Introduction to the older patient: a "first exposure" to geriatrics for medical students

In 2003, Weill Cornell Medical College developed a 4-hour module to introduce the geriatric patient within the required first-year doctoring course. The educational intervention highlights the importance of communication between older patients and physicians, the utility of an enhanced social history and functional assessment, and the pitfalls of ageism in the medical setting. The module incorporates film, the performing arts, and small-group exposure to a community-residing older person. To evaluate the module's effect, four successive classes of first-year medical students (2003-2006) responded to a 14-item questionnaire and three opened-ended questions at the end of the 4-hour curriculum. Quantitative and qualitative analysis reveal consistently strong positive student feedback to this module. Almost all students agreed that the learning objectives were clear (99%) and had been met (99%). Several curricular interventions received high endorsement from the respondents in their questionnaire and narrative comments. Most (94%) were in strong agreement that meeting the older patient in the small group was a worthwhile experience. Also, students appreciated observing an example of a substandard interview (76% in strong agreement) and then a demonstration of effective communication (83% in strong agreement) through dramatic enactments. The majority of students (97%) commented that exposure to these presentations enabled them to see ageist behavior firsthand and to observe how ageist attitudes interfere with appropriate diagnosis and medical care. This approach to introducing the older patient may be of use at other medical schools. Future studies will need to evaluate the long-term effect of this educational intervention.     

Heartburn refractory to proton-pump inhibitors

Opinion statement The most appropriate diagnostic and therapeutic approach to patients with heart-burn that persists despite the use of proton-pump inhibitor (PPI) therapy currently is not known. In general, patients with heartburn refractory to PPIs may have more than one explanation for their persistent symptoms. These include uncontrolled esophageal acid exposure (“PPI failure”) in a small subset of patients, as well as other potential etiologies in the majority of patients who have controlled esophageal acid exposure on PPI therapy (“PPI success”). Some potential explanations for persistent heartburn in this latter group include hypersensitivity to acid reflux, nonacidic or duodenogastric esophageal reflux, as well as functional heartburn. Patients who present with heartburn refractory to PPIs should be investigated further to determine the potential cause. We believe the diagnostic modality with the most clinical usefulness is 24-hour pH and multichannel intraluminal impedance monitoring with symptom index performed while the patient is on high-dose PPI therapy. This approach allows the patient to be properly categorized and also identifies a substantial proportion of patients who will have functional heartburn, a condition that should discourage the use of endoscopic or surgical therapies. Therapeutic options for patients with heartburn refractory to PPIs are limited and have not been thoroughly studied. As a result of the paucity of information, we favor a therapeutic approach based on the outcome of diagnostic testing.     

Eosinophilia: Causes and pathobiology in persons with prior exposures in tropical areas with an emphasis on parasitic infections

Eosinophilia in patients exposed to tropical or subtropical environments is caused most commonly by helminth (worm) infections. Besides a detailed exposure history, the diagnostic approach must consider other infections and noninfectious causes of eosinophilia, as treatments for many of these disorders differ.     

The virtual pathology lab experience

Learning pathology is a challenge, students must develop the skills to identify microscopic abnormalities, explain the interaction of functional disorders, and their causes. This study assesses a novel approach to teach pathology using clinical cases through digital images, virtual online slides, and a learning management system. Satisfaction of 83 students in the Pathology class was assessed with an online survey, using a Likert scale from 1 to 5 where 1 stands for total disagreement and 5 for total agreement. Regarding the impact of virtual pathology lab experience in their academic performance, 97.6% of students believe this approach was useful to achieve learning objectives as it allows self-directed learning, easier feedback, and collaboration between peers.     

Screening for and surveillance of gastric cancer

Although the prevalence of gastric cancer (GC) progressively decreased during the last decades, due to improved dietary habit, introduction of food refrigeration and recovered socio-economic level, it still accounts for 10% of the total cancer-related deaths. The best strategy to reduce the mortality for GC is to schedule appropriate screening and surveillance programs, that rises many relevant concerns taking into account its worldwide variability, natural history, diagnostic tools, therapeutic strategies, and cost-effectiveness. Intestinal-type, the most frequent GC histotype, develops through a multistep process triggered by Helicobacter pylori (H. pylori) and progressing from gastritis to atrophy, intestinal metaplasia (IM), and dysplasia. However, the majority of patients infected with H. pylori and carrying premalignant lesions do not develop GC. Therefore, it remains unclear who should be screened, when the screening should be started and how the screening should be performed. It seems reasonable that screening programs should target the general population in eastern countries, at high prevalence of GC and the high-risk subjects in western countries, at low prevalence of GC. As far as concern surveillance, currently, we are lacking of standardized international recommendations and many features have to be defined regarding the optimal diagnostic approach, the patients at higher risk, the best timing and the cost-effectiveness. Anyway, patients with corpus atrophic gastritis, extensive incomplete IM and dysplasia should enter a surveillance program. At present, screening and surveillance programs need further studies to draw worldwide reliable recommendations and evaluate the impact on mortality for GC.     

