John Kugler

Renal failure and rhabdomyolysis associated with sitagliptin and simvastatin use

Background  Sitagliptin is a new oral glucose‐lowering medication that acts via the incretin hormone system. The most common side‐effects are headache and pharyngitis, and few serious adverse events were observed during clinical trials. Dose adjustment is recommended in renal insufficiency, but long‐term safety experience is limited.

The Road Back to the Bedside

According to that old story, a local giving directions to a lost traveler says, “If I wanted to get there, I wouldn’t start from here.” Medicine finds itself far from the bedside,1,2 seeking a way back, unsure where to begin. That we have wandered far afield is plain to see. Core bedside skills of history taking and physical examination—still vital to comprehensive assessment, diagnostic accuracy,3 and truly patient-focused care—are taught and assessed in the first two years of medical school but largely ignored once the student reaches the clinical years.4 During residency, development of these skills is assumed when in fact they wither further.5 The physical examination of newly admitted patients is often cursory and, what is worse, perverted by drop-down boxes into an exaggerated and invented form that reads better than the truth. Technology drives diagnosis, but it often merely substitutes our fears of uncertainty with delusions of certainty. We seem increasingly chained to the computer, providing perfect care to our virtual patient, the iPatient.2 More has seemed better than less for so long that we now need a national campaign6 to alert our patients to “Just Say No” and save themselves from the hazards and costs of diagnostic misadventure. While we all agonize over the spiraling costs of a “Hi-Tech, Lo-Think” approach, many stand to gain from its persistence. But we have to start somewhere. The way physicians are taught is fundamental to the type of health care they deliver. The road back to the bedside will, we believe, start at the bedside, in the way that clinical skills are taught and assessed. We in the United States stand out among other major Western health care professionals in having a summative postgraduate medical certification process that is entirely dependent on the assessment of knowledge. Elsewhere, for example, the United Kingdom, internal medicine trainees must additionally pass a clinical skills assessment in which independent facultylevel examiners directly observe resident-level trainees assessing real patients.7 In the States, no high-stakes clinical skills assessment for the purpose of certification in internal medicine has survived. The USMLE Step 2 CS is for many trainees the last time that their clinical skills are objectively assessed, and it ensures that a basic level of competence is attained. But given its current content and standard, it cannot equip internal medicine trainees for future practice and appears to mark an end, not a beginning. Meanwhile, high scores on tests of knowledge directly translate into better career prospects. If “assessment does indeed drive learning,”8 we should not be surprised if our trainees prefer books to the bedside. In the absence of a high-stakes assessment of postgraduate clinical skills, we have myriad formative workplace-based tools, but we use them infrequently and inconsistently,9 perhaps because we doubt their veracity or perhaps because it is difficult enough to find faculty willing and confident in their own clinical skills sufficient to teach or assess residents. Escalating constraints of work hour rules, rapid turnover, and the need for documentation add to the problem. Direct observation is the key to the development of competence10; in its absence a resident’s expertise in interpreting information gathered is taken to mean that he or she has similar expertise in gathering the information. As matters stand, assessment of residents’ clinical skills often appears to be based on little more than the general impression of attending physicians, whose own clinical skills were never directly observed. Can it really be that an internal medicine trainee passes through his or her entire residency without ever assessing a patient under the direct observation of a faculty-level assessor? What would our patients say if they knew? Much the same, we suspect, if they were told that their pilot had never been vetted in the cockpit. At Stanford, our interest in bedside medicine and the presence of a visitor (A.E.) on sabbatical from a system where high-stakes postgraduate clinical skills assessment remains the norm, led us to four principles to guide our own efforts to enhance residents’ bedside skills and begin on the path back: 1. Involve Real Patients. As valuable as “simulated patients”—of humankind or mannequin-kind—can be, the term is only 50% correct: “simulated,” yes; “patient,” no. Teaching and assessing higher-level clinical skills, such as the ability to discriminate between normal and abnormal in the physical examination, require real patients with real signs. Our first step is the establishment of a database of patients willing and able to help. 2. Observe Residents’ Practice. Direct observation and appraisal of trainees by trainers must increase both in informal day-to-day working practice or with new or established tools. We are piloting our own bedside skills assessment, with real patients and facultylevel assessors, modeled on the Membership of the Royal College of Physicians (MRCP) PACES examination, which is conducted worldwide (and for which A.E. serves as chair of the examining board). 3. Demonstrate Clinical Skills. Direct observation is a two-sided coin—trainees must also observe the clinical method of their trainers. In Workshops: We devote four morning report sessions each month to a Stanford Medicine 25 session: a hands-on demonstration of a physical diagnosis technique.11 At the Bedside: Our core group of attendings are our hospitalists, who have taken the lead in our bedside medicine efforts; their continued interest and experience as bedside teachers leverage A PIECE OF MY MIND

