Paul Bergl

Using social media to enhance health professional education

Editors’ note: As clinical teachers we may be sure that many of our students have access to and are using social media frequently; indeed many of us also have a virtual presence both socially and professionally. How social media are used, and also in some circumstances abused, by learners and clinicians has become part of the conversation about professionalism and professional behaviour. This toolbox focuses on another aspect of the topic: how educators may engage with social media to enhance learning and teaching. The authors explore the benefi ts and challenges of introducing various platforms, and students’ reactions to this type of interaction. In particular they discuss the use of Twitter, Yammer, Facebook, Instagram, Tumbler and YouTube. Tips for getting started give helpful advice for those wishing to try something new. As journal editors we know that there is a need for further research into the impact of social media as educational tools: one thing teachers cannot do, however, is ignore their existence.

Moving Toward Cost-effectiveness in Physical Examination

At present, 2 trends in teaching clinical medicine seem destined for harmonious marriage or perhaps mutually assured destruction: a renewed interest in physical examination and the push to provide high-value, cost-conscious care. On one hand, the physical examination has been touted as a way to reduce unnecessary diagnostic testing. When applied thoughtfully, physical examination theoretically represents a cost-saving diagnostic maneuver in itself. Indeed, specialty groups such as the American College of Physicians and the American College of Rheumatology have called on clinicians to use physical examination to choose advanced diagnostic tests wisely. Even specialty societies whose members may gain from indiscriminate testing and imaging have guidelines imploring frontline providers to use clinical skills to avoid unnecessary studies. However, physical examination might represent waste when applied without context. Like any other diagnostic test, physical examination is prone to uncovering incidental findings and false-positives that might beget unnecessary and potentially expensive follow-up testing. Applying aspects of physical examination without a reflection on the prior probability of disease itself may constitute overuse. As such, groups such as the Society of General Internal Medicine have advised against routine health examinations even though most commercial insurers and Medicare reimburse for them. Perhaps most important, that physical examination can be performed at low cost is merely a mirage; the examination requires the vanishingly scarce commodity of physician time and a substantial upfront investment in training keen clinicians to use these skills reliably and accurately. Although physicians’ examination skills are widely believed to be in decline, thought leaders in academia continue to champion the value of physical examination. Here we refer to value in the loosest sense, entailing a spectrum from sentimental to pragmatic. Luminaries in the field of physical examination have called for a cultural change that brings physicians back to the bedside and have implored us to make physical examination both an

Atrioventricular heart block and syncope coincident with diagnosis of systemic lupus erythematosus.

We describe a 59-year-old woman with cardiac conduction abnormalities caused by lupus-induced myocardial damage. She had a history of arthralgias and antinuclear antibodies but no clinical history of systemic lupus erythematosus. She presented with syncope and Mobitz type II second-degree atrioventricular block. Anti-double-stranded DNA antibodies developed coincident with the identification of heart block. Cardiac magnetic resonance imaging showed late enhancing foci of gadolinium uptake that anatomically correlated with her conduction abnormalities. We conclude that her conduction disease represents an early and structural cardiac manifestation of systemic lupus erythematosus that is unusual in its presentation at the time of initial diagnosis.

Individualizing Cancer Screening Recommendations: A Team-Based Learning Activity for Fourth-Year Medical Students

Introduction Cancer screenings are key preventive services that patients receive in primary care. Health care professional students are generally taught about major society guidelines and U.S. Preventive Services Task Force recommendations for cancer screenings. Unfortunately, students and novice providers may view these influential recommendations as a rule book by which to provide care. Experienced providers recognize that not every patient fits neatly into clinical guidelines. Appropriate use of cancer screening entails an understanding of patient preferences, patient-specific health factors, and screening risks and associated pitfalls. Methods This 2-hour team-based learning (TBL) session immerses learners in three challenging patient scenarios that are designed to stimulate nuanced discussion of cancer screening using controversial cases. The scenarios encompass the following cases: (1) a 68-year-old man actively seeking prostate cancer screening, (2) a heavy smoker with psychiatric illness and alcoholism being considered for lung cancer screening, and (3) a 42-year-old woman seeking to become pregnant who inquires about breast cancer screening. Results The materials were originally designed for fourth-year students on an ambulatory medicine rotation. Our students universally viewed this activity as a high-quality presentation applicable to their careers. They strongly agreed that the cases facilitated a deeper understanding of the nuances of cancer screening. Discussion This TBL encourages learners to critically appraise cancer screening guidelines and apply them to real-life examples. It is applicable for learners who understand the complexities of patient care but still suffer from a guidelines-are-rules mentality.

