Additional Info
- Audio Fileuab/ua184.mp3
- DoctorsKnox, Hogan
- Featured SpeakerHogan Knox, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4514
- Guest BioSpecialties include Cataract and Refractive Disease, Comprehensive Ophthalmology and
Glaucoma.
Learn more about Hogan Knox, MD
Release Date: February 1, 2021
Expiration Date: February 1, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners no relevant financial relationships with ineligible companies to disclose. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and I invite you to listen as we examine the effect COVID-19 has had on glaucoma patients and its impact on patient care. Joining me is Dr. Hogan Knox. He's an Ophthalmologist and Clinical Instructor at UAB Medicine. Dr. Knox, it's a pleasure to have you join us today and what a great topic this is. We've heard about how people have avoided hospitals for things like heart attack and stroke due to the fears of COVID. Have you noticed a sharp drop in care during the pandemic? Have you seen collateral damage specifically, in ophthalmology? Has that been hit particularly hard? Tell us what you've seen for your patients.
Hogan Knox, MD (Guest): Thanks for having me on. So I mean, the pandemic has been going on for such a long time, I feel like there's kind of been multiple stages in how we've cared for patients and what I've seen. But certainly in the first several months a lot of patients that weren't coming in for their appointments. And I mean, talking about collateral damage, I seen numbers of patients you know, three to four months after the pandemic started, that didn't come in when they were having a problem, because they were scared to come in. And then by the time that they did come in, their issue was irreversible and they lost vision permanently because of it.
So, I have a bunch of those stories to tell, but more recently I feel like as a clinic, as a whole, we've become better at making people feel comfortable about coming in. And I haven't seen as much of that recently, but certainly saw a lot of that two to three months ago.
Host: Well then Dr. Knox, how do you make the decision or measure the cost of seeing patients in clinic at their regularly scheduled appointments or a special appointment if their glaucoma is severe versus Telehealth or something if the risk of the patient's glaucoma is progressing to the point of irreversible vision loss? Can you share a status update with us on how you determine whether they do need to come in for that visit or whether it's something that can be done through a Telehealth?
Dr. Knox: Yeah, where we've used Telehealth since the pandemic has started as really just to try to check pressure in a more remote location, you know, one of the big exam things that we do when we check glaucoma patients and we do get visual fields, which, unfortunately requires them to come to the clinic. We get a sort of imaging modality of the eye. And then we also do pressure checks. You know, everybody kind of associates glaucoma with pressure, and it's more complicated than that, but it's an important piece of the treatment. And so if somebody's pressure of the eye is well controlled and it's consistently been well controlled, and their testing has not progressed, over the past several years then that's a low risk patient to have problems even during the pandemic. So, those are people that I would feel more comfortable about saying, you know, it's okay if you space your appointment out another couple of months, thinking the pandemic may come to an end, but, unfortunately for a lot of these patients, glaucoma is a blinding disease and we don't have the means in a Telehealth model to make sure that those patients aren't going to get worse.
And so, we did do some, at Callahan, we had some drive-through pressure checks. It was almost like a screening tool to see if patients needed to be seen or not. And that's good for some people who have already checked into the clinics and already had testing, but it wouldn't be adequate for a new patient exam. So, there's a lot of stuff. We have a lot of Telehealth research going on and stuff, but it's still not quite up to the standards to, to make sure that these people are going to be stable through the pandemic and just able to stay home.
Host: Are they considered high risk for COVID complications? Are they in the high risk category?
Dr. Knox: Well, that's more complicated than that. So, glaucoma doesn't make them in a high risk category, but the fact that they're predominantly an older population. So yeah, you could say yes from that standpoint.
Host: What about the emotional impact the pandemic has had on so many of us, but particularly those with blinding diseases? What have you seen as far as the mental health of your patients?
Dr. Knox: I would say fortunately, just from my routine patients that are coming in for more routine glaucoma care, I haven't seen other than being isolated from their family. It's nothing that the glaucoma specifically has created extra issues for them. People that I've seen, the biggest kind of emotional struggles are the people who are kicking themselves because they didn't come in because they didn't feel safe to come in earlier on during the pandemic. And then again, by the time, glaucoma is a blinding disease. And so if you don't catch it early and treat it early, you can permanently lose vision from it. And so, those are the people that, in my opinion, have had the biggest stresses and just the work, the hardest time with the, with COVID. But I've also seen coworkers, I've had family members and loved ones pass away from COVID.
It's definitely taken a toll on our healthcare system and ophthalmologists, we don't take care of COVID positive patients in the ICU at least currently, but it's just affected so many people now. It's, hard not to see a patient in clinic and not have some sort of conversation about COVID because we're all wearing masks. We're distancing. I'm not shaking hands. Not that we didn't wipe down equipment before, but we're like pretty OCD about wiping down everything and it's a lot different than it was before the pandemic, for sure.
Host: So, do you see in the future any change to care and research for glaucoma as a result of COVID or do you think things will go back to the way that they were? What are some of the things that you changed during this pandemic that you think will kind of stick, will stay with us after it's gone.
Dr. Knox: I think there's a big need for Telehealth. I mean, I know you've kind of harped on it at the beginning and as much as we can keep people home and feel certain that they're not going to be losing vision, then we will do that. It's just the main means that we have to see to check people out of the office is really with different some sort of instrument that we can check pressure.
But I think, yeah, you know, a lot of the resources going on through Callahan with Telehealth has to do with trying to put those imaging software and the visual field software in more rural locations to where patients can go just down the street to get that testing. And then that testing can then be sent to a glaucoma specialist that in a metropolitan area, such as Birmingham or something like that.
So, that's something I think for sure in the future is going to be impactful for glaucoma. It's just not quite there right now. The things that I'll take after this pandemic to change my practices, it’s, mainly I guess sanitation like washing your hands as diligently as you possibly can. And it definitely makes you long for just some of the social interaction that we had and the comfort that you had in just shaking somebody's hand before this pandemic started. Does that make sense?
Host: It does. And as we wrap up, what would you like other providers to know about glaucoma and the impact on patient care that you've seen at UAB as a result of the COVID-19 pandemic? Do you have any advice for other ophthalmologists that are dealing with this as you are from the experts at UAB?
Dr. Knox: You know I mean, everybody's trying to prevent people from going to see a physician. You know, you want to try to stay home as much as you possibly can. But I would just want to emphasize that, I think healthcare in general is a pretty controlled environment to be in, from a sanitation and spread standpoint specifically, in our clinics and hospitals. If anybody's having symptoms, they don't come to clinic. Everybody wears masks. All the chairs are distanced, everything's wiped down before you come in. You're just in the room with a physician. So, it's a pretty controlled environment. Unlike, you know, people that may still be going to restaurants and things like that. And so, I would just hope that we can try to make people feel safe to come in and get their eyes checked if they're truly having a problem. There are a lot of people that I see in clinic that fortunately don't have any issues and I feel comfortable telling those people that unless you're having an emergent issue, you can stay home until the pandemic's over.
But for those people that are truly having issues or their vision's changed, or their eyes hurting, or something's worrisome, those people, I would just want to make sure that they should feel comfortable coming in, just because of the patients that I have seen that have not come in because they felt like they wouldn't be comfortable. And then they've lost so much because of it.
Host: Certainly good information, Dr. Knox, thank you so much for joining us today. A community physician can refer a patient to UAB Medicine by calling the Mist line at one 800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. And please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua167.mp3
- DoctorsMullins, Haddon;Willig, James
- Featured SpeakerHaddon Mullins, MD | James Willig, MD, MSPH
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4360
- Guest BioHaddon Mullins, MD is a General Surgery Resident.
James H. Willig, MD, MSPH, is the Associate Dean of Clinical Education in the School of Medicine. He attended Medical School at the Instituto Tecnologico de Santo Domingo (INTEC) and completed his residency at the University of Virginia Roanoke-Salem. At UAB, Willig has earned an M.S. in Public Health and completed an Infectious Diseases Fellowship.Learn more about James Willig, MD, MSPH
Release Date: November 9, 2020
Expiration Date: November 9, 2023
Disclosure Information:
Planners:
James Willig, MD, MSPH
Professor, Infectious Diseases
C. Haddon Mullins, IV, BS, BA
UAB Medicine
Jill Deaver, MA, MLIS
UAB Medicine
Adam Roderick, M.ED.
UAB Medicine
Anne Zinski, PhD
UAB Medicine
Caroline Harada, MD
Associate Professor, Geriatric Medicine
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Presenter:
James Willig, MD, MSPH
Professor, Infectious Diseases
Dr. Willig have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity.
Submitted By: Kate Hiden - TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing clinical encounter. In this panel, are Dr. James Willig. He’s the Assistant Dean of Clinical Education at UAB Medicine and Dr. Haddon Mullins. He’s a General Surgery Resident at UAB Medicine.
James Willig, MD, MSPH (Guest): Greetings and welcome to the next edition of our podcast on medical education. Today, we are going to discuss a little bit more about the clinical encounter and the steps that you can use as an educator as you interact in a room with a patient and your students. Last week, we talked a lot about the preparation before you get into the room and today, let’s really talk about the particulars of what happens in the room. So, again, I’m James Willig and I’m here with Haddon Mullins. Haddon is of course, our resident expert who has reviewed a lot of the literature for us. And today, we’re going to start – we are going to follow our format here with just a few questions and today I’m going to be asking the questions to Haddon. So, Haddon, initially, the sort of the question is, is there a plan that you follow generally for bedside rounds? And this is a question that you’re asking a clinician. For me, generally, I think of bedside rounds really as sort of a sequence of three things.
The first is you walk in. There’s the greeting. There’s how are you today? Taking the moment to take the room in to look around, to see the family, to see the person, to see if there’s any clues that they are in distress or kind of what’s the status of the situation right now to see if there is anything that you need to respond to immediately. Assuming that things are well and things are okay, then we’ll produce to what I’m just going to refer to sort of the data sharing portion of the encounter where the student or the resident will really review the data from the last time we saw that person, get all the data from the previous night, discuss the data from today. Typically, that’s SOAP format and ultimately, we’ll really go into the assessment friend version of that SOAP format where we really discuss the management. And really tell – make sure that people know what’s coming now in terms of today and what’s coming – what’s the long term plan that we are working towards. But that’s about as much as I do in terms of having a general plan or outline for what’s going to happen in the room. What does the literature teach us?
Haddon Mullins, MD (Guest): So, there’s a number of ways that the literature deals with what to do when you are inside the room with the patient and your whole team is there. Like you said, what we talked about last week was more about preparation before you step in the room. And this would be from the moment you walk in to the moment you leave. And an introduction is a perfect place to start. We talked a little bit about orienting the patient last week and acclimating them to an academic environment and if that’s already been done, the introduction can be brief. If not, you can – we can revisit some of those aspects of the introduction including introducing the entire team, telling them why you’re here, and that this is an academic experience. There will be education going on, but this is also first and foremost about your care plan.
The introduction is a great place and the introduction, and the closing will be the only aspects of the encounter that the Attending leads. And so, this is the Attending’s moment to role model physician patient interaction, and professionalism to the students and the residents.
Another option if you feel that your residents are prepared to do this, you can allow the house officer to lead the interaction and that’s beneficial because the resident is most often the patient’s primary doctor and it allows you as an Attending to step back and better observe team interaction and provide better feedback from the encounter itself. So, if you have the resident leading this and doing the introductions, then instead of role modeling professionalism and the physician patient interaction; you’re observing your resident and then you can give your resident feedback as well.
Dr. Willig: Interesting.
Dr. Mullins: So, before I get into my recommendation, like I said, it’s an amalgam of a couple of different recommendations, are there any priorities that you have particularly during the case presentation or the data sharing portion?
Dr. Willig: My first priority is that the presentation is targeted at the patient and the family. So, the information has to be relayed in a way without jargon and it’s got to be relayed in a respectful and a direct way that’s inclusive. Again, patient-centered is the word that really should be underscored and highlighted in the case presentation. So, I would say that’s my first priority. My second priority is that we review, reconfirm critical history and physical examination findings. If there’s a detail in the history, maybe the sequence of symptoms or the severity of symptoms or an associated symptom that might lead us to consider something different in the differential; that would be a piece of data that I would want to reconfirm at the bedside. So, key decision making pieces of data I’d want to reconfirm. As well, as any abnormal physical exam findings. I think it would be a great opportunity to sort of have the student demonstrate what they have seen and have the Attending confirm them. If a physical exam finding is there and it’s interesting; it’s something that I often get the entire team to listen to while the presentation can be going on you might say okay, let’s walk away here and keep presenting. Make sure that the patient agrees and is okay with the student doing it and then maybe have the students line up and look at or auscultate a specific finding that was found there.
So, first, patient-centered presentation. Second, review of important history and physical exam and the third priority for me is that we really answer all of the questions from that patient and their family. Again, if we leave questions in the air, I really specifically say I don’t think we’ve done our job well enough and if folks need to know the plan immediately for today, as well as long term, this is what we are working toward. We think that disease pattern A or B might be going on. We continue to work towards differentiating those two patterns and today’s tasks are one, two and three. That sort of – I want people to really know what we’re doing and why we’re doing it. But that would be the priorities for the case presentation.
But now, what does the literature show us?
Dr. Haddon: Those are great priorities for a case presentation in general especially trying to limit the medical jargon and of course being patient-centered. As an Attending, there are a number of things that you can be focused on and the person presenting the case first of all, can be anyone from the student to a resident. And so these same aspects or techniques kind of apply to any student at any level, any learner at any level. And I found five I’s that a teacher can use to think about where his head should be while the case presentation and the data sharing portion is coming from the learner. That includes the introduction, which we have already covered, in the moment included focused listening, eye contact to the patient and the student, nonverbal cues. A lot of times, learners can be uncomfortable or uneasy or nervous about case presenting and for them to be able to look at the Attending and you give them a slight nod, they know you are listening, they know they are going in the right direction and everyone moves forward more smoothly.
Dr. Willig: Just a point on that is certainly more contemporary rounding when you have both pagers and smartphones, that people have access to you continuously; I can’t remember the last patient presentation that I got through entirely where I didn’t get sort of three things buzzing on my person. And it’s messages from all kinds. So, I think it’s important to know that word focused listening, to really, while you are in there, just really be looking at the patient and try to leave all of that external stuff to the side. Leave the phone in your pocket. If your pager rings, just kind of reach over and silence it and continue. Don’t even break eye contact if you do that. That’s something that someone highlighted to me as a behavior that they saw a physician do when they were speaking to them that really to them, it meant wow, this person cares so much about me that they are not even looking at their pager right now. They’re really sort of attentive and they are in me. And all the clinician did was kind of reach over and silence the pager and continue that encounter. So, that attentive listening and being in the moment is key.
Dr. Haddon: Right and that goes in with another I which is interruptions, particularly meaning to minimize them and that’s exactly what you just said to minimize as many distractions coming from pagers or anything else that might be going on and an important part about that, is to establish beforehand if you can, circumstances to the learner in which you might have to interrupt and that would include anything from certain emergencies, time constraints, if you want to clarification, if something is disorganized. And so that would let the learner know that we are not going to interrupt your case presentation except under these particular circumstances. And it let’s them know ahead of time that if you’re going to interrupt, it’s something that I as the case presenter, need to hear.
Another I would be inspection. And this will line up with our next step which would be the physical exam. The Attending can be acutely aware of the data that is being shared, the psychosocial aspects of the team and the patient and periodically be glancing at the patient. If the student is mentioning certain physical exam findings, and the Attending can point out certain things about the patient just from observation, that will be relevant to the physical exam findings; then that can help the Attending better prepare for the physical exam demonstration. It can also be a great opportunity for an Attending to show students the power of observation and if you as the Attending, have been inspecting the patient while listening to the data, you have an idea of what’s going on and you’re also practicing observation; then you as an Attending can show the students or the learners this is what I’ve learned just from that case presentation and just from this observation, before you’ve ever even touched the patient. And it can be an opportunity to show the power of observation.
Dr. Willig: This is very interesting to me. Because, moving to bedside rounds, and when you hear a presentation, and to have the opportunity to observe the patient while things are being presented; there seems to be some additional insight available there. And that insight is of course, comes from just watching the patient and watching sort of their demeanor and their status and are they in pain, or acutely ill, not acutely ill. There’s all of that clinical insight but there’s another level of insight where you can really look at how did they respond when different facts of the history were said, you can get a sense for are they really anxious about what’s going on, are they really concerned, are they really worried. Are there parts of their history where they seem to have a strong reaction yes or no? And you can even take a moment to really look a little bit more broadly than the patient and look at the next concentric circle around them, the people around the bed, their family or friends or whoever is there with them and see how things are affecting them. Sometimes, you’ll sort of see this look of anxiety when something is mentioned and you can understand that yeah, that’s – you can intuit that that’s probably something that they were talking about. That’s something that they’re worried about and they’ve been mentioning it, they kind of reacted to it. So, there’s a ton of information. There’s looking around the room. You walk in, you see what candy wrappers are lying around for example that are going to inform discussions that you might have about changing dietary habits or things like that.
So, there’s just a wealth of information lying around right there in the room. And I think using that time for inspection, while the case is being presented at the bedside, just is a whole – just a bunch of insights can be gleaned there.
Dr. Haddon: And it’s important in the sense of efficiency as well. And to prepare you for whatever discussions you might want to have with your learners or patient going forward. So, that was four I’s, introduction, in the moment, inspection, interruptions, minimizing interruptions and then the fifth can be independent thought. And this is I believe you said it last week but it’s important to have the students commit to a differential in the room before you give them a kind of hint or it the differential has been established, the plan and that needs to be done because it can allow for a couple of things. One, it can let you as the Attending know where the learner is and what knowledge gaps that you might want to fill in and it allows for the student, themselves to guide the teaching points. So, if they commit to a certain differential, or a certain plan and you already in your head are thinking either that’s great or you know where their head is at so that you can direct your teaching points specific to where their needs might be in terms of management or diagnosis.
Dr. Willig: This is so key. Right. Because this is the – that alchemy that we have to achieve where we have all of these concepts that we know in terms of how to illicit this data, then how do you organize those pieces of data into information and sort of spin that into an insight? So, as a student, then you need to encourage your students to do this. They have to independently come up with their differential. They have to come up with their assessment and plan. It doesn’t have to be accurate. It needs to be done. It is born from repetition and it is this task of taking this data, interpreting it, and sort of changing it into a treatment plan, a diagnostic plan. That’s the crux of our profession. And you’ve got to start getting your repetitions in.
Sometimes it is see students be worried or be overly worried about am I going to be wrong, am I going to look bad. They make a point of reading the resident’s note or the intern’s note and then go in to write their assessment and plan. I make a point of freeing my students from that burden. It says the exercise here is for you to do this. For you to get your practice. After you do it, you can maybe look and those plans and then go read some more, but I want to hear what you’re thinking. Because if I know what you’re thinking and where you are at, then again you have set the level of where you are as a learner. And then I can work targeting where you are to lift up your level. But if I don’t know where you are, then you’re telling me you’re kind of transcribing what was in the resident note or in the intern note, I know nothing about you as a learner.
