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The Teaching Physician
for those who teach students and residents in family practice Volume 2, Issue 4
October 2003
POEMs for the Teaching Physician
Intermittent Steroid Prevents Atopic
twice a week to the usually affected areas, (whichever they didn’t get the first time).
Dermatitis Relapse
along with emollient treatment, decreases A crossover trial increases the power of a study, making it possible to detect a statis- Clinical question: Can the intermittent use
tically significant difference in a small of a potent topical steroid prevent relapse Source article: Berth-Jones J, Damstra R, Golsch S, et al. Twice weekly fluticasone propionate added to emollient maintenance treatment to reduce risk of re- Setting: Outpatient (specialty)
lapse in atopic dermatitis: randomised, double blind, parallel group study. BMJ 2003;326:1367-70.
BMs per week; P=.001). Conversely, the Study design: Randomized controlled trial
colonic transit time decreased in the colchi- cine group from 63.1 hours to 29.1 hours.
Colchicine Effective for Idiopathic
Chronic Constipation
Synopsis: Two approaches are used after
in abdominal pain while taking colchicine, Clinical question: Is colchicine an effec-
with a potent topical steroid: (1) continue (borderline clinical significance), which steroid treatment on a regular basis using a decreased by the 4th week of active treat- lower potency steroid, or (2) switch to a Setting: Outpatient (specialty)
steroid-free emollient. The investigators ofthis project identified 376 adults with mod- Bottom line: Colchicine is an effective
Study design: Cross-over trial (random-
erate to severe atopic dermatitis who were treatment for idiopathic chronic constipa- experiencing a flare-up. All the patients tion in women. It causes a small increase received acute treatment with fluticasone Synopsis: Chronic constipation is a frus-
propionate cream or ointment, a potent topi- patients from requesting to continue treat- trating condition to treat, and a cause is of- cal steroid, once or twice daily for 4 weeks.
ment at study’s end. It is not clear whether ten not found. Colchicine has a good safety Patients whose dermatitis was brought un- the results of this small trial generalize to record in the treatment of gout and other diseases, but diarrhea is a prominent side emollient treatment twice daily. Half the effect. Hoping to turn lemons into lemon- patients received a placebo, and the other Source article: Verne GN, Davis RH, Robinson ME, ade, these gastroenterologists decided to et al. Treatment of chronic constipation with colchi- test colchicine as a treatment for idiopathic cine: randomized, double-blind, placebo-controlled therapy, with instructions for both groups crossover trial. Am J Gastroenterol 2003;98:1112-6.
chronic constipation on a group of 16 pa- to apply the product on healed sites and any tients. All had suffered from constipation newly occurring sites, twice a week in the for at least 10 years; had not responded to Mark Ebell, MD, MS, Michigan State
University, Editor
curred in 29% of patients using the steroid and had no identified cause for their symp- and 61% of placebo-treated patients (P toms after an extensive evaluation. All but 3.1). There was a difference between cream 25 to 89 years. This was a crossover trial, and ointment preparations of fluticasone, with relapses occurring twice as often in orally 3 times daily throughout the study baseline period, 4 weeks of active drug(colchicine 0.6 mg by mouth 3 times daily) Bottom line: After controlling symptoms
or placebo, 2-week washout period, and fi- of atopic dermatitis with regular use of a topical steroid, applying the same steroid Information Technology and Teaching
faster on the Tungsten C than on equiva-lent Pocket PC devices.
in the Office
Choosing a Handheld Computer for Teaching
and Practicing Medicine
and slower processor speeds. However, forthe majority of Palm OS programs, this is By Richard Usatine, MD, University of Texas Health Science Center at San Antonio; and Darrick Nelson, MD, Corpus Christi Family Practice Residency Program with slots to add memory. Memory cardscome in a number of forms now, but they all work in a similar fashion to allow more tions and offer them free to others to be data and program storage on your PDA.
nation for this is that it is easier to write [PDAs]) continue to proliferate. PDAs now programs for Palm OS than for Pocket PC.
