the Figures are clear, including Figure 4 which contrasts
different management recommendations in the US and “resource-limited
countries”.
I admit that I was unaware of the extremely high
frequency of HIV transmission to the infant by breast feeding and that by
utilizing antiretroviral agents to the lactating mother and extended
prophylaxis to breast-feeding infants the risk of post-natal HIV transmission
is reduced to < 2%. Obviously there is no risk if the infant is fed only formula.
This article highlights a seminal public health study
published in 1994 in the Journal which demonstrated that administration of a
single antiretroviral agent zidovudine given to the mother orally during pregnancy,
IV during labour and orally to the newborn for 6 weeks (in non-breast fed
infants), reduced HIV transmission by up to 70%.
IMAGES IN CLINICAL MEDICINE
Ocular Rosacea
A 58-year-old
man presented with recurrent facial flushing and redness, foreign-body
sensation, and blurred vision in both eyes. Examination revealed telangiectasia
with hyperemia of the eyelid margins, conjunctival hyperemia, and
neovascularization of the cornea in both eyes
An interesting series of photographs demonstrating
uncommonly recognised ocular acne rosacea and the response to standard therapy.
Recommended
learning:
Review the pathology, clinical manifestations and
management of the common skin disorder acne rosacea.
Important Articles Related to Mechanisms of Disease and
Translational Research
None
Other articles which should be of interest to medical students
Perspective
Leaping
without Looking — Duty Hours, Autonomy, and the Risks of Research and Practice
Critics
argue, essentially, that there is no ethical way to study residents' duty-hour
rules in a randomized fashion. But in assuming that untested practice is safe,
we have compromised trainees' freedom to judge for themselves when their
patients need them.
ORIGINAL ARTICLE
National
Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training
In
this randomized trial comparing ACGME duty-hour policies with more flexible
policies for surgical residents, the flexible policies resulted in noninferior
patient outcomes and no significant difference in residents' satisfaction with
overall well-being and education quality
EDITORIAL
Surgical Resident Duty-Hour Rules — Weighing the New
Evidence
There are three articles discussing surgical resident
duty-hour rules: the first, Perspective,
argues both for and against the ethics of a randomized study involving 59
surgical residency training sites in the US in which participants were not informed
of the study parameters in order to obtain more valid and meaningful data (I
believe this to be a non-issue); the second, the Original Article, provides the
data for the study; and the third, Editorial, presents a reasoned analysis by John
Birkmeyer, a Professor of Surgery and general surgeon. He is also an internationally recognized
health services researcher and leader in regional collaborative quality
improvement at Dartmouth in NH, USA, who provided a critical and reasoned
analysis (I would only read the Editorial, unless you have a particular interest
in this area) with focus on surgical training practice by postmillennial
learners in the US.
Clearly the past is the present when older members of
the profession expound on their earlier anecdotal residency training
experiences and where this can still effect current training policy. One recent
experience I had in Perth was at an RACP business meeting dinner sitting next to
a learned academic from the East Coast who was involved in formulating RACP
policy-making for medical school internship training. This individual argued
forcefully for more intrusive internship training for final year medical
students so they would be prepared for the rigours of their internship on day
one. His opinion stemmed from an
unfortunate initial first three-month experience he had as a new intern thrust
into a neurosurgical rotation at a major teaching hospital in Melbourne without
any senior residency supervision over this period. Needless to say this was a
harrowing experience for him and indelibly imprinted on the plasticity of his neurons. I feel sure that what was
regarded by him as a traumatic event was regarded by his senior neurosurgical
consultants and hospital administrators of the day as a valuable learning
experience.
My internship training experience, on the other hand,
was the polar opposite and one of the most academically informative training
experiences in my life at Sydney Hospital (of course excluding medical school
training at the University of Sydney and the Royal North Shore Hospital).
It would be assumed that if the two of us were members
of an RACP committee discussing internship training policy in medical school,
two differing points of view would have been represented. Clearly the role of
the Chairperson is to understand the agenda of the members of the committee in
order to limit polarizing points of view by providing balance and limit the
development of ill-founded policy decisions
My belief is
that the increased focus on internship training in medical school relates
directly to the hospital’s expectation that the newly minted intern should be
trained one and ready to fully function from day. The rationale is that this is
in the patients’ benefit, but my alternative interpretation is that cost containment
at the hospital level and passing on the training costs to the Universities.