So, you have to really emphasize, it’s okay. I want to hear your plan. I want to hear where you’re at and go from there.
Dr. Mullins: Right and that’s perfect. And it’s very important and it’s mentioned in a number of articles about the importance and a number of these teaching based strategies to have the student commit to a differential. Now, the case presentation is over. I think the next important step is demonstration of a physical exam finding. And that can be more than likely relevant to the patient and their condition. Even if the exam findings are unchanged, I still think it could be important as an Attending to demonstrate a certain maneuver in front of your learners. Is this something that you do regularly or is there a strategy that you have for demonstrating physical exam findings?
Dr. Willig: So, it makes me think what I hear you note this that there really are physical exam findings that are going to be evolving during the hospitalization, say the percussion or an effusion in the lung and ultimately after a thoracentesis, or another procedure; the fluid is gone and you see that exam evolve. The evolution of physical exam findings associated with acute exacerbation of say heart failure with a reduced ejection fraction. How do those physical exam findings evolve over time? So, I think there’s a lot of value in picking a couple of threads in the physical exam that are going to evolve over time and going back to them every day to give folks an idea of how these things are expected to evolve.
Sometimes it’s as simple as look at the ease with which the patient is breathing every subsequent day in someone with an acute exacerbation of chronic obstructive pulmonary disease or something like that. And then the other thing is sort of these one off physical exam findings which I often use to sort of introduce topics of discussion where I might have seen something yesterday and I might have said oh wow, look at this person has an interesting physical exam finding and it might be something as simple as look they have what I believe to be onychomycosis and look at their age and maybe the next day, the teaching point might be heh, look at all of these things that can mimic onychomycosis in someone this age. So, just don’t talk about that possibility.
Or sometimes, the other teaching point that I might make would be heh, let’s really talk about distinct presentations of onychomycosis and how some of them are associated with or have been associated with immunodeficient states or not. Here’s wide superficial, here’s proximal, here’s distal lateral onychomycosis and certainly there’s different associations with particularly the wide superficial and the proximal have been associated with some acquired immune deficiency states. But again, the point is, I’m going to use a physical exam finding as a gateway to make another teaching point or I’m going to really talk about how that physical exam finding evolves over time. And on either of those scenarios, demonstrating the appropriate technique of how you elicit that physical exam finding is crucial.
Dr. Haddon: Right and so, I think a key part of this is that this is a demonstration. So, this is not from what I read in the literature an opportunity for assessment. I think it can be afterwards if you feel that you have the time or the inclination to. But it should be led by the Attending as an expert and this is how this is done as opposed to a chance to have a learner do it and then you give feedback. I think it’s more important or one important aspect of a learner learning how to do this is to observe an expert actually performing it while describing it.
So, there’s a model to do this called the five minute moment which was developed out of Stanford. The paper is G2016 and the whole idea is that you can demonstrate a physical exam finding in five minutes or less. So, the idea for it is to first provide a contextual framework. This works perfectly at the bedside because the framework is already there, the patient with a certain physical exam finding. You can also provide historical context or a story of when this particular finding was of importance in terms of a diagnosis that you’ve had in your past or this is our patient right here with this problem with this physical exam finding.
So, a framework and textual narrative, demonstration by the Attending and then as you were saying, it’s important to talk about how to interpret it and then what are common errors or what else could this look like, or how do you differentiate this particular interpretation from that particular interpretation and how to use this physical exam skill to help your diagnosis. And this technique, the five minute moment, can be used independently of this whole case presentation but I think it also fits very nicely within it. Mainly because you have a context, you have a purpose, you, as the Attending are in there with your learners and it let’s you again, model your relationship with patients and you’re modeling professionalism.
Dr. Willig: And then you discuss the interpretation of it and the common errors associated with it.
Dr. Haddon: Yes.
Dr. Willig: So, that’s kind of the package for it.
Dr. Haddon: Right, that would be an easy way for you to work physical exam skills practice into your bedside rounds by you demonstrating.
Dr. Willig: So, let me talk about a practical concern here. So, at this point, I happen – I’m a subspecialist in infectious disease and I might not be – my cardiovascular exam might not be the greatest cardiovascular exam or it’s maybe – I would say not as good as I was when I was sort of hardened in the trenches, third year internal medicine resident. So, we work with people like that. That are incredibly skilled residents that have seen a great volume, maybe they just rotated off of cardiology rotation and they have all of this great information for us. What you’ve read here, really talks about the Attending demonstrating a physical exam finding and go on, did you see instances where you could ask a resident to lead the physical exam finding? Because frankly, in my case, I’ve seen it over and over. There are residents that are really great at parts of the physical exam whereas I might be okay at them.
Dr. Haddon: Yes, absolutely. And the residents as we’ve talked about, can be just as integral and should be viewed as teachers or Attendings in terms of how junior faculty or students view them. So, yes, absolutely. And that’s a common concern among Attendings. I can’t remember the exact paper, but that was a common concern about going to the bedside in terms of Attendings not feeling like they were equipped to demonstrate certain physical exam maneuvers. And I think it makes sense, and I think there are definitely people who are better at one skill than the other. But I also think the Attendings main advantage would be in the contextual framework or giving a historical narrative or giving some kind of a story to say heh, this is when – this was a case that this particular physical exam was really important or this is when I learned this for the first time or this is a history or a story from my own training. That can be important for students to give them a relevance for these types of maneuvers and why they’re being done and why they make you do it every single time you go to the room and you’ve never actually seen or found anything.
Dr. Willig: So, [00:22:30] is sort of the case in your experience?
Dr. Mullins: Right. Exactly.
Dr. Willig: Okay.
Dr. Mullins: And I think in terms of a – from a learner’s perspective, it can also be important to see the Attending interact with the patient as well. But as we’ve talked about, the resident could and should be seen as an acting Attending. So, yes, absolutely the residents can demonstrate this as well if they know the framework and if they’ve been taught the framework by the Attending or someone that’s familiar with it.
Dr. Willig: Okay. So, Haddon, you’ve told us a lot about sort of preparation and teaching at the bedside, but it looks like you also reviewed in the literature, several sort of published frameworks for teaching at the bedside. And I know that you want to share some with us now. Tell us about what you encountered that you found a lot of value in.
Dr. Mullins: Yes. So, there are a couple. Well there’s three really main ones. There’s a lot of literature papers that will give an outline of how to do a bedside encounter. This is what you should do. These are the steps you should take. But there are really three main mnemonics or teaching points that have really been established in terms of this is how you teach at the bedside.
So, this is after the case presentation, after physical exam finding, okay, everybody is looking at you as the Attending to teach something. Or to tell them something that they need to know. One is called the one minute preceptor. Another one is called SNATS. One minute preceptor is very well established. It’s easy. And it’s very quick and simple. SNATS is another one that tried to expand upon the one minute preceptor, and it was really more – tried to make it more student-centered as opposed to the one minute preceptor which is more Attending-centered.
The problem with both of those in terms of our discussion is that both of those are based mostly on outpatient care. So, Dr. Stickrath out of UC Denver wanted to come up with a plan for teaching for an inpatient setting. And so, he looked at the one minute preceptor, looked at SNATS and based a lot of this on adult learning theory or constructivism and came up with MIPLAN, M-I-P-L-A-N, meeting, which we have covered, introduction, which we have covered, and then plan which covers your teaching points.
Dr. Willig: And meeting was working with your residents at the beginning of their rotation, establish expectations about what’s going to happen through the rotation and through bedside rounds and the routine day.
Dr. Mullins: Yes.
Dr. Willig: The introduction is really how we walk into the room, how we interact with folks within the room.
Dr. Mullins: Yes.
Dr. Willig: And then there’s the plan part.
Dr. Mullins: Yes.
Dr. Willig: Okay.
Dr. Mullins: Which is teaching points at the bedside.
Dr. Willig: Okay.
Dr. Mullins: P is patient care. So, your first set of questions should be patient focused and involves patient care, patient management, or diagnosis type questions. These can help you probe for student knowledge and identify student gaps, can let you assess their clinical reasoning and again, this would be guided by what they committed to originally. So, whatever their commitment for patient care was, those questions should come back off of that committed differential or plan.
Dr. Willig: So, you start with questions about like heh, here’s what you just presented. I want to confirm or clarify this in the history or I want to maybe look at this physical exam finding and do it independently, confirm it independently and then if you, the student commit to diagnosis, then you can sort of say okay well what did you commit to, why that, what do you think of that pattern. So, you hold your initial set of questions around there.
Dr. Mullins: Exactly.
Dr. Willig: Okay. What comes next?
Dr. Mullins: Then after you’ve established patient care questions and one important point for this is to try and involve the whole team so these questions could be graded up but it’s important never to downgrade the questions. So, if you are going to ask your senior resident a question about management and you disagree or think that’s not right, never to ask a junior faculty member that same question. So, you can grade these questions up –
Dr. Willig: Junior faculty or like a junior year student.
Dr. Mullins: Your student.
Dr. Willig: Your learner. Okay.
Dr. Mullins: Or an internal like if you are asking your senior resident a question about management and they get it wrong or disagree with what your own opinion is, don’t ask that same question to the intern. Because these questions aren’t meant to be competitive. It’s supposed to be educational. But you can grade up questions if you would like. So, you can go from student and say what is your committed differential, okay then you can ask your intern, well what would your differential be and go up to the senior resident. You don’t want to – especially because again, this is a different dynamic in front of the patient. You don’t want to undermine anybody’s authority. You don’t want to embarrass anybody. You want to make your learners comfortable sharing their answers without being nervous that oh I can’t get this wrong because a junior faculty member or a student might show me up.
Dr. Willig: And what’s interesting too is that sometimes I’ve – people as you’ve mentioned think gosh, I don’t want to get this wrong in front of the patient. That I’m going to look like I don’t know what I’m doing. And to manage that feeling, sometimes if I ask a question, I will – and I’m seeing my learners struggle a little bit, I’ll say something like it’s a great thing that we work in teams. And all of us work together. So, let’s kind of go to so and so, what are you thinking about this. And that’s how I’ll take my question on to the next level of learner and really not sort of say something like well it seems like you don’t know the answer so let me ask this other person over here. But rather just make it a smooth transition heh, we work as teams. And we share information to do it. So, I’ve heard what you have to say, let me include so and so in this discussion. And that makes it more of a transition as opposed – that isn’t in anyway kind of negative towards gosh you didn’t know that.
Dr. Mullins: Right and then it’s more of a layering of information as opposed to senior members being undermined by other members or and the junior members or the students don’t want to have to disagree with the senior members either. I mean as a student you’re probably going to just spit back out whatever the senior resident said. So, you want to grade up as opposed to going down. So, that’s questions from the Attending about patient care.
Next step would be to ask your learners if they have any questions. We’ve had them commit to a differential and if they are allowed to ask more questions, they are allowed to guide the teaching experience even more and fell more involved as opposed to just a passive member. And that’s a really important part of the SNATS mnemonic and the MIPLAN mnemonic is to make this education learner-centered. And learner doesn’t just mean a student. It can also be an intern or a resident, but to allow them to ask questions and let them kind of guide what they would like to learn. It also let’s you as an Attending gauge where they are at based on what types of questions they are asking. And it allows you a chance to address specific problems or questions that your learners might have. This could also be done away from the bedside. Especially if there are questions of a sensitive nature or if there has been some kind of a psychosocial issue that your learners have questions about how to manage. Those types of things can be done away from the bedside. It’s important as an Attending to allow your learners to ask that question at the bedside if possible but I’m sure there are also practical time constraints and things like that, that you may not be able to answer every single question that your learners have at that time. But to give them the opportunity to say heh, this is what I would like to learn from this patient right now, is a good way as an Attending, to target your teaching points to where they are needed.
That’s plan, PLA is Attending’s agenda. So, if you’ve established patient care questions let’s say there weren’t that many questions, this is hospital stay day ten, and everything is the same and you are looking to discharge, there aren’t that many questions, learners questions weren’t many or have been answered, then you can move on to your agenda. And you can say okay, this is a teaching script that I have prepared for this certain disease. This is this patient reminds me of a patient that I had during my training. Here is some literature that I have read recently on this particular disease. This could be a good opportunity to incorporate chalk talks or just to teach general rules.
So, that would be after patient care questions, and learner questions is finally, when as an Attending, you can teach whatever you would like to teach until the learner has things that you think they need to know, they may not realize that they need to know.
Dr. Willig: This part, I’ve seen people do it in so many different and effective ways. I’ve heard people sort of talk about you almost have to have a lot of prepackaged content that you can share and with your learners at the bedside. I’ve seen folks have specific articles that help with the management of common conditions. I’ve seen folks have chalk talks or diagrams that were drawn to help people think through it. I’ve seen people have a thumb drive with some pictures of a physical – a cutaneous finding for example and there will be some teaching slides about it, or some questions associated with it. But this is really where as an educator, you get to kind of work on your portfolio and it builds over time and you have all of these great quick bedside teaching interventions that you’re going to have available to you, that you can use with your learners. It would be great to see something like an online resource where people can sort of maybe it already exists, but it would be – this is a fantastic – there’s a fantastic set of resources around there if you take a look around and you see what your colleagues are doing. It’s a great way to really build up your own arsenal and portfolio of educational interventions.
Dr. Mullins: Right. And I hesitate to give particular specific advice on this because I feel like a lot of Attending teaching points probably grow and develop organically just over the years of seeing certain disease patterns over and over and over again. Or being familiar with the literature around certain pathology or certain treatment or certain plans. And so, there really is no prior experiences, citing literature, chalk talks. I think all of that works in its own way and personally, I think it works even better if it comes from the Attending as opposed to being dictated by someone else. So, I fell like, as a teacher, the Attending is going to be more enthusiastic and more involved if it’s something that they have developed themselves as opposed to something that comes from some kind of protocol.
Dr. Willig: Yeah, and you make a very good point about how a lot of these things, we can think about the mass option, let me show you causes of pathology A. but there’s a lot of teaching that doesn’t have to be just knowledge about a pathology. There’s interactions about here’s how I work through that difficult encounter. Or here’s how I usually go through a conversation where I have to deliver difficult news. Or here’s how I navigate a difficult interaction between two family members or gosh I had a suspicion that there was something amiss, maybe I suspected it was spousal abuse, and how did I navigate that and have the opportunity to speak to the person individually. So, there’s a lot to do and teach beyond just here’s some great insights into the latest and greatest therapy or knowledge of the pathophysiology for condition A.
This is really where you get to share a lot of your professionalism to model how you do things to even if a consultant comes up, how do you interact with the consultant, how you interact with the nursing staff. One thing I always like to say is that whatever you do as an Attending, makes it permissible for everybody else to do that.
So, you really have to manage your professional relationships in a very high level way as you go through with learners around you. Because everything they see you do, you have just made permissible and your normalize that behavior. So, even ill comments about gosh, someone came from a [00:35:18] hospital and look at this poor job that I think the people over there did. Even that’s problematic. It can be framed as heh this person is here now. We understand how it was done before. Now we really have to make every decision going forward based on our knowledge and what we feel is the best course of action here.
So, there’s so much that you need to be aware of as an Attending. And there’s so many times where you teach intentionally but you also teach unintentionally when people just observe you going through your things.
Dr. Mullins: Right and it’s important to remember that all of this is happening with the patient. So, your agenda for the day could be patient education. Or it could be further interaction with the patient. This is an opportunity. It is important for you to teach your learners. And so that’s where the patient care questions and the learner’s questions comes in but here, the A, Attending agenda is your agenda as an Attending. So, if you want to address the patient, if you feel like your learners are doing well or that you’ve established or done enough teaching with the first two sections and now here, we are; that can involve anything from patient education to more history from the patient to talking with the family to teaching scripts.
Dr. Willig: Yeah, no this a beautiful point because modelling teaching to the patient and how to you get folks on that path towards behavior change, needed behavior change; is another thing that we can model very effectively. And people will come up with all interesting ways. I saw a colleague of mine interact with somebody who was a plumber and the person had come in very late, after many, many weeks of symptoms for the specific condition that was bringing them in that day. And the idea was to really communicate to this person, listen, you’ve got to come in at the first sign of trouble. So, they kind of tried saying that about the condition and really wasn’t getting much traction. And then they kind of just started talking about – so tell me about the work you do. Oh, you’re in plumbing. That’s great. And kind of talked a little bit about that and then started talking about so, if something is wrong in my house, and I see sort of a wet spot in the ceiling, but it’s kind of small, should I just leave it there and call you a week or two weeks from now and all of that and the person said no, that would be ridiculous. You want to call me right away before there’s a lot of water damage. And then they kind of stopped in the midst of that and they looked at the provider and said, oh. And that was the way. That was the way to explain buddy, you can’t wait three weeks to come in when this is going on. You got to come in early. So, that was a very interesting interaction. I remember learning a lot from them because that was a very clever way to sort of understand that patient, their life, and really frame the message to get them to embrace the needed behavior change in the context of their life.
One last thing I want to challenge our learners to do is something that I actually did the last time I was on the wards. So, I kept a sheet of paper in my pocket and every day, I jotted down what I taught about on rounds. And my goal was to sort of do three things every day. So, it’s a lot of patients. And there’s a lot to teach and I think I started jotting down even if it was discussed today, I taught about this topic. Or I really went ahead and had a difficult conversation where I shared a tough diagnosis with someone and their family and then I went outside the room and sort of reviewed what was my strategy, this is what I was thinking when I saw their face, when they reacted this way, I decided to take the conversation here and that’s teaching.
But go ahead and try that sometime. I encourage our listeners to just kind of keep a log of what you do for just a week. Just do it for a week. And get an idea what are the things that you are teaching your learners and it also made me a little bit more aware that every day, gosh I wanted to at least three things. we are not going to get out of rounds focusing on three things. It also allowed me to kind of double back on lessons that I felt were particularly important that I wanted to emphasize because I saw another missed opportunity where that lesson could have been used in a conversation with a patient or a family member.
Dr. Mullins: That would be perfect. And I think the advantage to having a mnemonic like PLAN in mind is simple but it’s not strict. So, it lets – it gives you the facility and the flexibility to teach in your own way but it keeps it first of all patient-centered and learner-centered and then allows you as an Attending to kind of wrap things up and frame things in a certain way that you might believe is outside of where your learners might see it. To give your insight in terms of they might not recognize that they need to be asking this question is where I can step in and show them what they need to know that they don’t know they need to know.