fun addition to the new PDAs. You can use occupy pockets opposite the stethoscope in the white coats of preceptors, students, and medical programs are now available in both ings in your EMR or print the photo out for programs, ePocrates, was only available for the Treo by Handspring. If you are feeling give their learners PDAs with appropriate the Palm and was free. Now, ePocrates has the effects of aging eyes, you will probably want a color backlit screen regardless of the ePocrates Rx Pro that is no longer free. This their preceptors in the use of PDAs to prac- tice medicine. As a preceptor, it is time to PC as well as the Palm, but the free ver- there are great Web sites that will help you buy a PDA if you don’t have one. If you review the prices and features. We suggest have an old one, read on to find out what benefits are available in the new PDAs on sites for Palm OS devices. Hewlett-Packard, the market. Whatever your level of exper- than the same application written for Pocket tise is with these new peripheral brains, all PC devices. Some great Web sites to use to of us can benefit from finding ways to ex- tage of having a longer battery life. One gather information for your purchase include: has to regularly charge both types of de- quality of medicine we teach and practice.
vices, because it is possible to lose all your files and information if the battery runs out Which Operating System Is for
You—Pocket PC or Palm OS?
Pocket PC:
www.hp.com/country/us/eng/prodserv/handheld.htmlwww.dell.com/ PC account for the vast majority of the PDA their internal memory capability. This is market. Devices using the Palm OS are the Comparisons of Hardware:
most popular in the medical field. As the www.pdamd.com/vertical/tutorials/buyersguide.xmlhttp://reviews.cnet.com/Handhelds/2001-3127_7- fordable, their use has risen. However, the cessor speed of 400 mHz. This is an exact www.pdamd.com/vertical/tutorials/buyersguide.xml majority of medical software is written for match with regards to processor speed and internal memory with the HP iPAQ h2215.
Comparisons of Software:
available. This is especially true for the free based medicine InfoRetriever program, run mission. That is what people are using whenthey are beaming each other. If you havenot been beamed yet, you have something Comparison of Palm OS and Pocket PC Devices Features
Palm OS Devices
Pocket PC Devices
someone’s address and phone number with- out having to write or type. In the next edi- tion, we will cover how to go wireless with Bluetooth and Wi-Fi. Both formats will help Richard Usatine, MD, University of
Texas Health Science Center at San
Antonio, Editor
Clinical Guidelines That Can Improve Your Care
No Excuses—Lowering (Really Lowering) Blood
Pressure on Our Patients With Diabetes
By Caryl Heaton, DO; UMDNJ-Robert Wood Johnson Medical School By some estimates, there are about 16 mil- diovascular endpoints. The basis for the rec- ommendation for systolic pressure is less clear, primarily because that was not spe- cifically looked at, as it was in the HOT large group of patients who have suddenly “substantial” decrease in mortality and end- gained a diagnosis of “prehypertension.” points if the systolic BP was lowered.
UKPDS—United Kingdom Prospective DiabetesStudy Therefore, the target was put at 135 (the ADA guideline is 130, but the evidence here * Number needed to treat for benefit is very sensitive even the basic goals of blood pressure (BP) Recommendation 3: Thiazide diuret-
to the starting point from which treatment begins. In ics or ACE inhibitors can be used as first-
the UKPDS, the mean starting blood pressure was 160/ have wondered if the difficulty in achiev- line agents for blood pressure control in
94 mm Hg. Thus, it should be noted that the numbersneeded to treat (NNT) for benefit for this study may ing “ultra-low” blood pressure was worth most patients with diabetes. Although the
be smaller than what would be found in current the extra effort. The American Diabetes As- practice, where most patients are expected to have lower initial blood pressure levels.
ultra-low BP since early 2002 but without a clear systematic review to back it up. We hibitors more effectively decrease the rate of cardiovascular events (including mortal- Recommendation 4: Further studies
not pushing the blood pressure down—way are warranted on the relative contribu-
tions of glucose control and blood pres-
sure control to clinical outcomes such as
presented a guideline1 that has critically re- beta blockers. There is something intrinsi- microvascular and macrovascular com-
viewed the best literature that we have.
cally protective in these medications in ad- plications. Clearly the challenge for phy-
Recommendation 1: Blood pressure con-
dition to their ability to lower the blood sicians is to aggressively lower both the trol must be a priority in the manage-
pressure. “Taken as a whole, the evidence blood sugar and the BP. This guideline give ment of persons with hypertension and
presented here is most convincing for the us a reason to make the extra effort for our type 2 diabetes. Hypertension is a signifi-
use of diuretics, ACE inhibitors, and pos- cant risk factor for macrovascular disease sibly angiotensin-receptor blockers, while (coronary artery disease, cerebrovascular disease, and peripheral vascular disease).