THE USE OF PARTIALLY MATCHED, UNRELATED DONORS IN CLINICAL BONE MARROW TRANSPLANTATION

It is estimated that 60–70% of patients who might benefit from a bone marrow transplant will not have a suitably matched, related donor. We have, therefore, designed a clinical experiment to test the safety and feasibility of using marrow from partially matched, unrelated donors. This paper details our transplant experience in the first eight patients with leukemia. The first four patients had advanced leukemia at the time of transplantation. Each showed hematopoietic recovery, but all died from septic complications largely related to extended neutropenia encompassing both the pre-marrow-grafting and the post-marrow-grafting period. The next four patients were in remission at the time of transplantation. Each showed prompt and sustained hematopoiesis with variable graft-versus-host disease (GVHD). No acute or chronic GVHD was seen in two patients, grade II (skin only) was seen in one patient, and grade IV (skin, liver, and gut) was seen in one patient. One patient has died from sepsis five-and-one-half months following transplantation, and three are alive and well six-and-one-half to nine-and-one-half months postengraftment. This preliminary experience, together with several case reports in the literature, leads us to conclude that bone marrow transplantation with partially matched, unrelated marrow is a safe and feasible approach. If these results are confirmed by longer follow-up in a larger group of patients, the development of marrow donor pools would appear to be justified.

The Physical Exam and Other Forms of Fiction

The traditional physical diagnosis course taught in the first two years of medical school has changed little in over half a century, and it deserves some scrutiny, if only because it is quite out of step with what students see when they begin on the wards during their clinical years. They are surprised to find that the house staff and attending staff carry very few of the instruments the student has acquired: reflex hammers are occasionally spotted, but ophthalmoscopes are quite rare. Even more vexing for the student is the realization that the currency on the ward, the “clinical skill” they were so anxious to acquire, does not involve the patient as much as it involves finesse and efficiency on the computer in ordering tests, in discharging patients and in completing notes-throughput. Indeed, one could make the case that it is time to dispense with the physical exam course altogether because the physical exam is being dispensed with altogether. It would appear that the two-dimensional rendering of the patient through imaging occupies us more than the three dimensional reality of the patient.

The Five-Minute Moment

In todays hospital and clinic environment, the obstacles to bedside teaching for both faculty and trainees are considerable. As electronic health record systems become increasingly prevalent, trainees are spending more time performing patient care tasks from computer workstations, limiting opportunities to learn at the bedside. Physical examination skills rarely are emphasized, and low confidence levels, especially in junior faculty, pose additional barriers to teaching the bedside examination.

Point-of-Care Ultrasound in Internal Medicine: Challenges and Opportunities for Expanding Use.

The physical examination taught to medical students has not changed significantly in decades and the methods currently used would be as familiar to a physician training in the 1940s as they are to my students today. A major exception to this continuity is the introduction of point-of-care ultrasound (POCUS)—a US examination performed and interpreted in real time at the bedside by the treating physician to answer specific questions related to the patient’s presentation. POCUS is recognized by students as new and exciting and our medical schools are reacting: one survey found that 27% of schools have an integrated US curriculum for preclinical students. Another study indicated that 62% had integrated US training into the clinical teaching years. My own decade-long journey in practicing and teaching POCUS as an internal medicine (IM) physician has shown me that the main challenge to widespread adoption of POCUS in my specialty is not the lack of real clinical benefit or evidence of value, but the obstacles in educating trainees, faculty, and practicing physicians. So, what are the benefits, and are there specific obstacles to more widespread teaching?

Learning bedside medicine.

Many graduates from U.S. medical schools have poor clinical exam skills and rely increasingly on lab reports, imaging, and other diagnostic tests. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

The Role of Technology in the Bedside Encounter

Technology has the potential to both distract and reconnect providers with their patients. The widespread adoption of electronic medical records in recent years pulls physicians away from time at the bedside. However, when used in conjunction with patients, technology has the potential to bring patients and physicians together. The increasing use of point-of-care ultrasound by physicians is changing the bedside encounter by allowing for real-time diagnosis with the treating physician. It is a powerful example of the way technology can be a force for refocusing on the bedside encounter.