That’s PLA, N is next steps. And before I get into next steps, he makes a point that next steps could be just to move on, say we’re done with this patient, we have a lot to do, we’ve asked questions. Everything is good. The patient is good. Let’s just move on. So, next steps can be just that. But if not, one big part that I kind of adapted from another plan so is to give a learning prescription. And so we call them topic reviews. And it’s mentioned in here, but it’s not really detailed out and I found this format that I thought was really interesting that was applied to a different type of teaching strategy, but I think it also applies well here. And that’s the PICO format. And it’s actually supported by PubMed and you can use a mobile app on your phone to use this format to search PubMed for questions.
Dr. Willig: PICO?
Dr. Mullins: PICO, P-I-C-O.
Dr. Willig: Okay.
Dr. Mullins: And there are a number of people that have – it was originally designed by PubMed for systematic or for asking questions for systematic reviews but then there were a number of people that said heh, this might be a good way to ask clinical questions. And there was a group of physicians paper is Nixon 2014 that applied this to learning prescriptions. And there’s some other people that have applied it to learning prescriptions and they found that using the PICO format, you get a better quality answer from your students. Also, another important part about learning prescriptions is to keep them concise and narrow and that it is better to ask a specific question as opposed to saying why don’t you go do a topic review about heart failure.
And then they come back with a dissertation on heart failure that nobody has time for. And what did they really learn, nothing that they didn’t learn in the first two years of medical school. The PICO format is Patient Intervention Comparison Outcome. When you are asking a question, it involves a certain patient set, an intervention, a comparison to another type of intervention and then what your desired outcome is. And it’s best suited for therapy questions but can be used for questions related to etiology, diagnosis, harm, prognosis, prevention, cost analysis. You can still use the same kind of format and adapt it a little bit.
Dr. Willig: And it’s patient intervention comparison outcome?
Dr. Mullins: Yes.
Dr. Willig: So, let me throw a clinical question at you and see if you PICO it.
Dr. Mullins: Okay.
Dr. Willig: So, today we saw a patient and they’re having shortness of breath. It turns out that they have a genetic condition that makes them hypercoagulable and they have a history previously of having lower extremity clots that have sort of broken off and caused a pulmonary thromboembolism. And the question we need to ask is gosh, do we need a VQ scan here or do we need a CT Angio or something like that? Or which imaging study should we go after? So, how would you PICO that?
Dr. Mullins: Right. So patient would be your patient with that condition, it can also include the type of genetic disease that they might have if that’s relevant. Intervention would be what test you want to order. And the comparison would be compared to another type of test that might give you similar data or similar information. They don’t have to be related tests, but related to –
Dr. Willig: It would be contrasting the tests as to fata, specificity, cost, accuracy, those types of things.
Dr. Mullins: Right. And then outcome would be what do you want to know. Is this you are trying to determine a certain diagnosis, you’re trying to determine what kind of treatment plan to follow, you’re trying to determine a prognosis. That could all be what your desired outcome would be.
Dr. Willig: So, this is very interesting because a lot of times, I’ve sort of varied how I have done this over the years. Initially, I think I was much more general, like heh, tomorrow why don’t you come in and teach us a little bit about condition X. And I got a couple of dissertations and all of the sudden, it was like we don’t have 15 minutes on rounds to talk about condition X. So, over time, I basically said things evolved into more like tomorrow you are going to have three things, or you are going to have three minutes to tell us the three most important things about condition X or give us a general description of this condition.
And I think it felt even better if you say something like we’ve got to make a clinical decision tomorrow. And that clinical decision is going to be whether we are going to use treatment A or treatment B. And I need you to go tonight and I want you to review what our patient is, think about the specific intervention, compare the two interventions that we’re talking about and what our potential outcomes are going to be. And on rounds, you’re going to bring those data in and we’re going to – you’re going to inform the decision that we’re going to make tomorrow. If the clinical scenario lends itself to waiting, if it's that time for decision, what a wonderful way to include your student as an active participant in the medical decision making in terms of informing that decision and to give them a targeted format on which to look at the information.
Because it’s also medical students that are our learners are busy as well. So, when you tell them go read about condition X, well, I can probably read about any condition for a little amount of time. But if you give a specific question, you’ve targeted me, and I can really get you a well flushed out answer with a format like PICO.
Dr. Mullins: Right. And the great part I think about PICO is that it’s PubMed supported with a mobile app. So you can –
Dr. Willig: What does that mean?
Dr. Mullins: So, you can go to PubMed, you can type in on your phone PICO PubMed and it will come up as a mobile website or app that has patient intervention comparison outcome and you type in each one in it’s search and it searches PubMed for you. PubMed Medscape. So, it will do it for you. It has the format already established for students that you can do on a mobile phone.
Dr. Willig: I have never heard of this. This is very interesting.
Dr. Mullins: And originally it was designed like I said, for systematic- for asking systematic review questions or asking questions to write systematic reviews. And it’s recently being applied to the world of education and making these learning prescriptions for students and giving them targeted answers that can get targeted and relevant answers. Target questions to get targeted answers.
Dr. Willig: That’s awesome. That’s awesome.
Dr. Mullins: So, that’s PICO. And that would be applied on the last part of the plan mnemonic if you feel like it’s needed or if it’s relevant.
Dr. Willig: Or it’s an option for you.
Dr. Mullins: Right, it’s an option.
Dr. Willig: So, you have hit us with a lot of mnemonics today, sort of MIPLAN and PICO and the five I’s. what would you tell us here to close to wrap up? What are the key take aways we should have today?
Dr. Mullins: I think that what I came up with or what my recommendation is for inpatient rounding is to use the MIPLAN mnemonic which covers what we talked about last week and today from the meeting to the five I’s during the case presentation, to the PLAN mnemonic for teaching. Where I added or mixed in would be to be sure and include a physical exam skill which you can use the five minute moment for that I mentioned and that’s going back to our original definition for bedside rounds which was that is includes the demonstration of a physical exam skill. So, that’s something that’s not included in MIPLAN, but I think should be included in a bedside encounter. I also think if you are going to give your students or learners a learning prescription or a topic review; that to provide them with this PICO format will not only give them a better direction, but it will give you as an Attending, a better answer as well.
Dr. Willig: And ultimately to better and more focused patient care and a better discussion at the bedside.
Dr. Mullins: Right.
Dr. Willig: And give the patient, the student, the learner just a way to influence decisions. Because sometimes our learners we hear, gosh, a lot of this discussion is high level or I don’t feel like I’m part of the team but a learning prescription with a PICO question that’s going to result – it’s going to inform a decision the next day, they can easily put a line from their effort that night to a clinical decision the next day, making them feel included in the team.
Dr. Mullins: Right. Exactly. So, after all of that, this is the clinical encounter would obviously include a closing which should be patient-centered as well. So, and we’ve talked about this a little bit but just to summarize it you would summarize for the patient, make sure they don’t have any questions or that you have answered all their questions and have a genuine closing and again, as I mentioned at the beginning, the introduction and the closing are really where you as an Attending, are going to model this relationship for you. Or the resident. And if you want the resident to do it, then you as an Attending can sit back and then give your resident feedback on how the closing was, how the introduction was. How the demonstration of the physical exam was. If they are not ready, then this is your opportunity to show them how it’s done and I think this clinical encounter covers a lot and give you a lot of opportunities to educate but I also think that it allows you to keep your care patient-centered and patient-focused at the same time. And that’s really the problem or the question is how do I educate and keep this learner-centered while also keeping my ultimate goal of care management patient-centered? And I think the MIPLAN mnemonic does a great job of that and I think that adding on of demonstrating a physical exam finding compliments that and I think the learning prescription add on also compliments that as well.
Dr. Willig: Say real quick the key elements for a closing.
Dr. Mullins: So, the closing would be to summarize concisely for the patient, avoiding medical jargon, what you have talked about and what your plan is for that patient. It would also include summarizing for the learners what they have learned and turning to them and saying this is what we talked about, reemphasize a learning prescription if you have one. Then you want to make sure you’ve answered any questions that the patient has and make sure that they and their family are clear with what the plan is and that they feel comfortable with that.
Dr. Willig: All right. Then with that, we will transition to closing our session today and I’m really looking forward to the summary of the key points here. I think there’s a lot of great things to reinforce from these mnemonics and their elements in our key take away section.
Dr. Mullins: Yes sir and our next session, will be focused on giving feedback.
Dr. Willig: Fantastic.
Dr. Mullins: Thank you sir.
Dr. Willig: Thank you.
Host: And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua185.mp3
- DoctorsHollis, Sean
- Featured SpeakerSean Hollis, PhD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4504
- Guest BioSean Hollis, PhD is an Assistant Professor. His specialty is Neuropsychology.
Learn more about Sean Hollis, PhD
Release Date: January 29, 2021
Expiration Date: January 29, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Speakers:
Sean Hollis, PhD
Assistant Professor, Physical Medicine & Rehabilitation
Dr. Hollis has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionUAB MedCast is an ongoing medical education podcast. The UAB Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category 1 Credit. To collect credit, please visit UABMedicine.org/medcast, and complete the episode's post-test.
Welcome to UAB MedCast, a continuing education podcast for medical professionals. Bringing knowledge to your world, here's Melanie Cole.
Melanie: Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to listen as we examine post-concussion syndrome. Joining me is Dr. Sean Hollis. He's a neuropsychologist and assistant professor at UAB Medicine.
Dr. Hollis, it's a pleasure to have you join us today. And this is a really good topic. So first I'd like you to give us a little working definition for the listeners, what is post-concussion syndrome and how frequently does it occur?
Dr Sean Hollis: Yes, thanks for having me, Melanie. Post-concussion syndrome is having persistent symptoms following a concussion that lasts longer than three months after injury. About three to 4 million Americans sustain concussions annually and most of these people will fully recover within a week or two after the injury. But up to 20% of people who've had a concussion will experience these residual post-concussion symptoms up to a month. And then as I said, if the symptoms persist beyond three months, we're now in the territory of considering this post-concussion syndrome. Typically, these symptoms will peak by six months, but some people can experience these symptoms even beyond one year following their injury.
Melanie: Wow. You know, it's so frequent that we're hearing in the media now about concussion, and it seems like there's much more awareness, but not necessarily for post-concussion symptoms. Tell us what those are. And for coaches, other providers, pediatricians, anyone that's listening that might be dealing with the initial concussion, you just mentioned up to a year, but tell us about what symptoms you see and kind of the timeline that you might see them.
Dr Sean Hollis: The most common post-concussion symptoms can be divided into five categories. What we call somatic, cognitive, affective, vestibular and sleep dysfunction. So to give you some examples, somatic symptoms might include things like headaches, neck pain, nausea, sensitivity to light or sound. Cognitive symptoms would include things like difficulty concentrating or becoming forgetful. Affective or mood symptoms could include depression or irritability or anxiety. Vestibular symptoms are difficulty with balance or dizziness. And then there may also be sleep disturbance, which contributes to feelings of fatigue and may exacerbate all the other symptoms that I've already mentioned.
There can also be, depending on the mechanism of injury symptoms associated with a whiplash type injury, that neck pain, vertigo, due to those rapid acceleration and deceleration forces that maybe you see in a car crash or maybe you see in certain sports concussions like in football or soccer or other sports.
One thing that is important to note though, is that most of these symptoms are fairly general and nonspecific, and they occur in a large percentage of the population as a whole. So it's not always directly related to the concussion when people are having these symptoms.
Melanie: Well, that's so interesting that you say that. And as we're speaking about factors that might play a role in symptom presentation and recovery, we're hearing a lot more about various treatments and about return to play, which we'll get into, and about decompressing and removing yourself from electronics or school or whatever it is. Tell us about some of those factors that could play a role in some of these symptoms that you've described.
Dr Sean Hollis: The first thing it's important to consider are specific patient factors and the context of the injury. Some people are going to be very motivated to want to return to activities such as athletes and they might minimize some of these symptoms when discussing their concerns with a provider. On the other end of the spectrum, you might have somebody who might over-report symptoms in hopes of obtaining some sort of gain, if there's a litigation case following a car crash or Workers' Compensation issue. So you have to take into account the context of the injury when you're determining how many symptoms are present and in what severity and then what recovery is going to look like.
There are also factors involved beyond patient motivations. There's some evidence that women may be more likely to have prolonged recovery period. It's unclear whether that is due to a true physical difference or whether it's just that women may be more likely or more willing to report their symptoms and seek treatment than men may be.
There are also factors such as premorbid or post-injury psychological distress. People who are feeling depressed or anxious, people who are having post-traumatic stress following a traumatic event are going to be much more likely to have post-concussive symptoms. And they're going to be more likely to report these.
The other thing that's important is initial presentation. Certain markers of severity of brain injury that we typically think about like length of loss of consciousness, post-traumatic amnesia, Glasgow coma scale score, these are not consistently shown to be predictive of post-concussion symptoms. But what is predictive of post-concussion symptoms are initial presentation of symptoms immediately following injury. So the more symptoms somebody has right away, the more likely they are to continue to have symptoms several months down the line.
Melanie: That's so interesting. Dr. Hollis, you've made so many good points there about looking at the context that the concussion really happened with. So now tell us about treatments that you're offering whether it's for the concussion acutely or for post-concussion syndrome. We're hearing about things like Botox. Tell us a little bit about what therapies that you do recommend and when you recommend them, because not all concussions are really emergent or even require anything, correct?
Dr Sean Hollis: That's correct. And so symptom management really should be initiated if symptoms persist beyond one to two weeks post-injury and treatment should focus on specific symptoms. You would address these things by the domain. So if somebody has mood disturbance, perhaps you need to make a referral for psychotherapy. If somebody is having vertigo, they may benefit from vestibular therapy. If somebody is having chronic headaches following concussion, maybe there's medication management needed.
And so for a provider, seeing somebody with post-concussion syndrome, you're going to want to address individual symptoms and make referrals as necessary. You may also consider referrals to a multidisciplinary concussion clinic in challenging cases or with patients who have multiple symptoms. The other thing that we want to do is encourage our patients to resume regular routines as much as possible. And the reason for this is so that we avoid deconditioning our patients and so that we don't contribute to symptom intolerance or fatigue. So the goal is to slowly increase activity over time, to rebuild stamina and tolerance to any persisting symptoms and not to let our patients engage in avoidance behaviors where they're not going out in the sunlight or they're wearing sunglasses indoors because they're sensitive to light. The more they do these types of behaviors, the more sensitized they will get. And that's exactly what we want to try to avoid.
Melanie: And that's pretty much the answer to my next question, which is educations and expectations for patients, for recovery. Why is it so important to educate them about just what you were just discussing?
Dr Sean Hollis: What we will frequently see is that if patients don't know what to expect, they're going to potentially be hypersensitized to their symptoms. If they have an expectation that their recovery may be prolonged, then they are much more likely to experience these symptoms. And this is known as the nocebo effect. It's basically the opposite of a placebo effect. Patients with a placebo effect improve because they expect treatment to be effective. When we see post-concussion symptoms and a patient doesn't know what to expect, there may be a nocebo effect, which means that they will experience additional or worsening symptoms because that's their expectation that they will get worse or their symptoms or remain for the long-term.
And so it's very important for patients who have had a concussion or who are having post-concussion symptoms to receive information from their providers about what to expect in terms of which symptoms are normal and expected, what a timeline for those symptoms is in terms of symptom resolution and that these things are expected to resolve over time. All these symptoms should get better for most people within weeks or months. But for everyone one, the expectation would be 100% recovery from a concussion. And we want people to hear this from their medical providers, rather than seeking out potentially disreputable sources, like the internet or asking non-experts for advice and hearing things that really may not be accurate.
Melanie: What an interesting area of study that you're in, Dr. Hollis. As we wrap up, what would you like other providers to take away from this discussion on post-concussion syndrome, when you feel that it's important that they refer to a specialist? And kind of reinforce the importance of education and understanding these symptoms and even really the methods by which concussion occurs.
Dr Sean Hollis: The number one takeaway is just stay up-to-date on the most recent treatment recommendations. There is still a widespread understanding that after a concussion people should significantly limit activities and have a period of extended rest. And that's really no longer the recommendation, even though a lot of people continue to get this advice.
So current recommendations are now typically you should have relative rest, not absolute rest, for 24 to 48 hours. And then after that, we should start increasing activity so that we avoid any deconditioning or symptom avoidance. You also want to reassure your patients and normalize any initial symptoms. Give them a sense of what recovery should look like. And then if they do continue to experience post-concussion symptoms, make those referrals to specialty therapists or multidisciplinary clinics as needed after about one to two months following a concussion.
Melanie: Great information. Thank you so much, Dr. Hollis, for joining us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole, - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua183.mp3
- DoctorsRais-Bahrami, Soroush;Galgano, Sam
- Featured SpeakerSoroush Rais-Bahrami, MD | Sam Galgano, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4509
- Guest BioThe development and implementation of imaging for the diagnosis, staging, and treatment of urologic cancers is an area of great interest and expertise that Dr. Rais-Bahrami brings to UAB. He is a founding member of Program for Personalized Prostate Cancer Care, working closely with other faculty from the UAB Departments of Urology, Radiology, Oncology, Radiation Oncology, and Pathology. He brings experience in advanced prostate imaging, image-guided biopsy targeting techniques, and focal therapy.
Learn more about Soroush Rais-Bahrami, MD
Samuel J. Galgano, M.D. completed his undergraduate training and medical school at Emory University in Atlanta, GA. He then completed his residency training in Diagnostic Radiology at the University of Alabama at Birmingham, during which he acted as Chief Resident in his final year.
Learn more about Sam Galgano, MD
Release Date: January 29, 2021
Expiration Date: January 29, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Speakers:
Samuel J. Galgano, MD
Assistant Professor, Abdominal Imaging & Diagnostic Radiology
Soroush Rais-Bahrami, MD
Associate Professor, Urology
Dr. Galgano has the following financial relationships with commercial interests:
Grants/Research Support/Grants Pending - Advanced Accelerator Applications
Dr. Rais-Bahrami has the following financial relationships with commercial interests:
Grants/Research Support/Grants Pending - NIH/NCI, U.S. Department of Defense, Blue Earth Diagnostics, Genomic Health Inc.
Consulting Fee - Philips/InVivo Corp
No other speakers, planners or content reviewers (Ronan O'Beirne, EdD and Katelyn Hiden) have any relevant financial relationships to disclose.
There is no commercial support for this activity. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua182.mp3
- DoctorsDupont, Steve
- Featured SpeakerSteve Dupont, MS, RD, LD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4493
- Guest BioSteve Dupont, MS, RD, LD is a Clinical Dietitian.
Release Date: January 22, 2021
Expiration Date: January 22, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Steven T. Dupont, MS, RD, LD
Dietitian, Food & Nutrition Sciences
Steven Dupont has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and I invite you to listen as we discuss medical nutrition therapy for COVID patients. Joining me is Steve Dupont. He's a Clinical Dietician with UAB Medicine. Steve, I'm so glad to have you with us today. And this is a great topic. And one that I think is under-discussed. So, let's dig into this a little bit. In the big picture, how has the COVID pandemic changed your clinical practice? Let's start there.