“The clinical trials of blood pressure con- cium-channel blockers are unclear.” The Snow V, Weiss KB, Mottur-Pilson C; Clinical trol in diabetes have shown a consistent and Efficacy Assessment Subcommittee of the Ameri- dramatic effect in preventing clinical out- evidence that diuretics were more benefi- can College of Physicians. The evidence base fortight blood pressure control in the management comes.” In both the Diabetes Control and cial in self-reported black patients for re- of type 2 diabetes mellitus. Ann Intern Med ducing cardiovascular endpoints and stroke 2003;138(7):587-92. www.annals.org/cgi/con- and that diabetic patients with nephropa- Hansson L, Zanchetti A, Carruthers SG, et al. Ef- fects of intensive blood-pressure lowering and to decrease microvascular outcomes but not ARBs. Calcium channel blockers are “best low-dose aspirin in patients with hypertension: reserved as second- or third-line agents in principal results of the hypertension pptimal treat-ment (HOT) randomized trial. HOT Study Group.
Recommendation 2: Clinicians should
patients with diabetes.” Finally, the authors aim for a target BP of no more than 135/
admonish that these large trials repeated 80 for their patients with diabetes. In the
show that many, if not most, patients with diabetes will require two or more medica- Caryl Heaton, DO, UMDNJ-Robert
Study,2 a four-point difference in diastolic tions to attain the blood pressure target.
Wood Johnson Medical School, Editor
BP produced a 50% decrease in risk for car- Teaching Points—A 2-minute Mini-lecture
MS3: SLE? Rheumatoid arthritis? Can’t
think of anything.
Dr T: One of the problems with using cat-
By Carolyn Thiedke, MD, Medical University of South Carolina egories to generate a differential diagnosisis that some conditions don’t fit neatly into Editor’s Note: The process of the 2-minute MS3: Not really.
a category, because we don’t understand the Mini-lecture is to get a commitment, probe Dr T: OK, look that one up and any simi-
for supporting evidence, reinforce what was lar conditions, and we can talk about that right, correct any mistakes, and teach gen- MS3: I had it when I did Surgery.
eral rules. In this scenario, Dr Carolyn those. You said that her partner didn’t no- Thiedke (Dr T) works with a third-year stu- tice any snoring or apnea during her sleep.
MS3: Fibromyalgia, too. Some doctors I’ve
dent (MS3) who has seen a patient who is Let’s assume that the partner didn’t notice any jerky movements of the patient as she don’t. But I don’t think she has it, because is falling asleep, and the patient didn’t feel MS3: Ms Gilliard is a 35-year-old woman
Dr T: I think fibromyalgia and chronic fa-
who is here because she is feeling tired for in her legs. When we go back in, I’ll ask a the past couple of months. Her mood is not couple of questions to verify that. So, we partly because I can’t cure them. Some pa- really depressed; it’s more just tired and don’t think it’s depression or a sleep disor- tients find it very helpful, though, to have a irritable. She still enjoys her work and fam- clear diagnosis, whether or not the treat- ily. And her appetite is OK. She has trouble falling asleep, and she wants a sleeping pill.
MS3: Occlusive, like with ischemia . . .that
She feels that if she can just get a good generative—I can’t think of anything there.
night’s sleep she will be back to normal.
Emotion equals . . . you mentioned depres- might be angina equivalent, but she is kind She’s tried some over-the-counter remedies, of young for heart disease. And it’s not including melatonin, but they don’t really MS3: Could be, but I can’t think of where.
help much. Her partner hasn’t noticed any Dr T: It may not be occlusive, but CHF is
Dr T: Boy, feeling tired is one of those pre-
Dr T: Right! But no jaundice, no abdomi-
MS3: Oh, I suppose she could have had a
senting concerns that has a vast differen- nal pain-nothing to suggest pancreatic can- tial! Let’s run through the differential. It cer or biliary obstruction resulting from the cancer. No other clues to cancer. I suppose Dr T: Absolutely! And the last category?
sion as a cause. You mentioned what? Poor she could have a leukemia or lymphoma.
