Paul M. Cheon

Inadequacy of Palliative Training in the Medical School Curriculum

This report examines the literature on palliative training in the current medical school curriculum. A literature search was conducted to identify relevant articles. Physicians and medical students both report feeling that their training in end-of-life care and in palliative issues is lacking. The literature expresses concerns about the varied and non-uniform approach to palliative care training across medical schools. The authors recommend the development of more palliative training assessment tools in order to aid in the standardization of curriculum involving end-of-life care. In addition, increased exposure to dying patients will aid students in building comfort with palliative care issues. Such a goal may be accomplished through required clerkships or other similar programs.

Symptom clusters of gastrointestinal cancer patients undergoing radiotherapy using the Functional Living Index—Emesis (FLIE) quality-of-life tool

ObjectiveThe Functional Living Index—Emesis (FLIE) instrument is a validated nausea and vomiting specific quality of life (QOL) tool originally created as a 3-day test of the impact of chemotherapy-induced nausea and vomiting on cancer patients’ daily life. The primary objective of the present study was to retrospectively explore the use of the FLIE from data obtained in a previously published study of patients with gastrointestinal radiation-induced nausea and vomiting (RINV) and compare the extracted symptom clusters on a weekly basis for the entirety of gastrointestinal cancer patients’ radiotherapy treatments.MethodsQOL was assessed on a weekly basis using the 18-item FLIE questionnaire for patients’ radiotherapy treatments. A principal component analysis with varimax rotation was performed at each visit. The internal consistency and reliability of the derived clusters was assessed with Cronbach’s alpha. Robust relationship and correlation among symptoms was displayed with biplot graphics.ResultsA total of 460 FLIE assessments were completed for the 86 gastrointestinal patients who underwent radiotherapy. Two components were consistently identified except for week 5 where only one component was identified. Component 1 contained the items “Q10–Q18” which included all vomiting items. Component 2 included all nausea items from “Q1 to Q9”. All the variables were well accounted for by two components for most weeks of treatment with excellent internal consistency. Biplots indicate that the two symptom clusters were evident at each week, with the exception of the first week of treatment. Strong correlations were seen between the effect of nausea on patients’ ability to make meals, patients’ ability to do tasks within the home, and patients’ willingness to spend time with family and friends.ConclusionThe high internal consistency at all timepoints indicates that the FLIE QOL instrument is useful for the RINV population.

Retrospective review of the incidence of monitoring blood glucose levels in patients receiving corticosteroids with systemic anti-cancer therapy

BACKGROUND Corticosteroids are used adjuvant to certain chemotherapy regimens, either as an antiemetic, to reduce other side effects, or to enhance cancer treatment. Additionally, they are frequently used for symptom control in cancer patients with end stage disease. Corticosteroid use may induce hyperglycemia in approximately 20-50% of patients, which may negatively affect patient outcomes. OBJECTIVE To determine the frequency of blood glucose monitoring in patients with and without diabetes receiving continuous corticosteroids with chemotherapy, and to determine the incidence of treatment-emergent abnormal blood glucose levels and steroid-induced diabetes mellitus (DM). METHODS A retrospective review was conducted for 30 genitourinary (GU) cancer patients who were treated with continuous oral corticosteroids as part of their chemotherapy regimen. The Canadian Diabetes Association (CDA) criterion for diagnosis of diabetes was applied to categorize patients into two distinct groups, patients with diabetes and patients without diabetes. This categorization was made based on glucose measurements completed prior to commencement of corticosteroid therapy. Glucose monitoring was defined as receiving a laboratory blood glucose test before first chemotherapy administration along with a test within a week of each subsequent treatment cycle. The CDA criteria for diagnosis of pre-diabetes and diabetes was used to classify glucose levels as hyperglycemic. RESULTS The mean incidence of blood glucose monitoring was 19% and 76% in patients with diabetes and patients without diabetes, respectively. Approximately, 40% of patients with diabetes required an adjustment to their diabetes management and a further 20% required hospitalization. Fifteen patients without diabetes received a fasting blood glucose test, of which 40% had abnormal blood glucose results; half of these fell into the pre-diabetic range and half in the diabetic range. Ten patients without diabetes were tested for diabetes using the CDA criteria for diabetes diagnosis during or after their chemotherapy, of which 30% developed diabetes. CONCLUSIONS In order to optimize patient care, blood glucose levels should be monitored in all patients receiving continuous oral corticosteroids as part of their chemotherapy. Future studies should be conducted prospectively to determine the most effective manner of monitoring in order to implement screening guidelines and avoid unnecessary morbidity.

Restoring prognosis as a core competency in medical practice.