Steve Dupont, MS, RD, LD (Guest): Well, first of all, Melanie, thanks for having me on. I'm excited to be here. I wish I could say something really positive to start off about practicing in this COVID world that we're in. I've been spending a lot of time at my desk actually, which I don't particularly like to do because I really like to get out into the hospital and talk to patients face to face, talk to their families and really get a deeper sense of you know who they are and why they're here. So, that's been a little bit of a challenge. On the positive side, if I had to come up with something, I would say that looking out at so many unfortunate people out there who have been laid off and everything like that, I'm so, so, thankful and grateful to have sort of relative job security here in the healthcare field.
Host: So, what specific challenges are you facing with COVID patients in the hospital? Speak about some of the things that you've been seeing, medical nutrition needs. Tell us what you're seeing.
Steve: The big thing really is like I alluded to before is the physical distancing between the patients because of limitations on PPE and things like that. I'm not going and seeing these COVID even the ones that are able to talk. I'm not going to see them face to face. I may talk to them on the phone. But usually I'm not laying eyes on them, which when you're talking about malnutrition, it's not always obvious just by looking at somebody's medical record, whether or not they're malnourished or not. For example, you might have a patient that weighs 300 pounds and your first instinct is to think oh, well, they're perfectly, well-nourished or over nourished. Right?
But you may find out if you were to actually talk to that person or their family that, oh, by the way, two months ago they weighed 375 pounds. And they've lost all that weight and they have not been eating or whatever it is. Just being able to see people, being able to ask them questions, even talking to patients on the phone, sometimes, well it's hard to get people on the phone because either the phone's across the room or they're too weak to pick it up or whatever like that.
Or even if you do get them on the phone, of course, COVID patients tend to be kind of fighting for every breath. So, you don't want to necessarily be taxing them too much and put them into a code event or something like that, based on the fact that you're just peppering them with questions. So, you have to be a little bit careful there. And then of course there's obvious thing about appetite. I mean the, one of the main symptoms of COVID tends to be complete loss of taste and smell. So, you can imagine what that would do to your appetite. And then another thing I could mention would be a lot of these patients are on steroids as part of their therapy. So, you get some challenges there, mainly with respect to hyperglycemia and some other things that kind of get a little wacky with their lab values and stuff like that.
Host: So, are you allowed in the room? How have the concepts and what you've been discussing had implications for nutrition support? Tell us how you are providing this service.
Steve: Yeah, like I said really not going in the room. If push came to shove, I suppose, I could probably get myself into the room, but based on the guidelines that we've been issued, we're trying to conserve PPE as much as we can. So, providers such as dietitians, who technically don't have to lay hands on a patient we're kind of expected to do as much as we can remotely. So, I'm relying on, if I can't talk to the patient, I'm trying to get a hold of the nurse on the phone or somebody on the unit who knows what's going on with the patient so I can get a little more information. Sometimes I might have a phone number in the record of a next of kin or family member or something like that, that I can call and ask questions if I need to. But the less people that I have to bother, unless I feel like it's really a medically essential thing, I'm usually just trying to assess that person from the medical record and then trying to fill in as many of the gaps as I can.
Host: What about nutrition needs during prone positioning? How's that work?
Steve: Yeah, a lot of the patients you're referring to the, when they're laying prone stomach, a lot of the patients in the ICU are prone like that. I mean, I've not seen anything. And even in theory, I don't think that should really change your nutritional needs a whole lot. Now there's a lot of other things that I'll talk about with the ICU patient that kind of changes nutritional needs, but the prone positioning itself, now I think it does affect the GI function a little bit and the GI motility, because when you're flipped over the other way, it's obviously not a natural position to say, have a bowel movement. So, it stands to reason. And I have seen this, that those patients can be a little bit more likely to be constipated. So, usually a pretty aggressive bowel regimen is called for and sometimes, you have to use rectal tube or some sort of bowel management system to, from a practical standpoint to make it easier to keep the bowel maintenance underway as they're being treated.
Host: Well, then tell us Steve, how the critically ill COVID patient is different from the typical ICU patients you might see.
Steve: Yeah. So, all ICU patients are a little bit tenuous, right? I mean, that's an in a lot of cases, why they're in the ICU to begin with. But I think most clinicians would probably agree that the COVID patient in particular is just very unpredictable. I mean, we've all heard those stories or seen them firsthand of a person who one minute they're sitting there breathing room air and they're eating and drinking, whatever else. And the next thing you know, they're on the ventilator because they've just completely collapsed. I've heard it compared to a person who's been treading water for a long time. And you just don't know at what point they're going to run out of energy and kind of dip below the surface. A lot of the patients that are on ventilators are requiring very heavy sedation. And the sedative of choice tends to be propafol, which is a medication that is in a lipid emulsion. So it has 1.1 calories per milliliter. So, for example, I've seen patients on as much as 50 milliliters per hour of propafol, meaning that they're getting about 1300 calories a day.
Now, if those were well-rounded calories, that would be wonderful. But unfortunately, that's just fat calories. Okay. So, there's not protein, there's no vitamins and minerals. There's nothing else. So, in the process of trying to kind of fit in all those other pieces, it can be difficult to do and be kind of tricky sometimes without just completely overshooting on the total number of calories that you're giving the patient and you really don't want to overfeed any patient who's critically ill and, on a ventilator, and especially a COVID patient, just because it makes breathing even more difficult. But another one that we're seeing an awful lot is kidney failure.
These COVID patients are really having kidney failure at a much higher rate than the average ICU patient. And there's a number of theories as to why that's the case from cytokines that are produced from the infection, to blood clots and other theories as well. But from a practical standpoint that you're seeing a lot of people having to end up going onto dialysis, and usually in the ICU, that would be like a continuous dialysis or CRRT for short. And that, once you go from not being on dialysis to continuous dialysis, that does change your nutritional needs quite a bit. Your protein needs are drastically increased. Your electrolyte needs are drastically increased.
So, usually at that point, you're switching from a renal specialty formula to more of standard high protein formula for critically ill patients. And then the other thing I was going to mention was with the prone position, and we already kind of touched on that.
Host: This is really, like I said, a very good topic. Now, Steve, as we wrap up, for other providers that are counseling their patients on COVID at home or working with patients that are not on ventilators, and as you said, in prone position, are there any particular ways we can help treat or prevent COVID with nutrition? What do you as a clinical nutritionist recommend for COVID patients? And this one can really apply to any of us that are learning more about what we still don't know about this situation.
Steve: If you're the average person who is at home dealing with COVID and I actually have a colleague who's at home right now who's dealing with it. I mean, it kind of is staggering how much it can affect a person. You know, this is a colleague who's a young person, much younger than me. And she was saying the other day that she was so weak, that she could barely eat or drink. So, just trying to do the best that you can, especially to drink, to stay hydrated. Cause like I mentioned before with the kidney affects, the last thing you want to do is to get severely dehydrated.
So, personally, if it was me or somebody that I knew I'd be really forcing fluids. And if you got to the point where you couldn't take any fluids, then that would really be a junction where you would want to think about going to the Emergency Department to get some IV fluids. Apart from that, there are some associations between micronutrients, like there hasn't been a lot of research yet, of course, but we're looking at vitamin D status, looking at zinc status and things like that. I mean, you certainly don't want to be deficient in anything.
So, taking a multivitamin or something like that would certainly be appropriate. I don't think there's any evidence that taking additional amounts of any particular nutrient on top of what you know, a normal adequate intake is going to make much of a difference. So, really the only other things in terms of prevention would be you know, there's a lot of links to obesity, diabetes, hypertension, other chronic diseases. So, if you have one of those diseases or if you have several of them then the best advice would be to manage them as best you can. Keep them well managed. And if you don't have one of those conditions, then certainly do everything in your power to prevent from getting there.
Because it seems like COVID is going to be around for some time. I mean, even with the vaccine, it's just there's just no telling, I mean, probably going to be mutations that will evade the vaccines where it's going to be kind of a whack-a-mole affair so.
Host: Well, it certainly does. And thank you so much, Steve, for joining us today and really offering up your best advice and information for providers about clinical nutrition therapy and medical nutrition therapy for COVID patients. Thank you again. And a community physician can refer a patient to UAB medicine by calling the mist line at 1-800-UAB-MIST.
And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua166.mp3
- DoctorsMullins, Haddon;Willig, James
- Featured SpeakerHaddon Mullins, MD | James Willig, MD, MSPH
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4355
- Guest BioHaddon Mullins, MD is a General Surgery Resident.
James H. Willig, MD, MSPH, is the Associate Dean of Clinical Education in the School of Medicine. He attended Medical School at the Instituto Tecnologico de Santo Domingo (INTEC) and completed his residency at the University of Virginia Roanoke-Salem. At UAB, Willig has earned an M.S. in Public Health and completed an Infectious Diseases Fellowship.Learn more about James Willig, MD, MSPH
Release Date: November 9, 2020
Expiration Date: November 9, 2023
Disclosure Information:
Planners:
James Willig, MD, MSPH
Professor, Infectious Diseases
C. Haddon Mullins, IV, BS, BA
UAB Medicine
Jill Deaver, MA, MLIS
UAB Medicine
Adam Roderick, M.ED.
UAB Medicine
Anne Zinski, PhD
UAB Medicine
Caroline Harada, MD
Associate Professor, Geriatric Medicine
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Presenter:
James Willig, MD, MSPH
Professor, Infectious Diseases
Dr. Willig have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing patient care preparation. In this panel, are Dr. James Willig. He’s the Assistant Dean of Clinical Education at UAB Medicine and Dr. Haddon Mullins, He’s a General Surgery Resident at UAB Medicine.
Haddon Mullins, MD (Guest): Hello and welcome to evidence-based teaching with the two of us, Haddon Mullins and Dr. James Willig.
James Willig, MD, MSPH (Guest): Good morning Haddon. How are you today?
Dr. Mullins: Do well, how are you?
Dr. Willig: Fantastic. Fantastic. What do got for us today?
Dr. Mullins: So, I’m speaking to the introduction to what we’re going to be covering, mainly focusing on bedside teaching. This week, we’re going to talk about preparation. So, everything we’re going to talk about today will be before you actually go into the room with a patient and things you can do to best prepare yourself, and your entire team for that encounter.
So, from looking at the literature, a lot of people believe that one single meeting or an orientation with your entire team can be extremely beneficial for you, the team and the patient. And so this is something that as an Attending or as a team, you would only have to do once and would help set expectations, allocate roles, and allow you to better assess and get feedback to your entire team. So, really this would be something that you could or should do at the beginning of each clerkship when you have either new students, new interns, new residents or you are coming on to service for the first time.
Dr. Willig: So, it’s sort of a team specific orientation?
Dr. Mullins: Yes. It’s very important that the entire team is present for this. Because the entire team is involved in patient care. The entire team is involved in feedback and assessment of each other and the entire team should be aware of what roles are assigned to each team member to better facilitate communication and patient care as well. Is a meeting at the beginning of a rotation, is that something that you do or is that commonly done among Attendings and if so, how long does it take and what do you cover?
Dr. Willig: So, I think it’s something that I’ve certainly learned or was taught to do it by my senior residents. Even as a resident, stepping into a team. And initially, when I was an Attending, I didn’t really think about doing it but very quickly sort of realized that I’d better make – have a good conversation, level-setting conversation with the team in general and then I also do something with the resident in particular where I will ask the resident some about how they like to run the team, how I will empower them to run the team. I think that they are central to the teaching climate and I want to see how they interact and how they lead to interns and the students. I will speak the resident about what are their preferences regarding rounding. I have some preferences; they have some preferences. From preferences, we’ll try and negotiate those to arrive at a mutually convenient solution and I will let them know that I for example, like to round the day of call in the afternoon on a few patients to make the load post call less so. But I want to do that in a respectful way to the resident where I will tell him, heh try to get some cases already done and discussed with the interns or the students and when I come by in the afternoon, you tell me which cases to discuss. And they will be cases where you already have discussed the plan with them. So I’ll go over the plan. I’ll see the patient with them independent of you. You need to go see other admissions. Eventually, I will circle back to you and present what I think should be done differently or added to the management or just confirm that heh, your management is on point, I like what you’re doing. Let’s keep going.
But certainly, if you don’t negotiate that with the resident, if you don’t let him feel empowered to lead the team; I think it takes away from the learning.
Dr. Mullins: That’s great. And you can talk a little bit more later about the resident impact on teaching and how important they are in a role to the teaching experience. But what about students? Do you orient the students at all or give them a plan or a set of expectations?
Dr. Willig: So actually, so I have a general set of expectations that I share with everyone. And I’ve got a copy of the document here. The document really has twelve general points and it’s got sort of three specific rules of thumb. So, these twelve general points, to me, the reason I share this is I want students and house staff to both know exactly where I’m coming from. These are the things that I think about how we should – the standard that we should hold our care to. So, I’ll go over these things. At the same time, I will also point out that the expectations are different. I will point out to the students that though they will see the interns and the resident seeing cases very quickly; that they at this point in their training, they are honing their efficiency. I think our students get a little bit anxious when they see how fast the residents and the interns can do things. And they begin to try to learn how to do those things equally fast.
There’s a problem there because the student is at the point in their training when they really have to be focusing on building the basic skill set, the basic habits on top of which they will do further refinement towards efficiency in those subsequent years of their training. But now, at this point in your training, you are training for thoroughness, completeness, reproducibility. Those are the things that are emphasized, and I mention those things out loud to the students to give them permission to take your time. Don’t go in there with the resident and the intern every time and try to leave when they leave. Sometimes, let them go independent of you. Then go subsequently. Spend an hour, an hour and a half, whatever you need to spend with that patient and then go ahead and write your not independently. And then go discuss your plan with the intern and subsequently the resident or both of them together.
But you have to do these things by yourself. You have to walk in there and you have to know that gosh, I’m going to inspect, palpate, percuss and auscultate every organ system. Those are the things that as a student, frankly, you’re going to be tested on, on your step two CS. You’re not going to be tested on how quickly you can get to the diagnosis or the efficiency with which you go through all of those things. Those things are part of it, yes. But the completeness, the maneuvers being high quality and being reproducible; that’s what the students should focus on.
So, I make that plan that my expectation for them is completeness and thoroughness. With the interns and the residents, now we talk about having a different conversation. With them, I’m expecting more – I’m expecting the resident to be my partner in management. I’m expecting that the resident and I will have conversations really about here’s what the literature says about this, here’s the last time I read about this topic, this was a recommended therapy. What do you recommend?
With the interns, I tell them that I want them to be involved in management. That I expect their exams to be thorough, but they can be more focused than what I’ll expect the students to be. So, they can focus on efficiency and getting the repetitions in to increase that. But I tell them that everything that they mention, they have to have a rationale for in terms of management. If someone says to me, I want to get a CAT scan. Well precisely why? Why are you doing that? What’s your rationale? And I let them know that I will challenge your rationale not because I’m trying to disagree with it or pick at it, you just have to have a logical path. So, you have to be able to tell, I’m doing this test to differentiate these two conditions, and this is how I think it will help me.
So, every single on of our decisions has an underlying logic to it. And I’m going to pull out the strings of their logic to see if I see any flaws or things that I can focus on to improve on. So, those in essence, are the three sets of expectations and in this meeting, really letting people know this is what I’m looking for in you. This is where you are in your training. Again, highlighting these expectations to the students in their first day. This is what I expect for you with your interaction with patients. And this is what I expect from you in terms of your documentation and highlighting how they are different from my expectations for the residents and the interns I think empowers the students to really focus on what they should be focusing on at this point in their training.
Dr. Mullins: So, what about the difference between a third year medical student on his first rotation versus on his last rotation? Is there a difference in expectations and assessment? It is largely the same?
Dr. Willig: I think my expectation would be – I would be much more permissive in terms of gosh this differential didn’t really go in depth with someone at the beginning. The expectations really are the same. I really think that in that third year, the things that we’ve already discussed is what they should be focusing on. And I expect to see an increase in skill and refinement as the year goes by. So, if I were to see a student who comes in and in their first rotation is already showing me that their skills are very refined; that’s great then I can start focusing their teaching goals by talking about I want you to get a little bit better at – read more about your differentials, read more about your plans. I can certainly move them down the chain.
But if it’s late in the year and somebody comes in and they don’t have a good grasp of a thorough history and physical; then I think that’s a more problematic student for me. That’s a student where we have to kind of go in and say heh, let’s deconstruct some of these almost shortcuts that you’ve learned throughout the year and you’ve been giving a lot of value to these things and it’s right, they do have a lot of value, but they are going to have more value if you build them on a strong foundation of being thorough.
So, those are the – in general, I think my expectation is for that student towards the end is a little bit more refined because they’ve had more repetitions. They’ve worked through their technique. But sometimes at the end, you get a student who maybe did not receive permission to focus on the basics at the beginning or along the way and what they focused on is on learning the efficiency shortcuts that the residents and the attendings themselves that they’ve seen them use. And all of the sudden, you have a student wanting to run before they can walk. And so much of medicine is just thoroughness and being meticulous. And I think you’ve got to have that. So, with those students, then the conversation becomes take it back, take it back. I need you to be thorough and meticulous. This is where you are in your training. You can’t have shortcuts on a very thin base. The broader your base, the better your shortcuts, the more higher quality of your care subsequently.
Dr. Mullins: One thing that the literature seems to emphasize is to set your expectations and set your objectives but also to get the objectives from the students as well. What have you already accomplished? And where are you trying to go? And so, again, having the whole team there, everybody is aware of where the student is trying to go, what they are trying to learn, what they have already been through. So, they’ve already been through internal, OB-GYN and now they are on their surgery rotation. Everybody knows what that student should be expected to know how to do and what their primary goals and what their primary focus should be for this rotation.
Dr. Willig: I think that’s a very important point that knowing where your learner is, so that you can build from the level where they are at is a critical part of this. And I’m glad that the literature reflects that because certainly, I think some of the most skilled educators that I’ve interacted with over the years, they really start with some questions to sort of figure out where your level is and then they build on that. And that’s fantastic. I think in learning theory, that’s part of constructivism I think it’s called but I would have to check with Dr. Zinski.
Dr. Mullins: Yes, constructivism or adult learning theory is as some people might call it. and I think that’s a good point to make because it – I can see it alleviating a lot of frustration between the team and student. You can get students at different levels that have different expectations and it would only take a couple of minutes, a couple of probing questions to figure out where they stand, what they feel comfortable doing and how to build on that.