MS3: Metabolic/nutritional. Oh! Diabetes.
MS3: We could check a CBC.
She had considered that herself. But she has MS3: Yes, and appetite, sleep . . .
Dr T: Great idea. Trauma? But no history
no increased thirst, hunger. And not urinat- Dr T: That’s good. There’s also concentra-
of trauma. Infection? Toxin? This category tion, guilt, helplessness/hopelessness, psy- chomotor retardation, and suicidal ideation.
MS3: Caffeine? I asked about that. She
Dr T: Good. Other endocrine conditions?
MS3: OK. No, I didn’t ask directly about
drinks three or four cups of coffee in the morning but no soda, tea, or coffee later in MS3: Low thyroid function!
Dr T: I think that’s OK, in terms of diag-
the day. She doesn’t take any over-the- Dr T: Right! OK, so I’m sure we could
nosis of at least major depressive disorder.
come up with more, if we kept on with it, There are two criteria in that list, and you Dr T: Good. You mentioned melatonin, so
through an organized differential diagno- depression, you have to have at least one edies—things that could cause fatigue or sis on at least one patient today. This was a that she might have tried to help get some MS3: Poor mood and suicide?
sleep. What’s another big one that disrupts for creating a differential can help bring in Dr T: Poor mood, right! And the second
sleep and that people often try to help fall memory, without having to turn to a text- MS3: Umm . . .
Dr T: Sorry, it’s hard to answer a “Guess
what I’m thinking of” type of question. I don’t fit into neat categories. Great job— MS3: There’s sleep apnea?
MS3: Oh, of course. Right.
all of these diagnostic hypotheses. Let’s go Dr T: And the evidence for that would be?
Dr T: OK, keep going with the differential
back in and see her together, and I’m go- MS3: Someone hears her snore heavily and
ing to repeat some of the highlights around then not breathe briefly. But I would also MS3: OK, toxin. Then there’s the other I,
the differential and fill in the one or two expect her to be obese, and she’s not.
Dr T: OK. Good point about obesity. And you
polymyalgia rheumatica. I think of that di- found out about snoring and apnea? Outstand- agnosis in someone over the age of 50 or so.
Alec Chessman, MD, Medical University
ing job! Ever hear of restless legs syndrome? Dr T: Right, me too.
of South Carolina, Editor
Excerpted from “For the Office-based Teacher of Family Medicine”
Providing Difficult Feedback:
TIPS for the Problem Learner
By Jamee H. Lucas, MD and James R. Stallworth, MD, Palmetto Richland Family Prac-
tice Residency, Columbia, SC
Providing effective feedback to learners is of knowledge, or perform poorly in discus- The next step is “identify the category an important aspect of clinical teaching. In of difficulty experienced by the learner.” the office setting, giving feedback to learn- continued cognitive difficulties may have Using descriptions of the different types of ers is challenging because the time devoted to the learner often occurs in brief encoun- preceptor can identify the category of dif- ters outside the exam room. Preceptors typi- difficulty structuring their experiences in ficulty that the learner is having. This step is important since planning a strategy to clinical facts and pearls and devote less time to understanding the clinical thinking pat- ganization by arriving late at the clinic and/ assessment of the learner’s difficulty.
terns and learning styles of the student.1 rized the learner’s problem, feedback is best praise the learner for items well done, point provided using the concept of “perception out areas of weakness, and give direction not interact well with other people, includ- versus reality.” In this concept, the precep- ing patients, staff, or faculty. They may have tor describes the perception that he/she has monly used strategy is the “sandwich” tech- either a mild disorder characterized by shy- of the learner’s behavior but acknowledges nique, where positive feedback is given at ness or poor social skills or a more severe that the learner may have a different view disorder in which they are manipulative or about his/her actions. For example, if the negative feedback is given in the middle.2 preceptor observes the learner rebuking the Other aspects of effective feedback include the preceptor points out the inappropriate- that the learner understands the feedback, ness of the learner’s comments to the pa- and focusing on specific behaviors that can tient but also allows the learner to state his/ adapted this model to include more infor- aging the learner to express his/her perspec- form significantly below their potential due tive on the situation, the preceptor may be viewed as an ally, making the learner less Vaughn et al that the term problem learner proach uses the mnemonic TIPS (Table 1).