With the reduction in the residency training force, there is less one on one
training of interns by residents and registrars and hospitals are requiring
more direct clinical patient care by all medical staff, including paid
consultants and less time devoted to teaching and supervision. In fact, some
hospitals in Perth have requested that Universities provide the salaries for
salaried consultants who teach medical students!!! I believe that in Perth we
have a wonderful teaching system which is in slow decline for want of expending
more dollars on medical training of our future doctors, nurses and health care
professionals at the state level.
I have forged a long-term relationship with my favorite mentor Emeritus Professor Solomon Posen who in his nineties is a
prolific broadly educated reader and author and who comments periodically on my
blog. I will never forget my first medical ward round when I was asked,
“Andrews, tell me what you know about chimerism?” Those days (1969 through the
seventies) were very different. Virtually no interns were married and few had
partners like the current day. Most expected to work until late in the night
until their day’s work had been completed and their patients had all been
tucked in for the night. Contrast this to the current post-millennial intern:
many are married or have partners and children, even in medical school, and their
well-being is focused on a life balance between their professional and
non-professional commitments. Who can deny
the conclusion of Dr. Birkmeyer in his editorial conclusion that life has
changed and current postgraduate medical trainees now live in a different world
where they are expected home at a reasonable and predicted time. The myth
regarding patient safety between a flexible schedule and those in the standard-policy
group, within defined total number of hours worked ACGME defined guidelines,
has been exploded. Patient safety did not suffer if a trainee finished work and
handed patient-care over to a colleague, nor was the perception of fatigue a
perceived problem. If a surgical resident has to miss the surgery, they can
catch up on another patient.
Returning to anecdote, when I was an intern at Sydney
Hospital in 1969, when we had the weekend off we left at 12:00 md on Saturday
and returned at 8:00 am Monday morning – this was regarded as a civilized
practice. We handed over the care of our patients in a detailed and meaningful
fashion and frequently introduced the patient to our colleague. We would expect
that all of our patients would be seen daily and when problems arose they would
be handled efficiently. Among some of us, we might even try to find a
physical sign or even a treatment error that our colleague had omitted in the
chart. However, when I arrived in the US in 1976, I was amazed at the opposite
attitude to patient care. Residents and interns regarded their patients as
their own personal property and that they were the only ones who could take
care of their patients. Many expected to be called at all hours of the day or
night if any change occurred in their patients. Rounds would be routinely
expected every day. Personally, I regard this practice as a form of
intellectual arrogance accepting that a colleague, in general, cannot treat a
patient as you do. This attitude is now changing in the US as indicated in the
Editorial, with all consultants who treat Medicare patients at Public Facilities
expected to see and examine their patients each day and dictate in each
patient’s chart for Medicare remuneration for the hospital. This will happen I
predict in Australia within the next few years.
Trainee residents now understand that the Consultant is really in charge
of the patient, both physically, financially and medico-legally, and are
willing now to step back and accept the change in these well-deserved and
federally mandated changes in sane work hours in US hospitals.
CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL
Case
6-2016 — A 10-Year-Old Boy with Abdominal Cramping and Fevers
A
10-year-old boy was seen in the gastroenterology clinic because of abdominal
cramping and fevers. Abdominal imaging studies revealed circumferential
thickening of a segment of the colonic wall and mesenteric lymphadenopathy. A
diagnostic procedure was performed.
While the case presented is a very uncommon
presentation, the discussion revolves around the differential diagnosis of an
infiltrative lesion involving the right colonic wall in a 10-year-old boy. As
usual, most considerations focus on either a primary inflammatory process
(particularly autoimmune processes), a primary infectious cause or, a
malignancy.
For those particularly interested in the specific
details of the hereditary basis of colorectal cancer and recent genetic
developments, this offers a detailed discussion.
Recommended
learning:
Differential diagnosis of abdominal pain in children
Review of the pathology, genetics, epidemiology,
prevention, presentation and management of colorectal cancer in adults