The epidemiological approach to drug abuse: its relevance to the teaching of future professionals.

In most areas of the medical curriculum it is far more important to teach students the approach to problems, rather than to encourage rote learning of the specific diagnostic and therapeutic regimen indicated in every conceivable circumstance. This is especially true in the field of substance abuse, in part because there simply are no clear-cut answers which can be universally applied. Nevertheless, dogmatism has been all too common in the teaching as well as the treatment of addiction, and there is a general tendency to view the problem simplistically and to advocate a specific modality as the solution. Teaching new professionals to apply the holistic perspective of the epidemiologist will enhance the likelihood of establishing realistic program goals, and adopting a comprehensive, balanced approach.     

Diagnostic management of chronic obstructive pulmonary disease

Detection of early chronic obstructive pulmonary disease (COPD) in patients presenting with respiratory symptoms is recommended; however, diagnosing COPD is difficult because a single gold standard is not available. The aim of this article is to review and interpret the existing evidence, theories and consensus on the individual parts of the diagnostic work-up for COPD. Relevant articles are discussed under the subheadings: history taking, physical examination, spirometry and additional lung function assessment. Wheezing, cough, phlegm and breathlessness on exertion are suggestive signs for COPD. The diagnostic value of the physical examination is limited, except for auscultated pulmonary wheezing or reduced breath sounds, increasing the probability of COPD. Spirometric airflow obstruction after bronchodilation, defined as a lowered ratio of the forced volume in one second to the forced vital capacity (FEV1/FVC ratio), is a prerequisite, but can only confirm COPD in combination with suggestive symptoms. Different thresholds are being recommended to define low FEV1/FVC, including a fixed threshold, and one varying with gender and age; however, the way physicians interpret these thresholds in their assessment is not well known. Body plethysmography allows a more complete assessment of pulmonary function, providing results on the total lung capacity and the residual volume and is indicated when conventional spirometry results are inconclusive. Chest radiography has no diagnostic value for COPD but is useful to exclude alternative diagnoses such as heart failure or lung cancer. Extensive history taking is of key importance in diagnosing COPD.     

Awareness of Fabry disease among rheumatologists—current status and perspectives

Fabry disease is an inherited disorder of lipid metabolism caused by deficient activity of the lysosomal enzyme α-galactosidase A. Burning peripheral pain with triggered crises of excruciating pain and gastrointestinal dysmotility point to Fabry small fiber neuropathy; angiokeratoma, corneal deposits, and hypohidrosis are other common early manifestations. Progressive dysfunction of the kidneys, heart, and/or brain develops in adulthood. Diagnosis is often delayed which is of great concern, as therapeutic outcomes with enzyme replacement therapy are generally more favorable in early stages of Fabry disease. Results of a survey among 360 rheumatologists and pediatricians clinically managing patients with rheumatologic conditions demonstrate that Fabry manifestations are generally poorly recognized and that awareness of appropriate diagnostic tests is low. To raise awareness about the musculoskeletal aspects of Fabry disease among rheumatologists, the International Musculoskeletal Working Group on Lysosomal Storage Disorders has reviewed the current knowledge. We propose a diagnostic algorithm with burning pain in hands and feet and triggered attacks of excruciating pain as keystones. Evidence of autonomic nerve dysfunction and simple temperature sensitivity testing can provide important diagnostic clues. Multi-systemic involvement should be explored by taking a detailed medical history, including family history, and performing a thorough physical examination and appropriate laboratory workup. Confirmatory tests include the α-Gal A enzyme activity assay (males) and genetic testing (females). We propose that medical specialists use our diagnostic algorithm when evaluating individuals with peripheral neuropathic pain.     

What is pain management? What can rheumatologists do with no pain management team?