likely to be defensive and more likely to has a negative connotation, but we use this term to be consistent with other discussion in difficulty is to “type and specify the in- important that the learner also understands in the literature.4) It is especially difficult effective behaviors” and redirect these be- for clinical teachers to give feedback and demonstrate positive attitudes and actions direction to these learners. The S-T-P model in future encounters. The use of humor or (Children’s Hospital Medical Center, Cin- to read more” or “Your interactions with sharing personal stories of learning chal- patients need work,” leaves the learner feel- ing insecure and unsure about what he/she structural and/or interpersonal difficulties.4 sense of trust that is necessary to expose more detailed description about ineffective the nuances of many of these problems.
trouble handling important events, such as behaviors, the teacher gives the learner a new phases of their education, illness or must be a “strategy for treatment/follow- deaths in the family, and difficulties in their improve. An example of specifying and re- marriage or other relationships. This diffi- directing an ineffective behavior is: “Re- learners should discuss their concerns about culty in adjusting may lead to affective re- the learner’s difficulties with the clerkship actions that ultimately manifest as difficul- abuse made me feel that you do not under- stand how difficult it is to overcome sub- preceptor’s input, the clerkship or residency program director should develop a strategy ally have difficulty in written or oral com- are there to discuss a patient’s substance to help the problem learner deal with the munication, spatial-perception ability, or difficulty in the current rotation as well as integration of material. They may fall be- future ones. For medical students, an ap- hind in workload, demonstrate a poor fund propriate school official such as the dean ferral to an appropriate specialist should be sistance to these learners. Yet, helping a learner in difficulty with early and caring treat the learner him/herself. Learners with intervention is one of the most rewarding cognitive disorders should undergo evalu- aspects of clinical teaching. By using TIPS, ation for a learning disability. They often a preceptor can mirror the diagnostic ap- benefit from test-taking and reading-skill Type and specify the ineffective behaviors
improvement courses. Learners with struc- Identify the category of difficulty experienced by the
tural disorders may benefit from organiza- treatment plan to help the patient. The ba- Perception versus reality feedback
mentoring. Learners with interpersonal dis- sic skill set for using this strategy is present orders are often the most difficult to deal in all clinicians. The TIPS mnemonic just Strategies for treatment and follow-up
with since many cases may involve psychi- atric illnesses such as personality disorders.
As indicated, psychiatric referral should be Corresponding Author: Address correspondence to DrLucas, Palmetto Richland Family Practice Residency, 3209 Colonial Drive, Columbia, SC 29203. 803- of students should also contribute to the 434-6563. Fax: 803-434-7529. jamee.lucas@ development of the plan. For learners with severe difficulties, it may be necessary to ers overcome their difficulties often is a consult experts to formulate specific parts gradual process lasting more than one ro- of the plan. When appropriate, the learner tation, so close follow-up is needed. The Lucas J, Baxley E, Witherspoon P. Walking the may also participate in the planning pro- medical school official or residency pro- balance BEAM: the art and science of becoming gram director should maintain contact with the learner, monitor the learner’s progress does not follow the recommended steps for throughout different clinical rotations, de- teacher, second edition. Salt Lake City: Whitman Ende J. Feedback in clinical medical education.
JAMA 1983;250:777-81.
ally require psychological assessment and Vaughn LM, Baker RC, DeWitt TG. The prob- daunting experience, and it is often chal- lem learner. Teach Learn Med 1998;10:217-22.
tion. To obtain an objective assessment, re- lenging to give effective feedback and as- The Teaching Physician is published by the Society of POEMs for the Teaching Family Physician
Teachers of Family Medicine, 11400 Tomahawk Creek Parkway, Suite 540, Leawood, KS 66211. 800-274-2237,ext. 5420. Fax: 913-906-6096. [email protected] Information Technology and Teaching in the Office
Richard Usatine, MD—[email protected] Managing publisher: Traci S. Nolte Clinical Guidelines That Can Improve Your Care
The Teaching Physician is published electronically on a quarterly basis (July, October, January, and April). Tosubmit articles, ideas, or comments regarding The Teaching Points—A 2-minute Mini-lecture
Teaching Physician, contact the appropriate editor: Copyright 2003 by the Society of Teachers of Family Medicine

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