Dr. Willig: And you reminded me of some interactions with – I was fortunate to have a great resident on the first rotation I ever had as an intern in internal medicine. And her name was [Lana Nicotina 00:13:10]. She’s a cardiologist now. And I remember Lana sat me down and she said the first time – if you are doing something for the first time, you’ve got to tell me so that I can do it with you. The second time, I will expect you to try to do it alone, but you call me in to double check. And the third time, go read about it. So, she was pretty hardcore, but it made it clear that the expectation was that if she was asking me to do something I had never done before, that she was at fault. And that the only way that she would know that would be if I spoke up. And you’re right, that alleviated frankly a lot of fear for me as sort of a newly minted intern that I knew that heh, my resident doesn’t expect me to just know things. They want to help me, but I need to tell them I need help when I do. And that was a fantastic thing.
Another thing I can recall, is one of the residents that I worked for, that I worked with for the last couple of years, would – will ask the students heh, name three topics that you want to learn more about while you’re here. And that first day, all the interns and all the residents and the attending and the students will get to write three topics on the board and then our goal is to cross through all those topics as we go through the next couple of weeks working together. And that’s sort of a nice way for everybody to sort of say, heh, I don’t know everything. Here’s some things that I could really use a review on. So, I think it’s great to see that your attending doesn’t know everything, your resident doesn’t know everything, your interns nor your students know everything. Here’s some tangible evidence of that that we’ve all written on the board. And this is how we’re going to make each other better over the coming weeks.
Dr. Mullins: Yeah, I think that plays into another topic that’s emphasized in the literature is to create a safe learning environment and to emphasize how you’re going to teach and we talked about expectations but also, things like for students that may be just coming on at the wards, we do bedside rounds, I’m going to ask you questions. I’m going to ask the interns questions. I’m going to ask the residents questions and those questions will be graded based on what their expectations are and what their objectives are and the example that you gave, don’t be afraid to ask questions yourself and set an environment that we are here to learn, you are here to learn. And these are the ways in which we are going to do that is important especially for students I think but also for the interns and residents and we’ll get to the resident side of things in just a second. Because they are a key part in all of this.
But discussing the learning environment and what kind of environment that is going to be is as important as the execution of that.
Dr. Willig: I think that’s great. Two points that I make in this sheet that I give them on the first day is I talk about the authority gradient. And I first learned about this concept reading about errors in the airline industry. And one specific type of accident that was called controlled flight into terrain. So, this is from a great book called, “Why We Make Mistakes” where they – to sort of summarize, there would be – despite all the advances in technology for about 30 years, this is leading into the 80s in the airline industry, there was one category of accident that never changed. And that category of accident was a controlled flight into terrain. Which basically worked out something I was the pilot, and I was driving this plane and you were the co-pilot and you were checking the altitude and you were like ah, you know we are in this mountain range, the mountains typically aren’t this high, I think we are a little bit low based on the altimeter and I would look at you and say something like look, I’m the senior pilot here, I’ve been doing this for longer than – for ten years. I been doing this when you were in high school, leave me alone, I know what I’m doing.
And that plane would inevitably sort of clips it’s wing on the peak and a lot of people would die because of what basically is arrogance. So, this authority gradient where we look at people with – who have achieved the different rank and we view them differently or more capable than other ones is a double edged sword. It can hurt us. And it can hurt the people we care for as well. So, when you fly to the authority gradient, when you say on the first day things like you know we have to all engage in the care of this patient, all of us working together is going to find a better solution than any one of us working alone and I explicitly give – this is sort of a sense that I’m reading from this document, is I respect and want to hear your opinion, particularly if it disagrees with mine. To give our best to the patient, we have to create that learning climate where there’s a give and take and we are all working together for the benefit of that case.
Because the best ideas that I’ve seen, are rarely from just one mind. The best ideas are this amalgam where it’s 10% from your mind, 50% from someone else’s mind, 5% from my mind and so forth through the team and then collectively through discussion, we’re able to really iterate on an idea, get it to another level and that is our best as a team. Teams that function that way, I think provide excellent care, are immensely satisfying and empowering to all team members. I’ll tell the students; I’ll ask them questions. I’ll say, look, you know I’m an infectious disease guy. So, when do you think was the last time, I read about say hypothyroidism? And they say I don’t know. I say well I probably read about hypothyroidism last when I was recertifying for my internal medicine boards, four or five years ago. When was the last time you read about hypothyroidism? And they read about hypothyroidism within the last six months usually.
And I’ll say who do think has more up to date and better information to offer that patient about hypothyroidism? He says you got more book knowledge than I do. I might have seen a few cases. But the – so I have some insight too. But the best thing we can offer that patient is if you and I have a collegial respectful conversation and the best of what we both know combines into a treatment plan. Now we’re getting somewhere. Now we’re doing something that neither one of us could do independently and we’re both putting our best on the table in service of that patient. So, I love teams like that. And I haven’t always worked in teams like that. And part of the reason why I write specifically about the authority gradient and my fourth point which is you have to nurture your humility where I specifically talk about that certainty is an enemy in our profession. It leads to premature closure and a parochial view of possibilities, so you have to stay humble because those who are humble, they listen a little better, their hearing is a little better. Their vision is a little better.
And they are able to ask questions to enlist better responses. The minute you get overconfident in our line of work, is the minute that your senses dull a little bit. So, I think that that teaching climate to me, taking that evidence on the authority gradient from the airline industry experiences that when they really changed the culture around the cockpits, then that type of accident started to really change where everybody was empowered to say heh, wait a minute. Those ideas by themselves in our profession now, in the ICU for example. When someone is doing a procedure, anybody in the procedure team can call a time out. In the OR, these sort of team dynamics have found themselves and been infused into our profession as well and a lot of it is learning from the airline industry on how teams should function and how every team member should be empowered and how that leads to better outcomes.
And the point about humility I think is more of a personal point and I think basically, I think all our students are going to do amazing things. But the minute you start believing that you’re amazing as well, it’s a problem for everybody who depends on you for care. Because that’s the moment where you probably don’t see as clearly, listen as well and things will get missed because when humility hardens into arrogance, that intransigence does not help get good outcomes. So, those things are part of the learning climate and I think highlighting that to learners, you’ve got to be humble and it’s your responsibility to remain humble and to check yourself and as a team, there is no authority gradient here. None of us is the smartest person in the room. All of us, together, that is the smartest way to provide care.
Dr. Mullins: And I think that’s key and that’s exactly what’s reflected in the literature and within that context, of the learning climate, and the authority gradient; is a good placement to move and to role allocation. And we’ve talked about role allocation some already and the expectations for students and interns and residents. So, we will mislead the rhyme pneumonic in the slides at the end. But I think one key aspect to highlight especially during this meeting with the whole team; is that the resident should be treated with the same authority as an attending. And that they should be seen as a teacher just as the attending is. There’s a lot of people that are doing research in peer to peer education or near peer education so interns as teachers and residents as teachers.
There’s a study [00:22:58] 2001, and they did a lot of analysis as to what can predict clerkship grades. But they not only did clerkship grades, they did student grades and they did a number of parameters. They gave a pre-clerkship test and a post-clerkship test. They used grades. They used standardized test scores. A lot of things went into how they – into what they called student growth. But one thing that had the most effect on student growth was the residents. And that had the most predictability in terms of how that student was going to grow across the clerkship was the residents.
And so, the residents need to be viewed as educators and they need to view themselves as educators and they are – yes they are learning from the attending on how to do that, but as far as the student is concerned, and as far as the interns and the team is concerned; I think it’s important that they be viewed in that light as that’s what they are aspiring to be and so that’s how they should be treated.
Dr. Willig: To be honest with you Haddon, the way that I see it is, I got something to learn from everybody. Everybody on that team has read something more recently than I did. So, I think everybody on that team is empowered to make each other better. I sort of was chuckling thinking back to a gentleman that I worked with many years back called William Irwin and he really – his first day, he’d sit you down and it was a very brief meeting because Irwin had three basic rules. The first rule was we teach each other something every day. I love that rule because it really meant that we had the responsibility to make each other better every day. And that meant that some days he was going to teach, some days the resident was going to teach, some days the intern was going to teach, some days, the student was going to teach. But everyone of us had a collective responsibility to sharpen each other every day in the practice of our craft.
That was his first rule. His second rule was we give every patient our absolute best. Some people say this as we treat every patient as if they were our closest family. Which ever way you say it, everybody deserves your absolute best. Your retention, your focus, your go home and read about it so that you can come back and be more informed about what you are doing the next day. Everybody gets your best, personally, and professionally.
And the last Irwin rule was and we’re never late for lunch. And he would always say this with the most serious look on his face and walk away. And what he was really saying was, we’ve got to be efficient. We’ve got a lot of people to see and we need to distribute our time appropriately so that we can do a great job on all of them. So, let’s get to it. So, it was a very succinct way to envelope all these principles in just those three quick rules.
Dr. Mullins: And efficiency I think is the key part of this meeting and another important part is that it establishes a baseline for assessment as well from an Attending point of view. You have established with the whole team, these are your expectations, these are your objectives, you give them an opportunity for feedback to say well I don’t feel comfortable with this. I don’t feel comfortable with that. So, you can adjust your level of assessment and your level of expectations for them and if you want to take it the extra mile, you can – the Attending can do like you did and print out a sheet for this and that makes this meeting even more efficient.
But the main point of this whole orientation is to pre-answer questions, pre-address problems so that there on the road, you’re not frustrated, the students aren’t frustrated, and your team isn’t frustrated because nobody is on the same page. And I think these meetings could be done once every two months whenever the students come on board or you’re coming back on service, it would take ten minutes and then it would be done. And everybody would be on the same page. And if you want to print it out, and individualize it, I think that would be even better.
So, now, I would like to bridge the gap between that meeting and then the clinical interaction, the bedside encounter with the patient. And one aspect of that preparation for talking about patients in their care would be the patient. So, is there a patient preparation expectation at an academic hospital like this or is it before bedside rounds or is it well this patient either has been here before and knows about bedside rounds or they’ll figure it out?
Dr. Willig: So, it’s interesting because I did not used to be very sensitive to this. When I started doing bedside rounds, really as my preferred medium of teaching; I ran into – or I started noticing that people would - sometimes people would be sort of what’s going on. Why are all these people in my room? And some people I would come back in after rounds alone to double check on someone or maybe there was a little piece of history that I couldn’t recall, and I wanted to see if I could delve a little further. But I would find my way back into the rooms. And having good relations with folks, and eventually they’d say man I really like the way you guys do things here. And I remember thinking what do you mean here? this is just – and then that kind of made me think well wait a second. A lot of folks – the majority of folks are probably in private practice. This person has probably never been to an academic medical center before. They are from an area where there isn’t a medical center like this but their options for healthcare are more private in nature. So, I sort of started getting some insight into yeah, not everybody just views it as normal. This is sort of a unique thing where there’s a lot of learners.
So, what I migrated to because I don’t know the person’s experience when they come in. there are sort of a couple of sentences that I try to say to a family and the patient whenever I walk into a room. I find this particularly helpful with families. When you are nervous because your family member is on the bed already and you see one white coat walk in there, you are already a little bit expectant and maybe even anxious. All of the sudden, you see six or seven white coats in there with you. Now you are really not feeling good about things. So, I will usually try to introduce myself, introduce the team, have every person in the team really introduce themselves. I make a point of introducing myself by my first name. that’s just a matter of preference but again, to me, that’s just lowering that authority gradient right away.
I would say something like heh, we like to discuss cases at the bedside. I don’t want you to have to tell your story yet another time. You already told it several times and we really appreciate that. I want to share everything that we know about you for a couple of reasons. The first is our decisions are only going to be as good as the facts that we base those decisions on. So, I need you listening closely to make sure that we got our facts straight. Because if there is anything that we’re talking about that isn’t a fact, please correct this because we need the best facts, we can to provide the best care we can.
Then I’ll transition to say we want you to know everything that we know. So, we discuss things very openly here at the bedside. You’re going to hear us talking to each other and really getting ideas polished up as we exchange them with each other. Everybody is going to contribute. We really believe that none of us is as smart alone as all of us together. Sometimes I’ll joke and I’ll say heh you’ve got the six doctors for the price of one special or sort of if I sort of get a feel for that person’s sense of humor, that might be sort of a joke that I’ll attempt to make.
But really just let people know heh, we’re going to be talking about you and I want you to see what we’re doing. And I want you to see how much everybody in here is invested in doing the best for you and how much we all care. And then the last thing I say is, if we walk out that door, and we haven’t answered all your questions; we haven’t done our job well enough. So, you’ve got to ask anything we didn’t explain correctly or anything that you’d like to touch on again, go ahead and let us know. If we walk out that door and again, we’ve not answered your questions that you have; we’ve not done our job as well as we think it should be done. So speak up.
Dr. Mullins: That’s perfect. The patient, a lot of times, they can feel uncomfortable and an orientation like that makes them more likely to be involved in their own management. And a couple of key points that line up with that I’ve read in your handout here is to review expectations associated with medical language that lines up with another point is to emphasize that there is a teaching aspect of this encounter as well and so establishing that expectation that we are educating learners here. there will be medical language associated with that and then at the end, if we can’t clarify in a language that you can understand what’s going on and allow you to ask questions based on that language then we have failed at our job. And hopefully, orienting the patient to those expectations makes it more likely for them to clarify their own expectations or to clarify when they feel like they need a better explanation.
Dr. Willig: And I think this is such an important subtlety because it’s intimidating to see a bunch of us walk into the room and just start talking to you when you’ve never met us. And our colleague J. R Hardig from Med Peds made a point to tech me something that I try to do as regularly as I possibly can and he says that when you finish discussing things, a lot of us say do you have any questions. And that’s fine, but I know that if I get asked do you have any questions after a lecture where I’ve been sort of lazing over, my immediate reflex response is no. Because it’s almost that if I admit that I have questions, maybe I wasn’t listening or I wasn’t paying close enough attention so, sometimes people are reluctant to answer that question.
So the questions he – the way he frames it, he phrases it, he says what questions do you have. So, this a beautiful phrase because it establishes, it sort of presupposes of course you’re going to have questions. We’ve just been talking about you incessantly for ten or fifteen minutes. There are questions. You have them. What questions do you have? And somehow, the intent behind this and that subtle change in phrasing, and he told me, he says you’ll see people feel – people will ask you more questions if you say it this way. And I was kind of skeptical. I don’t think that that few words change will really make a difference. But I really feel anecdotally that it has, and I encourage everybody to try that experiment. To go from do you have any questions with sort of a stern look and looking people in the eye to see what they’re going to say to a much more disarming what questions do you have with a smile and sort of leaning in and it’s of course you have questions is the message that comes across. And just run that experiment. See if you get a feel for a different number of questions that people will ask you.
Dr. Mullins: And involving the patient is a cornerstone of the whole idea of bedside rounds of course and so, preparing them and being aware of the subtleties, those types of subtleties is important and it’s something I feel like that can be marginalized in the larger context of even everything we’ve talked about today but it’s something that doesn’t take long, doesn’t take a lot of educational insight and it’s simple and it makes the encounter more patient-centered.
Dr. Willig: Yeah, I think a real benefit that I see to it is that the patient-centeredness of it and when you – there’s so many ways that you show you care. And the more ways that you show you care, and that you’re invested in that person, and that you want to do what you can to help them; those are all building blocks and they build this foundation to where if the situation leads to a very difficult diagnosis and some difficult conversations about what comes next; it’s so much easier to have those conversations if you have already shown that person in multiple layers in this interaction, we care about you. This team cares about you. We’re working for you. We’re attentive to your needs and the needs of your family. You’re the focus of what we’re doing. And then if you have to have a hard discussion, you already have those set in the foundation that’s going to facilitate being able to sit at the bedside, look someone in the eye and have difficult discussions when unfortunately in the business that we’re in, tough things will happen.
Dr. Mullins: So, we talked about the learner. We talked about the patient. Now the Attending. Is there anything that you do as an Attending to prepare yourself for bedside rounds?
Dr. Willig: So, I think it’s a combination of things for me. First, just like I saw when I was a student then a resident, you learn as much as from the people around you as you do independently. So again, that’s part of keeping your humility, keeping your eyes open, keeping your ears open, looking for best practices wherever you look. I will literally see students do something that has never occurred to me and I will try to incorporate that. I will see very senior people do things to a level of refinement that I may never reach but that I can aspire to and I can sort of really break down the elements of how they had that interaction.
A couple of months ago, I invited a colleague who had taken care of a woman with HIV for about a couple of decades and this woman had developed an advanced malignancy and we had to have an end of life conversation. And boy, I asked this colleague to come into the room and how she interacted with that lady and that relationship and how she was able to just thread so much caring and respect into delivering those news to me it was – I mean I felt like I should just be taking notes. It was unbelievable. And this is something that I’ve been doing for a long time as well for a couple of decades. And I saw so much. I saw what the other level looks like. So, I think that you learn so much from everything that is around you. And that’s part of the learning you do that you can have as an Attending. Just really look for best practices and practices that you like to avoid everywhere with every interaction with all of your colleagues.
The next level of it is – one of my favorite times is, we’ve seen everybody post-call, I’m alone in a quiet place, preferably my office. I have two screens in front of me and I’m listing my problems and I’m combining them into patterns and I’m trying to think about what this could be and the most optimal diagnosis. One of my favorite moments in the world is when I open up to date on that other screen or some other resource and just in real time, sort of check facts and thread it into my note and sort of bolster my thinking by looking at the evidence at the time that I’m putting my thoughts together. Gosh if – I mean those are golden hours for me. I mean it’s just wonderful.
And as you teach yourself and as you really round out your knowledge about a pattern that you are suspecting; as you look at what your residents and your students thoughts and why they thought it and you look at the evidence that either supports or refutes their logic; that’s a great moment that I very much enjoy. And at the same time, that creates a list of things that I’m going to bring in the next day to either just say well you all are on the right track. Did you also consider these facts that I read. Look at this. I think this even adds more support for your hypothesis. Or, even better, I might say, heh, here’s some other evidence that might take this in a different direction. What are your thoughts on this?
So, that to me, as I’m working on those notes, I’m also making a couple of things, sometimes on a word document and I’m dropping phrases in there, these are things that I want to do or sometimes I might print out an article that we’re going to bring the next day that’s centered around a certain patient. The other thing that I’ll do is when I’m on rounds, again, we each have the responsibility to make each other sharper so it might be heh, I need team member X, tomorrow you are going to have three minutes to teach us about this particular thing here. So, look at the evidence, come back because tomorrow we are going to make a decision based on the evidence that you look up. That’s a great thing to do with a student. That sort of says and you incorporate them, and you make that decision with them at the bedside or you get to that point the next day, you basically say okay, what did we learn about this? Student steps in, says what they found our about it, it’s the evidence. What’s your recommendation? I recommend we should do this test, and this is why. Okay. Look around the room, all of us are fine. Okay. All right. That’s the move we’re going to make.