Respiratory Physiology in Liver Disease

In this chapter, we will discuss hepatic-pulmonary pathophysiologic interactions in acute and chronic liver disease. Most of our understanding of how liver disease compromises the key functions of the respiratory system comes from studies of physiologic extremes. From these data, we can infer how milder manifestations of liver disease may contribute to abnormalities in ventilation and gas exchange. In liver disease, it is well established that optimal ventilation is most often perturbed by altered respiratory mechanics from ascites, hydrothorax, and hepatic cachexia. Ventilation-perfusion (V-Q) mismatching may be caused or worsened by compressive atelectasis from ascites or hydrothorax, imbalanced matching in hepatopulmonary syndrome, dynamic small airway collapse from increased pulmonary blood flow, or any of the various causes typically seen in hypoxemic hospitalized patients. Diffusion abnormalities also have myriad causes, and a low diffusion capacity (DLCO) without alternative explanation may represent the uncommon but well characterized hepatopulmonary syndrome. Additionally, acute liver failure may be complicated by the acute respiratory distress syndrome (ARDS), which itself hampers respiratory mechanics, V-Q matching, and gas diffusion. Patients with chronic liver disease are also at risk for ARDS as they are prone to sepsis and aspiration pneumonitis. Managing ARDS in these populations requires special consideration of extra-hepatic complications of liver failure such as elevated intracerebral pressure and tense ascites.

Teaching Physical Examination to Medical Students on Inpatient Medicine Teams: A Prospective, Mixed-Methods Descriptive Study

Physical examination (PE) is a core clinical competency, and the internal medicine clerkship is a premiere venue for students to develop PE skills. However, clinical rotations often lack opportunities for real-time instruction. We sought to measure the frequency, content, and factors affecting PE instruction during the internal medicine clerkship. We conducted a prospective mixed-methods study at a single academic center. Data were gathered by a student researcher who directly observed inpatient teams over 3 months. We quantified the frequency of PE teaching activities and analyzed daily written observations using qualitative content analysis. PE was most frequently discussed during bedside rounds and least often during workroom rounds. Direct observation of students’ examinations rarely occurred. Multiple factors in the learning environment were posited to affect PE instruction. In brief, we found that residents and attending physicians who are part of internal medicine teaching services do not routinely emphasize PE instruction.

Improving Diagnostic Decisions

To the Editor Dr Cifu1 stated in his Viewpoint that diagnostic calibration is “...the relationship between diagnostic accuracy and physician confidence in that accuracy” and suggested static and dynamic influences determine diagnostic calibration. We agree with Cifu and Meyer et al2 that the most worthwhile effort in improving diagnostic calibration is receiving regular feedback on diagnostic accuracy. However, we also advocate practicing metacognition and physicians educating themselves on the myriad cognitive biases that affect diagnostic decisions. These strategies promote the self-awareness that we believe is important for achieving appropriately calibrated confidence and diagnostic excellence. Static and dynamic influences determine diagnostic calibration and other factors such as fatigue, ambient conditions, and team dynamics contribute to diagnostic accuracy. Often, these static and dynamic factors lead physicians down an appropriate cognitive pathway or “cognitive disposition to respond” and to provide a correct diagnosis.3 However, during periods of uncertainty, the summation of numerous static and dynamic factors may promote diagnostic misadventures. Awareness of these factors may be promoted during realtime clinical decision making. For example, by conducting “cognitive and affective autopsies” or a “diagnostic timeout” on rounds, trainees can increase their awareness of static and dynamic factors and review their actual cognitive response. Physicians in practice may find a similar approach helpful by routinely asking themselves the simple question, “What else could this be?” These brief reflections allow learners and practicing clinicians alike to refine their diagnoses in the context of associated dispositions and response. More importantly, they give physicians pause and an opportunity to recognize their level of diagnostic confidence. Cognitive errors or errors in data synthesis or faulty knowledge are purportedly the most common cause of diagnostic error.4 Cognitive errors often occur as a result of overconfidence and overreliance on intuitive modes of thinking.5 Using metacognition forces use of more analytical modes of thinking. Coupled with regular feedback on diagnostic performance, awareness of factors that influence decisions may realign clinicians’ diagnostic confidence and accuracy. In effect, diagnostic calibration itself may be recalibrated toward diagnostic harmonization.

Diagnostic Error in the Critically III: Defining the Problem and Exploring Next Steps to Advance Intensive Care Unit Safety

Diagnostic Error in the Critically Ill: Defining the Problem and Exploring Next Steps to Advance Intensive Care Unit Safety Paul A. Bergl, Rahul S. Nanchal, and Hardeep Singh Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Froedtert Hospital, Milwaukee, Wisconsin; Health Policy, Quality, and Informatics Program, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; and Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas

Encephalopathy With Psychosis Following Group A Streptococcal Sepsis—An Immune-Mediated Phenomenon?

Group A streptococcal (GAS) infections are a well-known cause of post-infectious immunemediated conditions, which may present with a variety of symptoms including neuropsychiatric symptoms, movement disturbances, and obsessive-compulsive features. We report a case of a 31 year-old woman who presented with acute psychosis characterized by severe aggression, hypersexuality, and hyper-religiosity following invasive GAS infection. Laboratory and imaging evaluation failed to identify an etiology of her psychosis. She was treated empirically with high dose corticosteroids and IVIG and had rapid clinical improvement, thereby supporting the diagnosis of a GAS-induced, immune-mediated encephalopathy. Our case depicts a unique manifestation of psychosis in an adult patient that enhances the literature on immune-mediated neuropsychiatric complications following GAS infection and reveals an overlap with other autoimmune encephalitis syndromes.

