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February 2006 E-Newsletter

Winter 2006 IMpact PDF

• Taking a Proactive Approach to Learning on Your Ambulatory Medicine Rotation
• Internal Medicine Interest Group of the Month: Uniformed Services University of the Health Sciences
• Review: Paired Quantitative Blood Cultures Most Accurately Detect Intravascular Device-related Bloodstream Infection
• Announcing a New Activity for Medical Students at the Herbert S. Waxman Learning Center During Annual Session 2006 in Philadelphia
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

Taking a Proactive Approach to Learning on Your Ambulatory Medicine Rotation

Ambulatory medicine is the backbone of our healthcare system. With the majority of healthcare being provided in the outpatient setting, your ambulatory rotations will provide the opportunity to see a variety of disease processes and learn the practical management of chronic illness. Additionally, you will begin to understand the ways in which culture and socioeconomic factors influence healthcare.

Unfortunately, ambulatory medicine rotations in any specialty can quickly turn into shadowing experiences, if you let them. Following these suggestions for a proactive approach to your ambulatory rotations will help you become more involved in the process and take responsibility for your own learning.

Be Prepared for Clinic

Chances are you will be working in a variety of clinics with many different faculty; on your first day of a new clinic, try to arrive at least ten minutes early. This will give you an opportunity to have a tour of the clinic and get acquainted with the logistics of the schedule. Make a point to introduce yourself to the nurses and other clinic staff; they will be able to point you in the right direction as you try to accomplish the day’s tasks with efficiency. Introduce yourself to your staff and/or resident physician and ask what they expect of you.1 Most experienced faculty will have relatively straightforward expectations in mind. An awareness of these expectations early in your clinic experience will improve your learning and your evaluations.

Ask for Independence

This one is pretty straightforward. Staff physicians always have something else they could be doing, so even if only one patient is waiting to be seen, ask if you can go see them on your own first. Most patients will be aware of your presence prior to your entering the room and will have made it known if they do not want to see a student. Often, patients at teaching institutions are familiar with the concept of students-in-training and will be happy to help you with your education. Be sure to thank each patient for working with you.

Show an Interest in the Specialty or Subspecialty

Try to read about a common disease you might encounter in a clinic before showing up. This will give you a foundation upon which you can base the history and physical examination of many patients in that clinic. If you are unsure of important history and physical exam components, visit the Physicians Information and Education Resource. This website has quick and easy tables with key history and physical exam components for most diseases encountered in the ambulatory clinic setting.

While you are in clinic, you may have to wait to staff a patient with your supervising physician. During the down time, take a moment to look up the condition you believe your patient may have. The additional knowledge you are able to acquire in just five spare minutes will improve the assessment and plan you are able to present to your supervising physician.

Be Aware of the Clinic Schedule

This can be one of the more difficult things to learn in an ambulatory rotation, in fact, many experienced physicians still have a hard time staying on schedule. Make a point to be aware of when each patient’s clinic appointment was supposed to start and when the patient arrived, in addition to how long for which the appointment was scheduled.

Attempt to alleviate congestion in the clinic schedule by going to see the patient on your own. Particularly with new patients, you can save your supervising physician a considerable amount of time by getting a complete history and review of systems before they enter the room.

Focus on the Interval History

In most ambulatory clinics, and particularly in internal medicine clinics, faculty physicians have well-established relationships with patients. You may never know as much about the patient as the staff physician but you can still contribute relevant information.

The interval history is the key to contributing new information to the medical record. You may have to remind your patient repeatedly to tell you what has gone on since their last visit, but this is really the most important information you need to know. Start by asking the patient what they would like to talk about and what they are most concerned about. For a patient with many medical problems, a good way to get at the pertinent interval history is to look at the assessment and plan from the previous visit. Going through the plan point by point with the patient will help you stick to the important issues. This technique will also give you a new appreciation for good documentation and a format to follow for your own clinic notes.

Make sure to ask which medications they are taking and how they are taking them. Patients frequently misunderstand the instructions given for taking their medications but may be afraid to bring this confusion to the attention of the physician. You are in a position to listen to your patients’ questions and try to clarify the confusion for them as well as bring the issue to the attention of the attending.