That student just like saw their effort, time just – in the teaching, in the decision an actual patient management decision and they’re enthusiasm will now be through the roof. Then they’ll be doing that without you asking them to do it for the rest of the rotation and they’ll be engaged at a different level. So, that’s part of that learning is sort of putting those people, putting somebody, keying somebody up for a decision every day. And then also as an Attending, you got to take your turn in that rotation. And so there will be someday where you will – you might notice a physical exam finding or someone might mention a physical exam finding for example that I’m not – I said well I need to brush up on that sign. I haven’t done it in a while. So, I might go, and I might read it and then I might ask someone the next morning to heh, demonstrate this, let me give you some feedback on your technique.
So, there will be little spot checks that I’ll do just to kind of take my spot in that rotation to keep the learning going, a team but I give that sort of responsibility that moves around every day then there’s specific things focused on the management of a patient that I’ll be reading on and brushing my knowledge up on that I’ll bring in for a discussion the next day. But those are the basic things I think about how I prepare for rounds.
Dr. Mullins: And what you described is a perfect combination of what I found in terms of they disease specific review and patient specific and if you can combine those things then even better. The whole goal of it is to create teaching points ahead of time as you do to incorporate the entire team. I see the apex of all of this and one point that a piece of old literature from 1993 comments on is to be aware when you are walking into the room of the conflicts of interest between the students or the learners, yourself and the patient. Because each of you all have in the context and everything we’ve talked about today, each person has different expectations, different objectives, and a different way of assessing those criteria. And for you to have a scaffolding of how this interaction is going to go, and being aware of what the patient wants out of this and what the student wants out of this and what you want out of this, you can better manage that situation as a whole and you feel prepared for what we will talk about in our next session the encounter with the patient.
Dr. Willig: Excellent. Well thank you. This has been an enlightening chat as usual. It’s great to learn about these evidence based practices and how to maximize the effectiveness of what we do on the wards.
Dr. Mullins: Yes sir. Thank you.
Host: And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua181.mp3
- DoctorsHuh, Warner
- Featured SpeakerWarner Huh, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4457
- Guest BioWarner Huh, MD is Professor and Director of the Division of Gynecologic Oncology, his areas of expertise include Gynecologic oncology, cancer vaccine, robotic surgery for gyn/onc, ovarian cancer, endometrial cancer.
Learn more about Warner Huh, MD
Release Date: January 10, 2017
Reissue Date: January 8, 2021
Expiration Date: January 8, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Presenters:
Warner K. Huh, MD
Division Director and Professor, Division of Gynecologic Oncology
Dr. Huh has the following financial relationships with commercial interests:
Consulting Fee – DySIS Medical
No other speakers, planners or content reviewers (Ronan O'Beirne, EdD and Katelyn Hiden) have any relevant financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionMelanie: Welcome to the UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we give an update on the latest guidelines for pap smear screenings for cervical cancer. Joining me is Dr. Warner Huh. He's the Chair of the Department of Obstetrics and Gynecology and a Gynecologic Oncologist at UAB Medicine. Dr. Huh, it's a pleasure to have you back with us again. You are a great guest, so let's get right into this. What are the current guidelines for pap smear and cervical cancer screening? What's different? Give us an update.
Dr Warner Huh: Yeah, there's a lot to report on this topic. I think the last time we talked, the recommendation was that we screen women starting at 21 years of age and you can use a pap smear, which is, I think something that all women are familiar with and you can do that every three years, if the pap is normal.
And then that starting at the age of 30, you can combine, what's known as an HPV test with a pap smear together. It's also known as co-testing. And if those test results are normal or are negative, then they can be screened every five years. And at that time that was a pretty marked change because we had greatly lengthened the interval of screening.
What has changed since our last time you and I spoke, is that both the United States Preventive Services Task Force and the American Cancer Society have released new cervical cancer screening guidelines, that really, for the most part start really focusing on the value of what we call primary HPV screening.
In other words, relying exclusively on just the HPV test and not a pap for screening. And some of your listeners may be wondering why. The reason is that we know that, HPV screening by itself is a much better test, for cervical cancer screening than the pap.
And that, when you combine the two together, really the pap doesn't really add that much above and beyond the HPV test. And so what the United States Preventive Services Task Force, although they still, basically recommend co-testing, they do put an emphasis on consideration of things like primary HPV screening.
But what's really very interesting is that the American Cancer Society earlier this year put out forth guidelines that basically look at another change, which is when to start screening. And so they actually now recommend initiation of screening at 25 years of age, not 21 years of age. And not so long ago, we had screened women at 18 years of age.
And again, your listeners may be wondering why. And the reason for that is that we know that the rates of cancer in women between 21 and 25 is exceptionally small. And that you, if you start screening women that you - there's a real risk of things like overtreatment and exposing patients to procedures that they don't need.
So that's the first major change, screening starting at 25 versus 21. And keep in mind that other countries like the United Kingdom, actually do this. So we're not the first to recommend this. The second one is that the American Cancer Society is very clear that they think that the future is, or the aspirational goal is basically primary HPV screening.
And so they want, providers to use just the HPV test and not PAP as a screening modality. They do acknowledge that there are areas of this country that can't provide primary HPV screenings. So they do allow for co-testing. And so in the end, when you actually take these two guidelines into consideration, the biggest changes are, in summary one, is that we're pushing out screening to a later age. Some of that is a little bit controversial because some people still believe that we should be screening at 21, but two, is also the fact that we're very much pushing towards the ideal of using HPV testing alone as a screening test and pushing away from PAP. Because we have more and more women who are vaccinated against HPV and that number will only go up, the utility of the PAP is only going to go down. If you continue to PAP people, you're going to wind up missing disease. And that's why, switching over to an HPV test also becomes really important. So these are pretty marked changes. I think the one thing that we're all waiting on from in the women's health side is formal recommendation from the American College of Obstetricians and Gynecologists on where they stand on this issue.
And I think they will, I can't guarantee this, but likely think that they will wind up making similar recommendations. But I think it's important for the listeners to recognize that cervical cancer screening is rapidly changing. I think it's changing for the better. And there are multiple variables to take into consideration, including rates of HPV vaccination. Again, the messaging is that we're going to be relying more on HPV testing as the foundation for screening.
Melanie: Wow. That's so interesting, Dr. Huh. I was going to get to ACOG. That was my next question is where do they stand on this? And so now tell us about women for other providers that are answering these questions, for gynecologists that are answering these questions for their patients; what do you want them to be able to say as far as if the woman is too old, I'm 56, for example, so I didn't get the Gardasil vaccine. So what about the older generation who are more at risk for cervical cancer, just based on their age, is HPV still going to be something that is just looked at? What's changed for the older population?
Dr Warner Huh: I think the last time we spoke, HPV vaccination now is approved up to 45 years of age, both in men and women. So that's a pretty marked difference because previously it was 26 years of age. And, and so HPV is unfortunately not something that goes away with age. And matter of fact, I would argue that, yeah, that we see about maybe a 20 to 25% of the cervical cancer cases that we see in our practice, and this is a true probably nationally occur in women after 65 years of age. So cervical cancer in women is a lifelong problem. To your question, again, is there any value to HPV vaccination in older women?
I mean, I think perhaps there is, it's definitely going to be a lot less than someone who's 10 or 11 or 12 years of age. But the one thing I will note is that the vaccine is extraordinarily safe. I mean millions and millions of doses have been given. And I would argue that this vaccine has been heavily scrutinized and it's a safe vaccine.
The problem is coverage and its off label and unfortunately patients will have to pay for it, but I think the greater issues that women need to continue screening. And the one message I'll leave with listeners is that, if we screen the entire United States, the way that we're supposed to, regularly and reliably and accurately, the issue of HPV vaccination, as it relates to cervical cancer would be somewhat irrelevant.
Cervical cancer would be truly a non-existent or rare disease. But, we don't live in that world and we still have breakthrough cases of cervical cancer because women are not getting screened in the United States. But what I want to stress is that really is that screening is still the cornerstone for cervical cancer prevention and that we're learning a lot more about HPV vaccination, but it is now officially approved up to 45 years of age.
Melanie: Thank you so much, Dr. Huh. As we wrap up, and I hope you'll come back on and update us as ACOG comes out with their statements and thing changes. What's new and exciting in the field of gynecologic oncology? Any game-changers in cancer treatment that you'd like other providers to know, things that you're doing at UAB that are really exciting?
Dr Warner Huh: I mean there's the lots of incredible stuff on, not the least of which is that a class of drugs called PARP inhibitors, which are oral pills, revolutionized the treatment landscape of patients with ovarian cancer, particularly women would that have BRCA mutations. There's been a lot of research done in the last, many years and multiple drug approvals, but, we know that this medication, particularly in BRCA mutated women with ovarian cancer has really revolutionized their outcomes.
That's the first thing. I think the second thing that we've seen as with other solid tumors is the role of immunotherapy and what we call checkpoint inhibition. In certain subsets of women that have, certain molecular alterations, again, some of these therapies are lifesaving. I think the bottom line is that we've had more drugs approved in the gynecologic oncology space in the last four to five years than we have in the probably the last 20 years combined.
And, much of it is basically geared towards a very personalized medicine. And so going forward, we look at each patient differently in terms of what their molecular alterations are, as it relates to their cancer. And those molecular alterations then define what kind of treatment they receive. So I suspect in the next couple years, again, our treatment paradigms are going to look completely different, but for the better. I really am highly optimistic that the outcomes for our patients going forward are going to be so much better than they have been in the last 10 years.
Melanie: Well I'm sure with docs like you on the case, you're just an excellent guest, Dr. Huh. Thank you so much for coming on and updating us this morning. A community physician can refer a patient to UAB Medicine by calling the MIST line at one 800-UAB-MIST. And that wraps up this episode of UAB Med Cast. For more information on resources available at UAB medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua177.mp3
- DoctorsRashid, Salman
- Featured SpeakerSalman Rashid, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4440
- Guest BioSalman Rashid, MD specializes in Pediatric Neurology, Pediatrics.
Learn more about Salman Rashid, MD
Release Date: December 23, 2020
Expiration Date: December 23, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Salman Rashid, MD
Associate Professor, Pediatric Neurology & Pediatrics
Dr. Rashid has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionIntroduction: UAB MedCast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit to collect credit, please visit UABmedicine.org/medcast, and complete the episodes Post-Test. Welcome to UAB MedCast, a continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
Melanie Cole: Welcome to UAB MedCast. I'm Melanie Cole, and today I invite you to listen in, as we discuss the pathway for the pharmacological management of status epilepticus in pediatric patients. Joining me is Dr. Salman Rashid. He's a Pediatric Neurologist and an Assistant Professor at UAB Medicine. Dr. Rashid, it's a pleasure to have you join us today. Terminology used to describe different seizure stages phases, reflect the complex and nuanced definition of status epilepticus. Tell us what it is, what's the prevalence and the different types that you see?
Dr. Rashid: So, status epilepticus is a condition which results from either the failure of mechanisms, responsible for seizure termination or from initiation of mechanisms, which lead to abnormally prolonged seizures after a time point, which is termed as T1. It is a condition that can have long-term consequences if it continues for a long time. And the time point named at that point is T2. The long-term consequences could include neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type of duration type and duration of seizure. So for example, for a generalized tonicclonic seizure, T1 is thought to be five minutes and T2 is thought to be 30 minutes. In practical terms, it is thought that at point T1, the treatment of a seizure should begin. And by the time two status epilepticus should have been controlled. Now, there are a few more things in terms of the definitions, because conventionally, it was thought that if seizure lasts for less than five minutes, it would be termed as brief seizure.
If the seizure would last between five to 30 minutes, it would be termed as prolonged seizure. And if it would last beyond 30 minutes, it would be termed as status epilepticus. Now it could just be a single seizure, or it could be more than two seizures without full recovery of consciousness between the seizures. Now, since majority of the seizures are brief and once a seizure lasts more than five minutes, it is likely to be prolonged. Therefore, most of the treatment pathways like ours adhere to a five minute definition for decision management. This approach may reduce the risk for prolonged seizures without management and the adverse outcomes associated with unnecessarily terminating intervening on brief self limited seizures. A couple of other definitions to be discussed here would be a refractory status epilepticus. If the status epilepticus fails to respond to therapy with two antiepileptic medication, one of them being a benzodiazepine class of medication, it is termed as refractory status epilepticus.
But if the status epilepticus has failed to resolve or reoccurs within 24 hours or more despite therapy that includes a continuous infusion such as midazolam or pentobarbital infusion, then it is termed a super refractory status epilepticus. In terms of the prevalence of status epilepticus in children, it is estimated that around 17 to 23 of hundred thousand children experienced status epilepticus every year with the highest incidence in children less than one year of age. And one of the studies from United Kingdom, the overall incidence of status epilepticus was around 14.5 in a hundred thousand pediatric patients. The incidence was the highest in children, younger than one, which was around 51 in a hundred thousand. And then it progressively decreased to the point that it was around two in a hundred thousand in kids who were 10 to 15 years of age. It is also important to mention that there is some literature that suggests that social economic deprivation is associated with increased incidence of convulsive status epilepticus in children, although it needs to be studied in more details.
Host: What does it represent? Is this an exacerbation of a preexisting seizure disorder doctor or an initial manifestation of one, or can it represent an insult that something other than a seizure disorder? How does it present?
Dr. Rashid: Yeah, that's a very good question. Status epilepticus could be the initial presentation of a patient who does not have a diagnosis of epilepsy. And when that happens, you have to look into what may be causing such a prolonged seizure. It could also happen in patients with already existing diagnosis of epilepsy. And when that happens again, you have to look at what may be causing it. One of the common cause may be, for example, not taking the antiepileptic medications as prescribed or inappropriate amounts. In those scenarios, obviously you have to make a clinical judgment in terms of what may be the underlying reason for status epilepticus in those patients.
Host: So how emergent is this condition what's important to note in supportive care for these children in the prehospital setting? And why is this vital that EMS know what's going on?
Dr. Rashid: As the literature supports, if the seizures last too long, at a certain point, there comes a time when there is irreversible loss of brain structure and function, and it can lead to neuronal death, neuronal injury, and alteration of neuronal networks. So that is why it is extremely important for the primary care providers and also the first responders to be well aware of this situation, and to be well aware of some of the seizure abortive medication that can be administered for the seizure to stop before it gets too long. One often common medication that is used in pediatric population is Diastat, which is usually prescribed by the primary care practitioners after the kid had a seizure that lasted for more than five minutes. And similarly, some parents that are apprehensive on administration of Diastat because of the fear side effect of respiratory depression, and if the kid is having a seizure, they're talking to 911 or the first responders, and usually feel comfortable in administering that when the 911 is on their way.
Host: So then based on that doctor, I'd like you to talk about the treatment pathway and the route of administration. Is this usually in the ER, is this a planned treatment path?
Dr. Rashid: The treatment pathway that we proposed is basically for the patients who have seizures within the hospital. And obviously there are other situations. And as I mentioned, if the seizure happens outside the hospital or in the field, usually the first step is to give a medication that is called a seizure abortive medication in a hope to prevent the seizure from lasting too long. So in general treatment pathways are likely to be more helpful when evidence-based guidelines are combined with the cultural practices. Our status epilepticus pathway is largely based on 2016 guidelines for the American Epilepsy Society. We utilize a quality improvement type of approach to synchronize our local practices with guidelines. Our team included a group of pediatric neurology providers, pediatric critical care providers, as well as pharmacy and nursing staff, including nurse educators. It also involves looking at our local resources, cultures, and practices. For example, we carefully looked at our medications suggested in the pathway available within the desired time window.
Where are these medications located? For example, are they located in the Pyxis machine? What is the desired dilution for the medication? And what is the rate of administration? Through tabletop simulations, we also looked at the common problems encountered by the healthcare providers while managing status epilepticus and try to account for all these scenarios in our pathways. It is also important to remember that this pathway is for the management of status epilepticus in non neonatal pediatric age group. It is designed to assist clinicians for treating patients with status epilepticus. It is not intended to establish a standard of care or replace a clinical judgment or establish a protocol for all patients. Therefore, other approaches that are not covered within this pathway may also be appropriate for management.
Host: Well, then please speak about that. Speak to us about the first-line medications, second line, and some of the other treatment options in patients who are refractory to the first and second line medications?
Dr. Rashid: So, the initial phase of the management of a seizure is stabilization of the patient. Look at their airway, breathing, circulation, do a neurological exam if you can. Time the seizure, monitor vital signs, and assess their cardio-respiratory status. And if it is nearing five minutes, obtain an IV access. One of the lap tests that is very important to be obtained urgently is a point of care blood glucose, because if status epilepticus or seizure is due to hypoglycemia, it is less likely to respond to other medications, and can lead to brain damage relatively quickly. So in essence, the first five minutes is basically stabilizing patient and evaluating for urgent causes for seizures. Now, if the seizure is prolonged beyond the first five minutes, the first-line medication is usually a benzodiazepine. And the choice depends upon whether the patient has an IV access or does not have an IV access.
If the patient has an IV access, we recommend using lorazepam 0.1 milligrams per kilograms, up to the maximum dose of four milligrams. But if the patient does not have an IV access, there could be multiple medications that could be used. But for this pathway, we have recommended intramuscular midazolam. If the patient is between 13 to 40 kilograms, the dose would be five milligrams. And if the patient is more than 40 kilograms, the dose would be 10 milligrams. Now, if the seizure continues, then repeat these benzodiazepine, class of medication can be administered. If it is IV lorazepam. Again, the dose would be 0.1 milligrams per kilogram with the maximum dose of four milligrams. But at the same time, the staff should also get ready in preparing for second line medications. Now, if the seizure is prolonged and lasts beyond 20 minutes, then the second line medication should be used.
If the patient has no known diagnosis of epilepsy or is not on anti-epileptic medications, in those scenarios, we recommend three medications and one of them can be used for the management. These medication are suggested based on their safety, tolerability and efficacy profile. The first medication that we recommend would be intravenous alazopram. The loading dose of the medication is 60 milligrams per kilogram with a maximum dose of 4,500 milligrams. If the patient is allergic to, for example to the lorazepam, or if there are other contraindications, then intravenous Fosphenytoin can be used. The loading dose is 20 milligram PE per kilogram, the maximum dose of 1500 milligrams, PE per dose. And if both these medications cannot be used, then phenobarbital can be used. If the patient is not intubated, we suggest using a dose of 15 milligrams per kilogram.
This dose is in accordance with what is suggested by the American Epilepsy Society guideline from 2016. If the patient is on anti-epileptic medications already, then we suggest that initial presentation lab values of those medications, that the patient is on should be obtained. And neurology should actually be contacted before 20 minutes to guide management for the second line medication, if the seizure lasts that long. Now this is the treatment up to 40 minutes from the onset of seizure. In scenarios where the seizure lasts beyond that, for example, more than 40 minutes, or if the patient has more than two seizures and does not gain awareness between the seizures, then unfortunately we do not have evidence-based guidelines for guiding therapy. But what is usually suggested is that you can repeat the second line therapy, or you can go to the next step of anesthetic doses of medications, for example, midazolam or pentobarbital. In such scenarios. EG also becomes very important.