A Word From Our Sponsors

Occasionally, the stars align in our family’s busy weekdays, and my wife and I arrive home early enough to catch the evening news. Yes, despite being millennials, we enjoy these vestiges of the pre–internet days as a primary source of the day’s headlines. If we are lucky, we can catch the national broadcast at 5:30 PM local time. Usually, we resort to listening to the 6 PM local edition blaring on the television in the other room while we arrange both the food and the children in the dining room. In late October, as we were going through our harried routine, I overheard a public interest piece about prostate health come on the broadcast. Since I regularly facilitate a team-based learning activity on cancer screening with our students, I try to lap up any popular press on the subject. I swiftly moved to the living room to see what the fuss was all about. That night on the broadcast, two local professional athletes were shaving their heads and facial scruff for a clean start to the upcoming “Movember.” The stated motive for these rituals was to raise awareness for men’s health with particular attention to the prostate. As I watched, I immediately flashed back to a grand rounds I had attended two years prior. I recalled the speaker presenting his data on the persistently high rates of prostate cancer screening after the 2012 US Preventive Services Task Force recommendations advised against this routine practice.1 In his presentation, our speaker replayed a similarly themed local news piece about prostate health that had aired in the wake of the 2012 guidelines. In the video clip, a jovial urologist gave his “You can never be too careful” spiel, a remark that caused the grand rounds audience to erupt in laughter. Although my academic colleagues could have been amused by the urologist’s wry smile or the banality of such public interest pieces, I suspect they were most entertained by the unintentional self-satire in this fine piece of reporting. Back in my living room and in the moment, I too had a chuckle. I had thought the prostate health movement had been fading as quickly as the hairlines of the athletes on the screen. Yet three years after the USPSTF’s guidelines came out, here was another local news segment touting prostate cancer awareness. My own amusement abruptly turned to consternation when I discovered that the health care system sponsoring the Movember event was the strategic partnership between my academic practice and our affiliated hospital network. In the ensuing days, I tried to put the news segment behind me. The piece was innocent enough, right? I couldn’t fault the news station for aspiring to produce a lighthearted piece that might benefit public health. I couldn’t fault the athletes; they were using their positions of influence to draw attention to a seemingly important issue. But could I really support my organization highlighting an area that is perennially fraught with controversy? As the autumn wore on, I became increasingly aware of our health care organization’s widespread marketing efforts to promote prostate cancer awareness. Posters plastered in the elevators at our clinic advised men aged 45 years and older to consider getting screened for prostate cancer, for all men aged 50 years and older to be screened, and men older than 70 years to discuss it with their doctor. A more abbreviated ad in the local Sunday paper was even more guideline-discordant; the word consider was dropped for the younger group. The home page for our hospital intranet regularly displayed employees proudly donning paper mustaches in support of the national Movember campaign and our hospital’s local prostate cancer awareness efforts. For many patients and colleagues, these materials probably went relatively unnoticed. To me, though, they were a source of enduring frustration that had been building since the Movember news segment. I was vexed. As a new health professional in our clinic, I was building up my patient panel with a fair number of middle-aged men, many of whom had been receiving annual digital rectal examinations and testing of prostatespecific antigen levels. An alarming number of these men exceeded the age of 70 years or had more pressing health problems. Thus, I found myself trying to wean them off theyearsofexcessivepreventiontheyhadreceived.However, in the background of these conversations—and visibly on the very elevator my patients would have taken to see me—our health care organization was putting out unequivocally positive messages that more attention to theprostatewasbetter. Icouldgothroughmyentirescript onthecontroversyofprostatecancerscreening,thenumber needed to screen, the downstream harms, the false-positives ... all to be potentially undone by the patient’s reasonable retort, “Then why did your ad in the newspaper tell me to get checked out?” Sure, the advertisements had a disclaimer of sorts, advising patients to seek a physician’s counsel before committing to screening. But the masterminds of the campaign—or any other like it—have to know the expected results. Given the US public’s unbridled enthusiasm for cancer screening2 and generalized failure to appreciate any of screenings’ harms,3 the most likely outcome is increased prostate cancer screening. With how time-pressed most primary care professionals are these days, having a truly informed discussion about a controversial screening test is nearly impossible. As wellmeaning as “Be sure to ask your doctor if this test/drug/ device is right for you,” the purveyor of any such message must recognize how meaningless and impractical it is. As a pragmatist and a US health care professional, I have learned to tolerate some of the marketing propaganda of the industrial health complex. Locally, I see competing health care organizations broadcasting messages of dubious legitimacy, but these announcements are A PIECE OF MY MIND