During the era of Hippocrates (460–370 BC), the lack of effective diagnostic and therapeutic modalities made prognosis the most important physician competency. Conceptually, Hippocrates described prognosis as a two-dimensional construct: quoad vitam (predictions about survival and life expectancy) and quaod sanantionem (predictions about healing and restoration of function) (Christakis 1999). The Hippocratic prognostic process consists of two basic components, namely, foreseeing (formulating the prognosis) and foretelling (communicating the prognosis). Thus, a complete and comprehensive approach to prognosis must involve both components. Major advances in diagnostics and therapeutics have relegated this once highly valued core competency to an almost negligible role in modern medical practice. Not surprisingly, medical curricula are devoid of teaching opportunities focused on prognosis. This void is driven by a corresponding relative dearth within physician competency frameworks. In order to assess the level of content related to prognosis within CanMEDS, a foundational and prototypical physician competency framework, we conducted a quantitative content analysis using Foxit Reader 5.1 (Foxit Corporation, http:// www.foxitsoftware.com/company/press.php?action1⁄4 view&page1⁄4 201110265722.html), a keyword scanning software (Foxit Corporation). The complete compilation of CanMEDS 2005 framework documents of 29 physician specialties and 37 subspecialties across the seven physician roles (medical expert, communicator, collaborator, manager, health advocate, scholar and professional) were scanned. The keywords used in the search included prognosis, prognostic, prognosticate, and prognostication. Of the combined 66 specialties and subspecialties only 22 (33.3%) contained at least one citation of the keyword ‘‘prognosis’’, and 4 (6.1%) contained at least one citation of the keyword ‘‘prognostic’’. The terms ‘‘prognosticate’’ and ‘‘prognostication’’ were completely absent from all CanMEDS 2005 documents. Overall, the combined citations for ‘‘prognosis’’ and ‘‘prognostic’’ were linked with the following competency roles: Medical Expert (80.3%), Scholar (11.5%), and Communicator (8.2%). Prognosis is both an imperative and an enabler for truly patient-centered care. The formulation and communication of prognosis also intrinsic for the delivery of healthcare that is ethically, morally and legally sound. Therefore, given the fundamental importance of prognosis within medical practice, it is recommended that physicians develop appropriate attitudes, skills and knowledge related to the formulation and communication of prognosis. Reforming competency frameworks that build more content for outcomes involving prognosis has the potential to drive medical curricular reform. Thus, the content of objectives related to prognosis within CanMEDS should be addressed in advance of its planned update in 2015. Moreover, it is recommended that foreseeing and foretelling be emphasized within the scholar role and communicator role respectfully.

Prognosis: the "missing link" within the CanMEDS competency framework.

BackgroundThe concept of prognosis dates back to antiquity. Quantum advances in diagnostics and therapeutics have relegated this once highly valued core competency to an almost negligible role in modern medical practice. Medical curricula are devoid of teaching opportunities focused on prognosis. This void is driven by a corresponding relative dearth within physician competency frameworks. This study aims to assess the level of content related to prognosis within CanMEDS (Canadian Medical Education Directives for Specialists), a leading and prototypical physician competency framework.MethodsA quantitative content analysis of CanMEDS competency framework was carried out to measure the extent of this deficiency. Foxit Reader 5.1 (Foxit Corporation), a keyword scanning software, was used to assess the CanMEDS 2005 framework documents of 29 physician specialties and 37 subspecialties across the seven physician roles (medical expert, communicator, collaborator, manager, health advocate, scholar, and professional). The keywords used in the search included prognosis, prognostic, prognosticate, and prognostication.ResultsOf the 29 specialties six (20.7%) contained at least one citation of the keyword “prognosis”, and one (3.4%) contained one citation of the keyword “prognostic”. Of the 37 subspecialties, sixteen (43.2%) contained at least one citation of the keyword “prognosis”, and three (8.1%) contained at least one citation of the keyword “prognostic”. The terms “prognosticate” and “prognostication” were completely absent from all CanMEDS 2005 documents. Overall, the combined citations for “prognosis” and “prognostic” were linked with the following competency roles: Medical Expert (80.3%), Scholar (11.5%), and Communicator (8.2%).ConclusionsGiven the fundamental and foundational importance of prognosis within medical practice, it is recommended that physicians develop appropriate attitudes, skills and knowledge related to the formulation and communication of prognosis. The deficiencies within CanMEDS, demonstrated by this study, should be addressed in advance of the launch of its updated version in 2015.

Deathless models of aging: time to reform CanMEDS

Cosco and colleagues deserve accolades for their article in CMAJ .[1][1] Although there may be many factors that have led to the development of a death-denying culture, we believe that the main driver relates to deficiencies within medical education. Medical curricula are driven by competency

Penile necrosis secondary to purpura fulminans: a case report and review of literature

Abstract We report the case of a 60-year-old Hispanic male with widespread necrotic purpuric lesions involving the penile, suprapubic, inguinal and hip dermis due to purpura fulminans. Purpura fulminans describes a rare syndrome involving intravascular thrombosis and hemorrhagic infarction of the skin; this rapidly progressing syndrome features vascular collapse and disseminated intravascular coagulation. This patient’s penile necrosis involved the majority of the penile shaft and glans penis, and ultimately required partial glansectomy and repeated debridement for treatment. Subsequently, full thickness skin grafting was completed for reconstruction with good effect. While reports of penile necrosis secondary to various causes are documented in the literature, no prior reports describe penile necrosis secondary to purpura fulminans.