Host: That is such an interesting topic. And you gave such a great description of the first and second line and whether or not those don't even work at that point. So what would you like other providers to know as the take home points from this discussion and when you feel that it's important that they refer their patients with status epilepticus?
Dr. Rashid: So, the take home points I would like to mention are that number one, it is to be remembered that this pathway is for pharmacological management of status epilepticus in children, and does not take into account individual patients’ scenarios. For example, does the patient need urgent intubation? So while managing the patient pharmacologically, it is extremely necessary to think why the patient is suffering from status epilepticus, therefore diagnostic workup, including labs and imaging should be completed as soon as possible and occur simultaneously, and in parallel with the treatment. Number two, when establishing disease management pathways, it is important to analyze and find ways to synchronize evidence-based medicine with local resources, cultures, and practices. Now, what we have presented in this pathway is based on the best evidence and then our culture, but the management of seizures and status epilepticus pathway is likely to change in coming times.
And we should all keep our eyes open for the new literature and new evidence that is coming in. I think that if the patient has status epilepticus, whether it is a febrile status epilepticus or not, usually those patients present to the emergency room. And in those scenarios, on-call neurology is usually involved and they guide management based on a patient's presentation. So most in most of these scenarios, the neurologists are already involved in care. And my experience has been that with patients with prolonged seizures, most of the pediatricians do refer them for further management. Now whether the treatment for epilepsy is required or not, that would be a different topic and will be covered in the upcoming talks.
Host: Thank you so much, Dr. Rashid and I invite you to come on with updates as we learn more. Thank you again for joining us. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB MedCast, to refer your patients, or for more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua165.mp3
- DoctorsMullins, Haddon;Willig, James
- Featured SpeakerHaddon Mullins, MD | James Willig, MD, MSPH
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4350
- Guest BioHaddon Mullins, MD is a General Surgery Resident.
James H. Willig, MD, MSPH, is the Associate Dean of Clinical Education in the School of Medicine. He attended Medical School at the Instituto Tecnologico de Santo Domingo (INTEC) and completed his residency at the University of Virginia Roanoke-Salem. At UAB, Willig has earned an M.S. in Public Health and completed an Infectious Diseases Fellowship.Learn more about James Willig, MD, MSPH
Release Date: November 9, 2020
Expiration Date: November 9, 2023
Disclosure Information:
Planners:
James Willig, MD, MSPH
Professor, Infectious Diseases
C. Haddon Mullins, IV, BS, BA
UAB Medicine
Jill Deaver, MA, MLIS
UAB Medicine
Adam Roderick, M.ED.
UAB Medicine
Anne Zinski, PhD
UAB Medicine
Caroline Harada, MD
Associate Professor, Geriatric Medicine
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Presenter:
James Willig, MD, MSPH
Professor, Infectious Diseases
Dr. Willig have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing an introduction to bedside teaching. In this panel, are Dr. James Willig. He’s the Assistant Dean of Clinical Education at UAB Medicine and Dr. Haddon Mullins. He’s a General Surgery Resident at UAB Medicine.
James Willig, MD, MSPH (Guest): Welcome to the first episode of The Medical Educator podcast series. Haddon Mullins and myself, James Willig have decided to discuss a lot of important topics about medical education, looking at both the perspective of a clinician who has been teaching on the wards for about 15 or let’s just say, far too long to mention and Haddon who has carefully reviewed the evidence available to a lot of the things that we do. And our goal with this podcast, is to really fuse both some experiential learning about teaching on the wards and clinical education in general and to contrast and with the evidence that’s available, so that we may all become more evidence based educators and offer the best of both worlds to our students. So, with that, Haddon, tell us about the topic for today.
Haddon Mullins, MD (Guest): So, the topic for today, is bedside teaching. And this is an introduction. So, we’re asking the question why bedside teaching? Why should clinicians be concerned with taking teaching to the bedside, performing bedside rounds with students and making sure that they follow certain steps during that encounter with the patient? What’s the advantage of a bedside round over a conference round? Or what’s the advantage of just say interaction with the patient that doesn’t necessarily meet specific criteria?
To begin the conversation though, I think it would be smart to define bedside teaching. So, I have some definitions that have been defined by clinicians in the literature but what would your offhand definition of beside rounding be?
Dr. Willig: So, to me, I think beside rounding really involves going to the bedside, interacting directly with both the patient and the family and really having the conversation where you update them about the news of the day, and you have the opportunity to field their questions and provide them information so that they know which direction treatment is going to take. What’s the literature say?
Dr. Mullins: Well there’s a number of definitions in the literature. I think one of the best ones is defined by Gonzalo and others in 2010, defined as bedside teaching rounds as a minimum of two physicians attending or house staff, performing all three of the following at the bedside in the presence of the patient. One, case presentation and history. Two, performance of at least one physical exam skill and three, discussion of the patient’s daily plan of care. Other definitions of what could also be considered rounding included walk rounds, which was any form of interaction with the patient by a minimum of two physicians that did not meet all three of the parameters above. And any form of rounding that did not include patient interaction was defined as a card flip.
Dr. Willig: I see. Well those certainly are comprehensive definitions. So, really it talks about the elements and has to be more than one clinician in the room and then the other three elements are that you both present the case, that you perform or demonstrate at least one physical exam finding, and ultimately, that things are patient-centered in terms of discussion of the case and the plan and the questions are fielded and answered.
Dr. Mullins: Correct. And I also think it’s important to define the vocabulary for what we are comparing against too. So, walk round, or a card flip or a conference round.
Dr. Willig: What are those?
Dr. Mullins: So, a walk round would be an interaction with the patient but maybe let’s say you don’t perform a physical exam finding. Or you don’t present the case. You interact with the patient, but you don’t meet all three criteria.
Dr. Willig: So, if I’m going rounding across the wards and we are presenting in the hallway and I step in and I say heh, say a couple of words to the patient and maybe answer a question or two; that would be more of a walk round as opposed to a bedside round.
Dr. Mullins: Exactly. That is a walk round. And then they define it as a card flip a conference round would be in a conference room. The patient is not involved at all in any way.
Dr. Willig: Certainly, we do that particularly for time limitations is we are post call, or sometimes to get initial presentation but one thing that really bares out in clinical practice that sometimes we have a combination of these strategies where you might start with discussing something in the conference room and then combining that with some bedside interaction, maybe not to the level of to be considered bedside teaching, but at least to have sort of a walk rounds. But surely, it’s a hybrid of a couple of strategies.
Dr. Mullins: Right and so we can talk about that and there’s some literature that asks that same question or tries to ask the same question in terms of out of those three categories, what is happening on the wards or in inpatient round. Most of this data that I have is from inpatient medicine wards, which would be your experience. So, again, offhand or from your experience, if you could put a number on it, that would be great or just in generalities what is occurring. Are people meeting those three criteria every time? Is it more of a walk round? How many physicians prefer just a conference room? What about your personal preference? You could start with that.
Dr. Willig: Okay, so personally, I think I’ve seen an evolution in what I’ve done over the last decade. Initially, I was much more focused in presenting findings outside of the room and just kind of getting in there and for efficiency sake, just try to move through rounds in that way and I felt that that provided the best efficiency. Then in subsequent years, was introduced to literature talking about how if you take a seat in the patient’s room, there’s a perception that you spend more time there despite you spending an equivalent amount of time whether you are standing or you’re sitting. The clinicians that were sitting, really people feel like they spent a lot more time with them and that was a more meaningful interaction.
The move towards the bedside for me really came and I think it adds efficiency for me and I think in the last five years, I’ve probably been I would say over 90% bedside because I do think that it speeds me up. When I hear the students or the residents present the case and I’m standing by the bedside, I’m inspecting the patient, I can interject with some questions over there and get reconfirmed facts of the presentation or the physical exam right there as I’m hearing the presentation. It helps me remember stuff better. It helps me sort of target my physical exam as I’m there. And it gives me a ton of time to observe the interactions between the residents and the patients. It gives me a ton of time to observe the interactions between the patient and their other family members whether they hear strange findings, who do they look to for reassurance, are they scared, do they seem to be – what’s the family dynamic there?
And that’s all information that I can help as I try to move folks towards a treatment plan that we’re going to recommend, understanding the dynamics and who they – which family members are really involved, which family members do they rely on. I think that that allows me to include the right people in difficult discussions going forward. So, now, I really feel that bedside rounds really speeds me up and about the only time that I do what you would consider a card flip, would be on post call rounds where the night call resident is presenting to me and they’re not going to go out there and round with me. So, I’ll go ahead and hear the presentation. The only other time I might consider doing things outside is I’ll ask the residents is there anything of a sensitive nature that you feel would be counterproductive to discuss in the patient’s presence? Sometimes there’s sensitive things. Sometimes there’s a difficult history. I can imagine cases of sort of drug seeking behavior or cases where there really is – is there a suspicion of domestic violence and I have both partners in the room. Those are types of situations that it will help me know a little bit more about them ahead of time or any insight into the dynamics in the room that might help me more likely move towards a good treatment plan.
So, other than those two instances, for most of my rounds, I would say that I go right to the bedside and have that discussion there with the patient at the center of it.
Dr. Mullins: That’s great. And that seems to be what – it’s a little complicated in the literature. Because you deal with how do people categorize and how different studies define what a bedside round is. So, we’ve already come up with a definition for bedside rounds and for that definition, was Gonzales 2010, found that percentage of attendings hitting all three criteria was less than 1% of bedside rounds. Other people when you are a little more lenient with it, and say well, some people might be in a combination of strategies such as [00:09:59] 1986 found that 77% had a combination of conference room and beside. So, I feel like that’s a little more realistic that different attendings have different barriers or different inclinations at different times to get towards the bedside or go to the conference room.
Another study, found that hallway rounds was the most preferred 58% but that could mean that part of it’s being done in the hallway, part of it’s being done at the bedside like you initially did. So, it seems that there is bedside teaching going on but maybe not an entire clinical encounter so often or they are some of it’s done in the conference room like you said.
Dr. Willig: Now just to clarify, those are studies. You mentioned some dates on them. There was something as recent as 2010, but I believe you quoted some literature from the late 80s and – I wonder what – if this has evolved over time or if you found evidence in the literature that bedside rounds are more prevalent nowadays as opposed to a few decades ago.
Dr. Mullins: Yeah, so, that’s a good question. It’s a little bit of a complicated question. A lot of the literature lists two particular studies to quote the decline of bedside teaching as I stated and it’s in a lot of introductions and they’ll say bedside teaching has decreased from 75% to 16% are kind of the numbers over the past 30 years. and it’s a little misleading. The two studies that they are quoting are 1964 study by Reichmann quoted 75% of attendings and students see the patient together during or after case presentations.
So, it’s a liberal definition. But that 75% of the time, they saw the patient together at some point. And then the other study is Collins from 1978 that said 16% of time during rounds occurred at patient bedside. So, when they say it’s a decrease from 75% to 16%, it’s from two different studies that are using two different definitions of bedside rounds. So, there is some indication that bedside rounding has dropped off and there are a number of other studies that people use the same study from 1986 that had 77% of the combination also reported 8% of teaching rounds done only at the bedside. So, that’s 8% of people recorded in 1986 are doing what you say you do now and that the whole encounter is done at the bedside.
The most recent from 2017, was who listed 58% at hallway rounds. So, if you look at the 1986 and they say 8% of teaching is done only at the bedside and then you look at 2017 and say 58% is done in the hallway with 19% done only at the bedside; that indicates either actually an uptrend in strictly bedside teaching or probably more likely staying close to the same where people are teaching in the hallway and at the bedside, in the conference room and at the bedside or a combination of any of those.
Dr. Willig: So, comments about all of that, that you just shared with us. I mean certainly these are very different decades and the evolution of rounding and the patient interactions in terms of the societal norms of judging those interactions or facilitating those interactions have probably changed over time. So, it’s in some ways, it might be factors like what role does that play. What role do the specific institutions or the size of these studies or the methodology used. I guess it’s tough to quantify exactly how much it’s occurred but it seems like the more recent literature really points to a combination of strategies whether it’s around 19 to 20% exclusively bedside but it sounded like it was in the high 70s where people were doing what we would define as hallway rounds where they would discuss the case but then go in and interact with the family and the patient directly. So, really, it seems like rounding overall, has rounded out or has migrated out of a conference room into at least the hallway and the room overlapping those two areas or really, migrating entirely into the patient room in at least one out of every five locations by the latest literature that you quoted.
Dr. Mullins: Right and so, like I said, some of these papers in the literature quote these two very old studies, the 75% to 16%. That’s a little misleading and not necessarily a good representation of what is actually going on. But all of these studies and the big problem with all of these studies is that they are low numbers, low response rates and what we can talk about here in a second is individual barriers are going to vary as well. And reasons for doing certain things are going to be everything from practical to theoretical, I guess you could say.
Dr. Willig: Well let’s pull on that thread. Because I know that this was a part of your literature review. Why do bedside rounds not occur? The barriers that people point to, what are the things in the literature that say stand between us and the beside to have these rounds?
Dr. Mullins: Right so, initially, there were a number of studies done decades ago that really point towards patient comfort and concern. There was a lot of studies done to test that. Does presenting at the bedside, concern the patient or is it even some studies ask the question is it traumatic for patients? As recent as 2009, Gonzalo 2009, reported 75% or respondents believed that rounding prevented freedom of discussion, 66% were concerned for patient comfort and another 66% had concerns for patient’s feelings.
Dr. Willig: And these are clinicians being asked about what is your perception of how this interacts with the –
Dr. Mullins: Yes, these are clinicians.
Dr. Willig: This is very interesting because I think I see some of that reluctance in some of our learners. And certainly some of our attendings. And yet, I think that prefacing around conversation with some comments like heh, listen, all of us are working together to find the best possible solution for you. So, we’re going to engage in some discussion to find the best way that we an collectively come together with because none of us is as smart as all of us together. So, here we go. And sometimes, you can see people’s anxiety, particularly when we slip into jargon, when we use strange vocabulary and you can sort of see the eyes darting around and people getting nervous. But I found that prefacing with those types of comments I’ve heard a lot of appreciation from people that actually see us working, that actually see us having discussions about the risks, the benefits, and when we take the extra step to go from the jargon to really explain things in plain language; for the most part, I’ve encountered a lot of comfort and appreciation where people see their physicians being very honest and they don’t have all the answers and they also see you working through things, trying to provide them the best care that we can do collectively.
My impression is that it almost elevates every learner in that room in the eyes of the patient. Because they can see, they are engaged, they are participating members, they are all contributing to the discussion and I think that has for the patients that I’ve treated, for the most part, created more of a sensation of comfort and understanding that this team really cares about you.
Dr. Mullins: Yes and there are – in spite of that one study, and those concerns, there are a number of studies that have looked at and surveyed and questioned and even measured blood pressure and as far as norepinephrine levels of patients during bedside rounds and the consensus is that to not perform bedside rounds due to patient concern is not a legitimate reason to not perform bedside rounds.
Dr. Willig: What do you mean?
Dr. Mullins: Patients from surveys, surveyed from 1989 had 85% of patients like presentations at the bedside. From 1980, 94% were pleased with bedside rounds and believed they should continue. 1941, most patients preferred discussions especially if they had experience with bedside rounds before, which is something we can return to again. 1997, patients with bedside presentations reported doctors spent more time with them, 2003, you have inpatient exam, in room exams, patients had greater satisfaction working with medical students, 2010, patients received bedside rounds preferred them and perceived more time spent at bedside.
And that is a number of studies saying patients, for a large majority, prefer bedside rounds especially if they had experienced them before. And that’s interesting and it leads me to another point in that one of the main barriers to bedside rounds or a barrier to bedside rounds, it’s kind of interesting, in the literature that attendings seem to prefer them and if they don’t have time or they don’t – there are different practical barriers that prevent them from going to the bedside. They still believe, tend to believe in the educational value of bedside rounds and want to perform them.
House staff, on the other hand, residents, interns, and students tend not to prefer bedside rounds. They tend to prefer a conference presentation in conference rooms. Namely because sometimes they believe a bedside round can undermine their authority if they appear to not know the answer in front of the patient or from a student perspective, stress, nervousness, they feel more comfortable in the conference room or from a personal experience, and from literature as well is that students also had these concerns about patient comfort.
So, that tends to be a barrier as well but from the same literature that studies a lot of this and asks a lot of different questions to patients and residents and students at the same time, is that the more students are exposed to bedside rounds, the more they tend to prefer them. So, and that tends to be an important distinction in terms of why take students to bedside rounds if they don’t prefer them. Or why should you make the effort to overcome that barrier to bedside rounding.
Dr. Willig: It’s very interesting that a lot of the barriers really come more from our side than from the patient’s side who across decades of literature, clearly prefer that discussion at the bedside. And I do think that there’s things that you can do to show respect to your learners, to ensure that you are discussing things clearly with them, that you’re not – that you’re including them in the decision making, that you’re not just throwing what they said off to the side or being very mindful of being respectful and inclusive to your learners can decrease some of that sensation. And sometimes a subtlety that I will do is I’ll wait – if I have feedback on the quality of the presentation or on things that the student can do better; I will wait to provide that feedback, back in the hallway. But the discussions about the case, often the student will read something about the case, and I give them their time to really say okay what have you read about this. What are your thoughts? How about consider this treatment course?
But I do think that treating the learner with a measure of respect and really including them in the decision making that’s going on there, can really take away some of these negative feelings. An interesting quirk is that I’m often asked by students well, how do I get honors? How do I get honors in the rotation? And I always sort of say that you get honors when you do things that I don’t directly observe but that really are patient-centered and patient-focused. And sometimes I don’t have a window into that. Other people come up and tell me things or patients will sit and share their appreciation of the student with me. One thing that I can see, is when we’re in the room, and sometimes I will make a suggestion in terms of the management to the patient and there will be a moment where the patient will look over quickly at the medical student and the medical student will imperceptibly nod in agreement and then the patient will look back at me and say, okay, we can do that doc.
And it always makes me smile because how I read that interaction is this strange man over here is telling me to do something let me turn to the doctor that I trust who has spent hours with me, has educated about my disease, has shown interest and has earned my trust, okay, they agree with this relatively strange attending at the foot of the bed so, now they turn back to me as the attending and they say, okay, we can do this. That to me, speaks about the hours that the student has spent in that room and how much they’ve earned the trust of that patient and their family. And that to me really gives me an insight into who that – what type of professional that student is and how they’ve gone the extra mile with that patient and the family.