SIR, Having run a back pain clinic for 23 years and a neck clinicfor over 10 years I entirely understand the thoughtful editorialby Cooper, Booker and Spanswick [1]. I have faced the emotionsrelated to ‘heart sink’ patients and totally understandthe inadequacies of the diagnostic model of history taking.Indeed, medical students from Imperial College School of Medicinejoining the musculoskeletal firm at Northwick Park are taughtthe     

A diagnostic approach to hemochromatosis.

In the present clinical review, a diagnostic approach to hemochromatosis is discussed from the perspective of two clinicians with extensive experience in this area. The introduction of genetic testing and large-scale population screening studies have broadened our understanding of the clinical expression of disease and the utility of biochemical iron tests for the detection of disease and for the assessment of disease severity. Liver biopsy has become more of a prognostic test than a diagnostic test. The authors offer a stepwise, diagnostic algorithm based on current evidence-based data, that they regard as most cost-effective. An early diagnosis can lead to phlebotomy therapy to prevent the development of cirrhosis.     

Clinical reasoning learning (CRL) sessions. An example of a contextualized teaching activity adapted to clinical stages in medicine

Clinical reasoning learning (CRL) sessions stem from an educational reform brought about since 1987 at the Faculty of Medicine of the Université de Sherbrooke. This reform is student-centered and based on situated learning and teaching. The objective of the CRL sessions, designed and implemented at the clerkship level, is to help students develop problem solving competencies through the use of effective general clinical reasoning strategies and the development of a highly organized network of specific knowledge. These sessions also strive to offset the difficulties of random clinical exposure and often highly complex cases encountered by trainees during clinical rotations in teaching hospitals. Formed of small groups, sessions recreate a clinical consultation setting focused on a specific priority problem and clinical condition identified among the mandatory objectives of the rotation. Emphasis is placed on early generation and subsequent testing of diagnostic hypothesis, and the active search and gradual disclosure of clinical data using hypothesis-driven inquiry strategy. Students are asked to verbalize their reasoning process under the close supervision of a clinical expert in the field under discussion. Implemented in 5 different clinical disciplines since 1990 in Sherbrooke, assessment data are now available and support the relevance and usefulness of CRL sessions.     

The approach to children with recurrent infections

Recurrent and chronic infections in children are one of the most common reasons for physicians' visits that make a diagnostic challenge to pediatricians. Although the majority of referred children with recurrent infections are normal, underlying causes of recurrent infection such as atopy, anatomical and functional defects, and primary or secondary immunodeficiency must be considered in evaluation of children with this complaint.Although primary immunodeficiency diseases (PIDs) were originally felt to be rare, it has became clear that they are much more common than routinely appreciated. Early and accurate detection of PIDs in children is essential to institute early lifesaving care and optimized treatments. Therefore in the approach to children with recurrent infections, careful medical history taking and physical examination with more attention to warning PIDs signs and symptoms are essential to distinguish those children with underlying PIDs from those who are normal or having other underlying disorders. If indicated, appropriate laboratory studies including simple screening and advanced tests must be performed.     

Effectiveness and costs of a stepwise versus an all-in-one approach to diagnose mild bleeding disorders

The diagnostic work-up of patients referred to the haematologist for bleeding evaluation is performed in a stepwise way: bleeding history and results of screening laboratory tests guide further diagnostic evaluation. This can be ineffective, time-consuming and burdensome for patients. To improve this strategy, the initial laboratory investigation can be extended. In a model-based approach, effectiveness and costs of a conventional stepwise versus a newly proposed all-in-one diagnostic approach for bleeding evaluation were evaluated and compared, using data from an observational patient cohort study, including adult patients referred for bleeding evaluation. In the all-in-one approach, specialized platelet function tests, coagulation factors, and fibrinolysis tests were included in the initial investigation. Final diagnosis, hospital resource use and costs and patient burden were compared. A total of 150 patients were included. Compared to the stepwise approach, in the all-in-one approach, 19 additional patients reached a diagnosis and patient burden was lower, but total costs per patient were higher [€359, 95% bootstrapped confidence interval (BCI) 283–518, p = 0.001]. For bleeding evaluation of patients referred to the haematologist, an all-in-one diagnostic approach has a higher diagnostic yield and reduces patient burden, at a higher cost. This raises the question what costs justify the diagnosis of a bleeding disorder and a less burdensome diagnostic strategy.     