A Good Presentation Speaks Volumes

Usually you will only have a few minutes to synthesize a presentation, so have a format in mind and try to use the same format in every clinic. You should be able to present a patient in five to seven minutes. If you are interrupted it may take longer but a good format should minimize questions during the presentation. A “SOAP” format will work well for your presentations in most clinics, and your staff physician will be familiar with it. “SOAP” stands for subjective observations, objective observations, assessment and plan. Include pertinent history since the last visit, pertinent review of systems and positive findings on the physical exam. Include negative findings only if they are relevant to the patient’s chief complaint. For example, it is unnecessary to report the details of a normal abdominal exam in a patient who is presenting to pulmonary clinic for a follow-up lung nodule. On the other hand, in a new patient, perform a complete physical exam, as it may be the most thorough physical the patient has had in years.

During your first semester of clinical clerkships, you may get away with a “SO” presentation, but by the second semester, you should attempt to include an assessment and plan in your patient presentations. It is acceptable to be wrong about your assessment and plan, it is acceptable to suggest unnecessary tests; your staff physician understands that you are learning. Do not worry about sounding unfamiliar with the disease; you may make a valid suggestion that the staff physician had not considered.

Request Frequent Feedback

This is particularly important if you will be initiating an evaluation. To prevent surprises, ask for suggestions for improvement about half-way through your clinic experience with a preceptor. Always thank your preceptor for taking the time to explain what you did well and what you can improve. So be proactive, open to suggestions and remember this is your education—if you sit back it will pass you by.

Heather Strah
Central Region Representative, Council of Student Members
University of Iowa College of Medicine, 2007
E-mail: heather-strah@uiowa.edu

References

1. Alper, E. et.al. 2004. “Primer to the Internal Medicine Clerkship: A Guide Produced by the Clerkship Directors in Internal Medicine.” Pp. 14-17. © Clerkship Directors in Internal Medicine. Available: www.im.org/cdim.

Internal Medicine Interest Group of the Month: Uniformed Services University of the Health Sciences

The Internal Medicine Interest Group at the Uniformed Services University of the Health Sciences (USUHS), named Club Med, has continued its tradition of offering activities related to current topics in medicine and is pleased with its high level of student participation. This year several of our panel discussions focused on the relevance of medicine in humanitarian operations abroad and in the United States in addition to internal medicine’s essential role in supporting our troops that are in harm’s way. Other panel discussions have explored opportunities in infectious diseases and how residents perceive their training. Guest speakers have described and reflected on their experiences that have ranged from practicing in a Department of Defense facility, deploying to the Middle East, and providing aid to the victims of hurricane Katrina and last year’s tsunami.

Club Med sponsors at least two activities for students each month. Panel discussions are open to everyone, and we have had strong attendance from both first and second year students (anywhere from 50 to 120 students per meeting). The panel format facilitates interaction between guest physicians and students. Our goal has been to provide panel discussions on a variety of topics so that students are exposed to the many career paths that internal medicine offers. Both generalists and subspecialists have shared their experiences and fielded questions from our student body.

Our workshops and morning report activities are limited to a certain number of participants because of our desire to provide hands-on instruction in a variety of topics germane to internal medicine physicians. One of our most successful workshops this year was about how to write a case report. Several of the students applied what they learned and presented posters at the ACP Navy Chapter Scientific Meeting in San Diego or the ACP Washington, DC, Chapter Scientific Meeting, while other students will present posters at the upcoming ACP Air Force Chapter Meeting in San Antonio. Upcoming workshop topics include, “How to Approach Monoarticular Arthritis”, “The Ins and Outs of Renal Failure”, “The Undilated Eye Exam”, and “ECG Interpretation Vignettes”.

In November 2005 many of our Club Med members participated in the activities of the ACP DC Chapter Scientific Meeting. USUHS hosted many events for students, and one of the most popular of these was the breakfast with residents. The breakfast provided a relaxing environment to talk about what lies ahead for students when they become residents in medicine. It was also a great local opportunity for students to experience presenting their research posters to judges.