Dr. Mullins: That’s great. Another study that assesses not just patient concerns but some other concerns among physicians, analyzed barriers to bedside teaching. Romani 2003 was a series of focus group interviews and these are different from patient concerns. And I think they are interesting to talk about. He had the most significant barriers to bedside teaching were one, and this is physicians, this is attending physicians. Declining bedside teaching skills, the aura of bedside teaching or belief that bedside teachers should possess an always unattainable level of diagnostic skill that creates intense performance pressure, three that teaching is not values and four, an erosion of teaching ethic.
So, those were four things mainly on the attending side that they perceived as reasons either not to go to the bedside or maybe – and I think this is interesting because it mainly focuses on physical exam. And it correlates back to that definition that we had that a bedside round, a component of a bedside round and we can talk about this in a little bit too, I think an essential component of the bedside round is demonstration of a physical exam finding. And it seems here that in 2003, that a lot of the attendings did not feel comfortable with that particular component of the bedside encounter.
Dr. Willig: That’s very interesting. And I mean I can see how those would be valid concerns. But again, I think that team based approach to this and the ability to discuss things as a group and the belief that again, none of us is as smart as all of us but we are in a team working through it together. I almost tell my team we have to be sort of a wireless interconnected network of brains working to find the best collective solution to this problem. And the reality is, that none of us is going to have 100% of the answers. The best answer is probably a certain percentage in each of our brains. And if we have a culture where we can discuss things openly, and share ideas, the amalgam of those ideas and the evidence supporting those management decisions is probably what’s best for the patient. So, I’ve found that – I’ve certainly felt – I’ve worked with learners that far exceed me in many areas of medicine in terms of their diagnosis skill or their fund of knowledge, but I’ve found that keeping that open climate where sometimes I will know more but sometimes you will know more.
I tell my students actively listen, the last time I read about topic X, might have been when I was studying to be recertified on my board exam a couple of years ago. But you, you read about it last week. And you have the latest evidence in your mind, and I think that what this patient deserves is the greatest evidence, the benefit of my experience, your knowledge of the latest literature and evidence together, are going to provide better treatment.
So, I’ve really sort of that flattening that gradient and just sort of saying almost as the attending, I am a learner, everything I know is here for you, and likewise, we should be making each other better. So, I know that there’s things that you know better than me, but the success is all of us sharing what we know best to serve this patient and their family. That environment, I think has helped me get over some of those concerns that I can understand them.
Dr. Mullins: Let’s talk a little more about some of the other advantages to bedside teaching. And now, kind of get to the point of why go to the bedside. The big study done on the value of bedside teaching Gonzolo 2013, identified six main themes for the advantages of the bedside teaching. Skill development for learners, observation and feedback, role modeling, team building among trainees, attendings and patients, improved patient care delivery through a combined clinical decision making and team consensus and the culture of medicine as patient-centered care. Do any of those particularly resonate with you.
Dr. Willig: You know several of them do, honestly. I mean the modeling is so key. I mean we’ve discussed our learners as being all of us are a combination of the skills, knowledge and attitudes. And certainly, the experiential part of how do you treat someone. How do you navigate a difficult conversation? How do you go through an uncomfortable topic? How do I give someone bad news? How do I really deal with a very – an angry family member? The discussion about a near miss or a medical error. How do I discuss someone who is very anxious about what’s going on with their family member? Or how do I just have an honest discussion with someone about heh, this is where you are, and these are the changes that I think you need to make to your health to have success longitudinally?
The feedback that I get from learners over the years is some of them are sort of surprised about some of the things that we discuss at the bedside. And frankly, I think shying away from this topic, from sensitive topics doesn’t really help us or the patient get to where they need to get to in order to have the most success that they can as defined by their condition. But just being frank, saying heh listen, I see here in your history that you have a history of injection drug abuse, that you have a history of addiction to this, or you have some pain seeking behaviors, that concerns me. How are we going to navigate that amongst ourselves? It’s tough to bring that up and people sometimes react or will say things but honestly, I sit there, I look them in the eye, and I try to have a frank conversation. When I leave the room, we can have frank discussions with the team about heh, how does the patient’s history affect my thinking? How does it bias my decision making? Being aware of those things, being aware of sort of why we think what we think, that level of metacognition, I think we do better work when we’re honest with the patient and with ourselves about all of these elements.
So, the role modeling to me, is very important. I think it leads to better care because we can have more frank conversations. And I think people seeing you have those conversations prepares them. Because you can do the best [00:30:18] work in the world but if you fail at how you treat people, you’re not going to get great outcomes. Patient satisfaction is a real outcome. I think we’re in a service profession. And knowing how to treat others with respect and really be patient-centered and patient-focused, I think makes the care that we provide to be better.
I often give an example of a very ill family member of mine who ultimately expired and they – I went to a hospital and I spoke with a neurosurgeon and it was almost my – what I remember from those difficult interactions, my family member would go on to expire in about thirty days but the things that I remember about that hospital stay were a nurse coming to take my uncles coat and hanging it. Someone coming in with a cup of coffee for my elderly uncle. That hand on the shoulder when difficult news was delivered. None of these things are quantifiable or show up in our evaluations. But you see the skill of the clinicians was expected. They are working in a quality hospital. The skill is expected. The humanity has so much to do with the care. And when learners can watch you do that, when I tell a learner if someone’s sick enough to be in that bed, it’s not just them, but their whole family. There’s an impact created around an illness. And we all need to contribute to the different facets.
There’s a lot of things that we can do to provide care and when we don’t have a cure, we can still provide care. And modeling that and being patient-centered and family-centered, I think is a great gift that we give to our learners that ultimately, they can pass on to us and our family when it’s our turn to be on those hospital beds. So, all those things resonate, to a large degree, with me.
Dr. Mullins: And that’s exactly what lines up with what I’ve read in the literature. Common theme, especially going back to some of the literature that was PhD written literature on education in the clinical setting and as recent as 2009 from an attending opinion survey, professionalism, 72% from Gonzolo 2009 ranked very important or somewhat important for learning. And the physician-patient communication skills 83%. Again, these aren’t things like you said that are quantifiable and I guess you can get into a discussion on how to quantify these things, but it is the subtlety and the nature of the disposition that is demonstrated by the physician and observed by the student. And only at the bedside is the implication in the literature.
Dr. Willig: I think that’s very interesting. And I know that in the – in future talks we going to get into the structure of bedside rounds and what can be done about it. So, let me take us to the end here. if I were to ask you, make the case, make the case based on the evidence why should bedside rounds occur?
Dr. Mullins: Well I think some of the biggest evidence comes from something that we touched on a little bit, haven’t exactly hammered down yet, is physical exam and clinical skills. And you have a number of studies from 1994 that tried to do a year long teaching lecture series for residents and interns, not only did not improve their own physical exam skills but before and after, were controlled by fourth year medical students showed no difference. Then you have another study in 2004, that did another intervention directly at the bedside teaching physical exam skills had a 66% increase in correct diagnosis.
Dr. Willig: Wow.
Dr. Mullins: So, that’s a pretty strong evidence compared to a year long lecture series, no increase, compared to fourth year medical students among house staff and then you have a study in 2004 where ten physicians completed forty five minute sessions directly at the bedside and had an increase in 66%. So, I think that’s some strong evidence. I think going to the bedside, it was one of our components listed as a definition performing a bedside physical exam maneuver. I think another thing is time. And I think a lot of physicians are time constrained, have time limitations and a number of people have tried to actually standardize the beside round and say we are going to monitor and assess adherence and you’re going to do these X components. And we could go through what all those components are and what factored into them but for the majority of studies, bedside rounding standardized compared to a control, so either a walk around or how ever else you are going to do it; was either the same or decreased time. So, some studies showed decreased time.
Funny enough, one study had actually showed a decrease in time, but it was perceived as taking longer by students. So, that’s I guess somewhat of a catch, but you can decrease time, you can ensure that you are performing physical exam skills in front of the students. Another big part that we will get into later is you can give direct feedback to students which is a component that is also key I think and was listed as one of the main advantages of bedside rounds and then as we talked about, I think the main advantage is the modeling of professionalism, patient-physician interaction, team building among your team and those intangibles that can only be experienced by a young medical student at the bedside.
Dr. Willig: Well Haddon, you’ve convinced me. I think that those are all very compelling reasons to pursue bedside rounds and we want to thank everybody for spending some time with us today. and hopefully, you can bring some of these strategies and some of this evidence to bear in your teaching at the bedside. Have a wonderful day. Thank you.
Dr. Mullins: Thank you.
Host: And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua180.mp3
- DoctorsHarrigan, Mark;Liptrap, Elizabeth
- Featured SpeakerMark Harrigan, MD | Elizabeth Liptrap, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4402
- Guest BioMark Harrigan, MD specializes in Endovascular Neurosurgery, Neurosurgery.
Learn more about Mark Harrigan, MD
Elizabeth Liptrap, MD grew up in Maryland and received a B.S. degree in Biochemistry and Molecular Biology from the University of Maryland, Baltimore County (UMBC). She received an M.D. degree from the University of Maryland School of Medicine in 2011. During medical school, she was an Alpha Omega Alpha Carolyn L. Kuckein Student Research Fellow and received awards for excellence in Biological Chemistry, Surgery and Neurosurgery.
Learn more about Elizabeth Liptrap, MD
Release Date: November 30, 2020
Expiration Date: November 30, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Presenters:
Elizabeth Liptrap, MD
Assistant Professor, Brain and Tumor Neurosurgery,
Mark Harrigan, MD
Professor, Endovascular Neurosurgery,
Dr. Liptrap and Harrigan have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie: Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to listen in as we discuss state-of-the-art management of carotid disease.
Joining me in this panel are Dr. Elizabeth Liptrap, she's a neuroendovascular and vascular neurosurgeon and an assistant professor, and Dr. Mark Harrigan, he's an endovascular neurosurgeon and a professor of neurosurgery, and they're both with UAB medicine. Doctors, thank you so much for joining us again. It's always a pleasure.
Dr. Liptrap, let's start with you. Just tell us a little bit about carotid stenosis and really anything you'd like to kind of set the stage. The studies that are performed and the workup of atherosclerotic disease, the prevalence, anything you think is important.
Dr Liptrap: So atherosclerotic disease is a very common problem in the United States and especially for us here in Alabama. What we are focusing on today is carotid atherosclerotic disease. So that's when you have a buildup of cholesterol plaques within the carotid bulb. And so you've got two carotid arteries, one on either side, that bring blood flow to your head.
And so when you have carotid disease and plaque buildup in those blood vessels, you can be at risk of stroke. And the stroke can come either because the plaques caused so much narrowing that you're not getting enough blood flow to your head or because small pieces of the plaque can break off and go to the brain or, if the lesion erodes, you can form clots on that plaque, and those can also go to the brain and cause strokes.
Here at UAB, we're a comprehensive center for treating carotid disease. And we work in a multidisciplinary fashion with our stroke neurologists, interventionalists, neurosurgeons and vascular surgeons to treat carotid disease. When we have a patient that we're worried about that may have carotid stenosis, there are a variety of tests that you can do. Besides the blood work, looking at their cholesterol levels and things like that, you can do a carotid ultrasound to look at the flow within the carotid artery. A CT angiogram of the neck can also give you an idea of the degree of narrowing and the plaque that's there in the carotid. And if the patient has had a recent stroke or recent transient ischemic attack, we'll do an MRI to look and see what lesions they have in the brain as a result of that.
Melanie: So as you're telling us about the studies, Dr. Liptrap, are these mostly symptomatic patients? For other providers that are seeing patients, are they asymptomatic? Is it found incidentally? How would we know?
Dr Liptrap: So both. There are patients that have carotid disease that is found incidentally because they haven't had any symptoms. But I think a lot of the patients that we see here at UAB are symptomatic and they've had either a transient ischemic attack or a stroke. And those patients get this full workup with imaging and blood studies.
Melanie: So as we've just talked about the studies, Dr. Harrigan, speak about the array of management strategies that you provide patients with carotid stenosis. Tell us a little bit about pharmacologic, and then we can ease our way into some of the interventional strategies.
Dr Harrigan: Okay. There's been a paradigm shift in the management of carotid stenosis over the last 10 years or so, this new paradigm called aggressive or intensive medical management. And that means very tight control of risk factors for atherosclerosis, management of hyperlipidemia, for example, management of diabetes. We'd like to target, hemoglobin A1c level of less than 7 consistently across the board. We like to optimize blood pressure control. American Heart Association guidelines for blood pressure control changed a couple of years ago, and now they want us to keep people consistently below 130 millimeters of mercury systolic. And then usually an anti-platelet agent, like low-dose aspirin. So this has the mix of pharmacologic and medical management that we use with all patients with carotid stenosis, symptomatic or asymptomatic.
Dr Liptrap: I would also add smoking cessation as well.
Dr Harrigan: Absolutely important.
Melanie: Well then, now tell us about some of the interventions and the exciting ways that you're treating people with atherosclerosis of the carotid artery. Dr. Harrigan, tell us about some of the exciting things you're doing.
Dr Harrigan: We have the privilege of being able to offer our patients the full range of interventions for management of chronic stenosis. So that includes carotid endarterectomy and carotid stenting. And that there's a new way to treat carotid stenosis on the scene now, it's called TCAR, transcarotid arterial revascularization. Should we go through each kind of intervention? Should we start with surgery? Dr. Liptrap, do you want to talk about carotid endarterectomy?
Dr Liptrap: So when we are considering a patient for an intervention, these are usually patients that have exhausted the medical management strategies and lifestyle changes or have recently suffered from a stroke or transient ischemic attacks. And so for patients who have greater than 70% stenosis and have recently had a TIA or a stroke, those are patients that we would consider for a carotid endarterectomy or carotid stenting or TCAR, which dr. Harrigan will talk about. And patients who are asymptomatic can be considered for intervention if they have also exhausted medical management and have greater than 60% stenosis.
Regarding carotid endarterectomy, we have multiple surgeons here who perform this procedure. What happens is the patient goes under general anesthesia. There are some indications for patients to have the procedure under conscious sedation, but typically we do our carotid endarterectomies under general anesthesia. An incision would be made in the neck on the side of the carotid stenosis and then we go down to the carotid artery where the plaque is, open the artery, take out the plaque and sew in a patch to expand the diameter of the artery. The patient then has a drain for a day or two, and usually goes up to our ICU and is monitored there for one to two days.
Melanie: Dr. Harrigan, why don't you expand on all of this for us and tell us about TCAR?
Dr Harrigan: So we'll talk briefly about stenting next and then TCAR, because TCAR is really a hybrid between open surgery and stenting. So stenting of the carotid artery has emerged as a viable alternative to open surgery. It has several very attractive features to it in comparison to surgery. So we can do carotid stenting through a needlestick puncture in the femoral artery. It's minimally invasive. In that way, the patient doesn't have to go asleep for general anesthesia. And it's more convenient for the patient because they're not recovering from a surgery, but rather just a procedure.
Now, TCAR is the new thing on the scene and it's very popular across the country. TCAR involves a clever technique for protecting against embolization during the actual procedure. So with traditional transfemoral artery carotid stenting, what we'll do is position a filter device up above or distal to the area of stenosis during the angioplasty and placement of the stent, so if any debris is released from the plaque during the procedure, it's caught by the filter device.
TCAR in contrast employs actually reversing flow in the carotid artery during the angioplasty and placement of the stent. And so the way TCAR works is we make an incision above the clavicle. We expose the common carotid artery and then directly insert a sheath, a plastic sheath in the common carotid artery. And then we connect that sheath to a tube that drains into the femoral vein. And so while we go up with the balloon for the angioplasty, we literally reverse flow in the carotid system. The blood comes down in a retrograde fashion through the carotid system, through the sheath, through the tubing into the femoral vein. We can protect against embolization of debris from the plaque during the placement of the balloon and the stent in that manner.
Now, the results from the trials of TCAR are extremely favorable. They seem to be even better possibly than the traditional transfemoral approach using a filter. And it's possible that we found the magic bullet that the optimal way to protect against embolization of debris during carotid stenting may be this reversal of flow strategy. The results we've had at UAB had been very favorable. We do the procedure in neurosurgery and the vascular surgeons do it well, and we've had good results.
Melanie: Absolutely fascinating. And Dr. Harrigan, tell us about any opportunities to participate in clinical trials that you'd like other providers to know about.
Dr Harrigan: Absolutely. So we are enrolling patients in a major NIH sponsored trial of patients with asymptomatic carotid stenosis. So any patient with asymptomatic carotid stenosis of at least 70% can enroll. And it's a major effort. This is a huge undertaking by the NIH.
People that sign up for the trial, all subjects, are treated with this aggressive medical management paradigm with aggressive control of risk factors for atherosclerosis, as we talked about earlier. And then, patients can be randomly assigned to either having revascularization or not having revascularization. And we can use carotid surgery for patients in CREST-2. We can use carotid stenting in CREST-2. And we're about two thirds of the way through the trial on a national scale. We plan 2,400 subjects. Nationwide, we're about 1,800 subjects into it. We've had good results here at UAB. We've had about 16 subjects enrolled at UAB. They've had good results across the board, and we are actively looking for further subjects, recruitment. So if anybody has any patients with asymptomatic stenosis, please let us know.
Melanie: Dr. Liptrap, I want to give you each a chance as we wrap up for some final thoughts. Do you feel this development of some of these effective endovascular treatments for carotid stenosis has really revolutionized the management? As you're telling us about game-changers, I'd like you to reiterate when you feel it's important to refer to the specialists at UAB Medicine.
Dr Liptrap: So we're happy to see any patients that you may have with a carotid disease. And regarding the new techniques and current techniques that we have, it certainly gives greater options and safer options for patients with this disease. Patients with carotid stenosis who have had a stroke are at continued risk of stroke if it's not treated. And so for patients who cannot undergo a carotid endarterectomy for whatever reason and need to have carotid stenting, TCAR as Dr. Harrigan mentioned has really revolutionized that treatment, because a big issue with carotid stenting obviously is having the emboli break off during the procedure. And having new ways to treat patients that are safer and prevent any complications, obviously, that's always a good thing.
Melanie: And Dr. Harrigan, last word to you. As we're talking about the surgically and medically managed patients with carotid artery disease, what would you like other providers to take away from this episode? What do you feel are some of the most important points we've covered today?
Dr Harrigan: We view carotid stenosis management as a multidisciplinary process. So we in vascular neurosurgery here at UAB work very closely with the UAB Stroke Service in handling patients who have symptomatic disease as well as asymptomatic disease. So we take this multidisciplinary approach to carotid disease very seriously. And we take pride in being able to offer the full spectrum, including medical management to patients with chronic stenosis.
Melanie: Such an interesting topic. Doctors, thank you again for joining us. You are great guests as always. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB MedCast to refer your patient or for more information on resources available at UAB Medicine, please visit our website at uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
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