Improving students’ sexual history inquiry and HIV counseling with an interactive workshop using standardized patients

Sexual history and HIV counseling are essential clinical skills. Our project’s purpose was to evaluate a standardized patient (SP) educational intervention teaching third-year medical students sexual history taking and HIV counseling. A 4-hour SP workshop was delivered to one-half of the class. Four weeks later, all students engaged in an SP examination including one station on assessing sexual history taking and HIV counseling. Workshop participants scored one standard deviation higher on sexual history and HIV counseling items than nonparticipants. Our sexual history and HIV counseling curriculum was associated with students asking more thorough sexual histories and providing more HIV counseling.     

Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement

OBJECTIVES: To assess the interobserver agreement on the diagnostic classification of shoulder disorders, based on history taking and physical examination, and to identify the determinants of diagnostic disagreement. METHODS: Consecutive eligible patients with shoulder pain were recruited in various health care settings in the Netherlands. After history taking, two physiotherapists independently performed a physical examination and subsequently the shoulder complaints were classified into one of six diagnostic categories: capsular syndrome (for example, capsulitis, arthritis), acute bursitis, acromioclavicular syndrome, subacromial syndrome (for example, tendinitis, chronic bursitis), rest group (for example, unclear clinical picture, extrinsic causes) and mixed clinical picture. To quantify the interobserver agreement Cohen's kappa was calculated. Multivariate logistic regression analysis was applied to determine which clinical characteristics were determinants of diagnostic disagreement. RESULTS: The study population consisted of 201 patients with varying severity and duration of complaints. The kappa for the classification of shoulder disorders was 0.45 (95% confidence intervals (CI) 0.37, 0.54). Diagnostic disagreement was associated with bilateral involvement (odds ratio (OR) 1.9; 95% CI 1.0, 3.7), chronic complaints (OR 2.0; 95% CI 1.1, 3.7), and severe pain (OR 2.7; 95% CI 1.3, 5.3). CONCLUSIONS: Only moderate agreement was found on the classification of shoulder disorders, which implies that differentiation between the various categories of shoulder disorders is complicated. Especially patients with high pain severity, chronic complaints and bilateral involvement represent a diagnostic challenge for clinicians. As diagnostic classification is a guide for treatment decisions, unsatisfactory reproducibility might affect treatment outcome. To improve the reproducibility, more insight into the reproducibility of clinical findings and the value of additional diagnostic procedures is needed.     

Pourquoi je n’abandonne pas la voie fémorale !

Since its introduction in 1989, the safety of transradial approach compared to the femoral approach is mainly due to reducing entry site complications, allowing early ambulation, but at the price of a higher rate of procedural failure, arterial occlusion and radiation for operators and patients. Nevertheless, these advantages can be minimized with a modern femoral approach requiring a 4-French catheter for diagnostic angiography and a low dose heparin, new antithrombotic drugs and a reasonable use of glycoprotein (GB)IIb-IIIa for angioplasty. The radial approach is the best way to go in hemorrhagic high-risk patients and the femoral approach is safer in complex procedures. The operator has to hold the two accesses and to know when to switch to another approach to minimize complications, procedure time, radiation and contrast use.     

Diagnostic procedures for pleural disease

Using a systematic approach based upon findings obtained from the patient's history, physical examination, routine laboratory studies, and chest roentgenograms, the clinician will establish the presence and location of pleural effusion in the majority of cases. The selective use of tests based upon the clinician's initial diagnostic impressions will allow accurate separation of transudative from exudative effusions; exudative effusions will be diagnosed in over 85 per cent of patients. There remain many unanswered questions regarding the diagnosis of pleural effusion. Prospective studies are needed to establish diagnostic algorithms that minimize under- and overutilization of tests. The introduction of Medicare Prospective Reimbursement under Diagnosis-Related Groups (DRGs) on October 1, 1983, may provide the appropriate incentives to hospitals and clinicians to carry out these important studies.     

Obscure gastrointestinal bleeding: an approach to management.

Obscure gastrointestinal bleeding provides an uncommon but frustrating and resource-intensive challenge for clinicians. Such patients hemorrhage recurrently from sites within the gastrointestinal tract that are not detected by routine endoscopy or radiography, and require a special diagnostic approach to localize or exclude less common bleeding sources such as small bowel angioectasia or neoplasia. The differential diagnosis of obscure gastrointestinal hemorrhage is discussed, and the performance of available endoscopic, radiological and surgical diagnostic tools including enteroscopy are examined critically. A stepwise management algorithm that progresses from the history and physical examination to surgical exploration is offered to facilitate early and efficient diagnosis.