Alberto Puig

How to become a better clinical teacher: A collaborative peer observation process

Background: Peer observation of teaching (PoT) is most commonly done as a way of evaluating educators in lecture or small group teaching. Teaching in the clinical environment is a complex and hectic endeavor that requires nimble and innovative teaching on a daily basis. Most junior faculty start their careers with little formal training in education and with limited opportunity to be observed or to observe more experienced faculty. Aim: Formal PoT would potentially ameliorate these challenges. Methods: This article describes a collaborative peer observation process that a group of 11 clinician educators is using as a longitudinal faculty development program. Results: The process described in this article provides detailed and specific teaching feedback for the observed teaching attending while prompting the observing faculty to reflect on their own teaching style and to borrow effective teaching techniques from the observation. Conclusion: This article provides detailed examples from written feedback obtained during collaborative peer observation to emphasize the richness of this combined experience.

A 21-kDa C-terminal Fragment of Protein-disulfide Isomerase has Isomerase, Chaperone, and Anti-chaperone Activities

A catalyst of disulfide formation and isomerization during protein folding, protein-disulfide isomerase (PDI) has two catalytic sites housed in two domains homologous to thioredoxin, one near the N terminus and the other near the C terminus. The thioredoxin domains, by themselves, can catalyze disulfide formation, but they are unable to catalyze disulfide isomerizations (Darby, N. J. and Creighton, T. E. (1995) Biochemistry34, 11725–11735). A 21-kDa, C-terminal fragment of PDI (amino acids 308–491), termed weePDI, comprises the C-terminal third of the molecule. The k cat for ribonuclease oxidative folding by weePDI is 0.26 ± 0.02 min−1, 3-fold lower than the wild-type enzyme but indistinguishable from the activity of a full-length mutant of PDI in which both active site cysteines of the N-terminal thioredoxin domain have been mutated to serine. Eliminating the ability ofweePDI to escape easily from covalent complexes with substrate by mutating the active site cysteine nearer the C terminus to serine has a large effect on the isomerase activity ofweePDI compared with its effect on the full-length enzyme.weePDI also displays chaperone and anti-chaperone activity characteristic of the full-length molecule. As isolated,weePDI is a disulfide-linked dimer in which the single cysteine (Cys-326) outside active site cross-links twoweePDI monomers. The presence of the intermolecular disulfide decreases the activity by more than 2-fold. The results imply that the functions of the core thioredoxin domains of PDI and other members of the thioredoxin superfamily might be modified quite easily by the addition of relatively small accessory domains.

Teaching during consultation: factors affecting the resident-fellow teaching interaction.

The subspecialty consultation represents a potentially powerful opportunity for resident learning, but barriers may limit the educational exchanges between fellows (subspecialty registrars) and residents (house officers). We conducted a focus group study of internal medicine (IM) residents and subspecialty fellows to determine barriers against and factors facilitating resident–fellow teaching interactions on the wards, and to identify opportunities for maximising teaching and learning.

Case records of the Massachusetts General Hospital. Case 13-2012. A 62-year-old man with paresthesias, weight loss, jaundice, and anemia.

Dr. Norifumi Kamo (Medicine): A 62-year-old man was admitted to this hospital because of paresthesias, weight loss, jaundice, and anemia. The patient had been well until approximately 2 months before admission, when numbness, tingling (“pins and needles”), and burning in his hands developed; the symptoms intermittently radiated proximally to the mid-forearm and gradually progressed to an estimated 40% of his normal sensation. Pain, stiffness, and weakness of the hands occurred; he noted decreased dexterity of his hands, without swelling, and he began to drop objects. He took ibuprofen, with minimal symptomatic improvement. His appetite decreased, and an unintentional weight loss of more than 6.5 kg occurred. Approximately 6 weeks before admission, the patient’s family noted that his eyes and skin (most noticeably his palms) gradually became pale and yellowed. Two weeks before admission, extreme fatigue, shortness of breath, and weakness with exertion developed, and episodes of abdominal pain occurred in the lower quadrants. Stiffness in his axillae developed, and it migrated to his shoulders and abdomen. One week before admission, his wife noted a change in his gait, and he appeared unsteady. He was unable to climb four stairs without resting and was unsteady on standing, with resolution after ambulating. Two nights before admission, dyspnea, weakness, and diaphoresis developed. During the day, pressure radiated up his arms; this was associated with diffuse abdominal pain that intermittently radiated to the axillae, and dark urine developed. On the day of admission, he rated the pain in his joints at 7 on a scale of 0 to 10, with 10 indicating the most severe pain. At that time, he came to the emergency department at this hospital. The patient reported increased respiratory secretions, with a cough of 2 weeks’ duration that was productive of white or yellow sputum, without hemoptysis, fever, headache, nausea, vomiting, hematochezia, melena, diarrhea, other changes in bowel function, or symptoms in his legs or feet. He had hypertension and benign prostatic hypertrophy. The patient had been well on routine examination 4 months before admission. Medications included lisinopril (daily) and ibuprofen and acetaminophen as needed Case 13-2012: A 62-Year-Old Man with Paresthesias, Weight Loss, Jaundice, and Anemia

Case 13-2012

Dr. Norifumi Kamo (Medicine): A 62-year-old man was admitted to this hospital because of paresthesias, weight loss, jaundice, and anemia. The patient had been well until approximately 2 months before admission, when numbness, tingling (“pins and needles”), and burning in his hands developed; the symptoms intermittently radiated proximally to the mid-forearm and gradually progressed to an estimated 40% of his normal sensation. Pain, stiffness, and weakness of the hands occurred; he noted decreased dexterity of his hands, without swelling, and he began to drop objects. He took ibuprofen, with minimal symptomatic improvement. His appetite decreased, and an unintentional weight loss of more than 6.5 kg occurred. Approximately 6 weeks before admission, the patient’s family noted that his eyes and skin (most noticeably his palms) gradually became pale and yellowed. Two weeks before admission, extreme fatigue, shortness of breath, and weakness with exertion developed, and episodes of abdominal pain occurred in the lower quadrants. Stiffness in his axillae developed, and it migrated to his shoulders and abdomen. One week before admission, his wife noted a change in his gait, and he appeared unsteady. He was unable to climb four stairs without resting and was unsteady on standing, with resolution after ambulating. Two nights before admission, dyspnea, weakness, and diaphoresis developed. During the day, pressure radiated up his arms; this was associated with diffuse abdominal pain that intermittently radiated to the axillae, and dark urine developed. On the day of admission, he rated the pain in his joints at 7 on a scale of 0 to 10, with 10 indicating the most severe pain. At that time, he came to the emergency department at this hospital. The patient reported increased respiratory secretions, with a cough of 2 weeks’ duration that was productive of white or yellow sputum, without hemoptysis, fever, headache, nausea, vomiting, hematochezia, melena, diarrhea, other changes in bowel function, or symptoms in his legs or feet. He had hypertension and benign prostatic hypertrophy. The patient had been well on routine examination 4 months before admission. Medications included lisinopril (daily) and ibuprofen and acetaminophen as needed Case 13-2012: A 62-Year-Old Man with Paresthesias, Weight Loss, Jaundice, and Anemia

Necrotising pneumonia and bronchiectasis in a previously healthy 30-year-old man.

We present a case of a previously healthy 30-year-old man who presented with a necrotising pneumonia and bronchiectasis. His infectious workup revealed a Staphylococcus aureus pneumonia. Since bronchiectasis and necrotising pneumonia are unusual findings in an otherwise healthy person, further investigation was pursued. His workup revealed non-classic cystic fibrosis (CF) and allergic bronchopulmonary aspergillosis (ABPA). This case discusses the differential diagnosis of bronchiectasis, the diagnosis and treatment of ABPA, and the role of CF mutations in the pathogenesis of ABPA.

Mystery Case: A 63-year-old man with progressive proximal pain and weakness

A 63-year-old man with a history of type 2 diabetes presented with hip and shoulder pain in June 2010. He was on atorvastatin 80 mg daily and his creatine kinase (CK) was mildly elevated, so he was switched to simvastatin 20 mg daily. Three months later, he was referred to a rheumatologist. His CK was 142 U/L and his erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were mildly elevated (28 mm/hour and 14 mg/L, respectively). He was diagnosed with polymyalgia rheumatica. He was started on a methylprednisolone taper starting at 16 mg going to 8 mg daily with mild, although transient, improvement. He remained on 8 mg daily methylprednisolone for several months. Eight months later, he began to notice progressive proximal leg weakness and difficulty climbing stairs. His serum CK was 1,600 U/L. He stopped the simvastatin and was started on gemfibrozil. An EMG was normal. His CK rose to the 3,000s U/L 3 months later. Nine months later, 8-day methylprednisolone tapers starting at 16 mg daily were symptomatically ineffective, as was prednisone 60 mg daily tapered over 2 weeks.

Fainting, Swooning, and Syncope

Have you ever been curious about how serious fainting, swooning, and syncope are or can be? Have you wondered whether, when, and how to work up these conditions? Have you ever considered how to best treat a patient with single or multiple episodes of syncope? If you have, then the following case vignette should provide a useful stimulus for discussion.

Hospitalist Perspective of Interactions with Medicine Subspecialty Consult Services

BACKGROUND Medicine subspecialty consultation is becoming increasingly important in inpatient medicine. OBJECTIVE We conducted a survey study in which we examined hospitalist practices and attitudes regarding medicine subspecialty consultation. DESIGN AND SETTING The survey instrument was developed by the authors based on prior literature and administered online anonymously to hospitalists at 4 academic medical centers in the United States. MEASUREMENTS The survey evaluated 4 domains: (1) current consultation practices, (2) preferences regarding consultation, (3) barriers to and facilitating factors of effective consultation, and (4) a comparison between hospitalist–fellow and hospitalist–subspecialty attending interactions. RESULTS One hundred twenty-two of 261 hospitalists (46.7%) responded. The majority of hospitalists interacted with fellows during consultation. Of those, 90.9% reported that in-person communication occurred during less than half of consultations, and 64.4% perceived pushback at least “sometimes” in their consult interactions. Participants viewed consultation as an important learning experience, preferred direct communication with the consulting service, and were interested in more teaching during consultation. The survey identified a number of barriers to and facilitating factors of an effective hospitalist–consultant interaction, which impacted both hospitalist learning and patient care. Hospitalists reported more positive experiences when interacting with subspecialty attendings compared to fellows with regard to multiple aspects of the consultation. CONCLUSION The hospitalist–consultant interaction is viewed as important for both hospitalist learning and patient care. Multiple barriers and facilitating factors impact the interaction, many of which are amenable to intervention.