We are also planning the third DC-area ACP medical student “Steps to Success” meeting. This meeting is a joint collaboration of faculty and students from USUHS, Georgetown University, George Washington University, and Howard University. There will be a mentoring breakfast, workshops, a medical jeopardy session, and multiple panel discussions. Last year over 100 faculty and students participated in this event.

Please join us at any of our future events if you can. The Club Med web site contains information about upcoming topics and locations. Feel free to check it out.

Wendy Gordon, Alison Smith, and Shane Biedermann
Club Med Student Leaders, Uniformed Services University of the Health Sciences

Review: Paired Quantitative Blood Cultures Most Accurately Detect Intravascular Device–related Bloodstream Infection

ACP Journal Club. 2005 Nov-Dec;143:77.
Safdar N, Fine JP, Maki DG. Meta-analysis: methods for diagnosing intravascular device-related bloodstream infection. Ann Intern Med. 2005;142:451-66.

Question

Which tests are most accurate for diagnosing intravascular device (IVD)–related bloodstream infection?

Methods

Data sources: MEDLINE (1966 to July 2004), Current Contents (1993 to July 2004), the Cochrane Library, conference abstracts, and bibliographies of relevant reviews.

Study selection and assessment: English-language studies of diagnostic tests for IVD-related bloodstream infection compared with a reference standard that provided data for calculating sensitivity and specificity. Studies assessing the utility of blood cultures drawn from venous or arterial catheters to test for true bacteremia as opposed to contamination, and studies of IVD colonization rather than IVD-related bloodstream infection were excluded. Quality assessment of individual studies included design, participant recruitment method, blinding of test interpretation, and presence of biases.

Outcomes: Sensitivity, specificity, likelihood ratios, and the equally weighted least-squares Q* statistic (corresponds to the upper left-most point on the summary receiver-operating characteristic curve, where sensitivity equals specificity).

Main results

51 studies on 8 frequently used diagnostic tests were included: qualitative catheter segment culture, semiquantitative catheter segment culture, quantitative catheter segment culture, IVD-drawn qualitative blood culture, IVD-drawn quantitative blood culture, paired quantitative peripheral and IVD-drawn blood cultures, acridine orange leukocyte cytospin testing of IVD-drawn blood, and differential time to positivity of concomitant qualitative IVD-drawn and peripheral blood cultures. Diagnostic performances of each test are in the Table. The most accurate tests were the paired quantitative blood cultures, IVD-drawn quantitative blood culture, and the acridine orange leukocyte cytospin test.

Conclusions

Paired quantitative peripheral and IVD-drawn blood cultures have the best diagnostic performance for detecting intravascular device–related bloodstream infection. Most other diagnostic tests have acceptable sensitivity and specificity. Qualitative catheter segment culture has low specificity.

Source of funding: Oscar Rennebohm Foundation.

For correspondence: Dr. D.G. Maki, University of Wisconsin Hospital and Clinics, Madison, WI, USA. E-mail dgmaki@facstaff.wisc.edu.

Diagnostic characteristics of tests for intravascular device (IVD)–related bloodstream infection*

*Diagnostic terms defined in Glossary; LRs calculated from data in article. Overall sensitivity and specificity were estimated using a random-effects model.

Commentary

Bacteremia remains one of the most serious complications related to the use of intravascular catheters. Determining which patients' catheters are the source of their bacteremia is challenging without the removal of the device. As a result, 80% of catheters removed for suspicion of infection are found not to be the source and thus were removed unnecessarily (1, 2). For this reason, attention has been focused on methods to diagnose catheter-related bloodstream infection (CR-BSI) without catheter removal. This is especially important for patients with long-term catheters who have poor vascular access.

Several methods exist to detect CR-BSI. In this meta-analysis, Safdar and colleagues have presented the best tests. They showed that paired quantitative blood cultures are the most accurate method to diagnosis CR-BSI in situ for long-term catheters. However, most other methods studied showed an acceptable sensitivity and specificity (> 75%) and high negative predictive value (up to 99% in most studies). In addition, the positive predictive value of all tests increased with a high pretest probability of having a CR-BSI. Not all studies in the meta-analysis excluded patients with low pretest probability of CR-BSI, thus the performance of some tests may be underestimated when applied only to patients with suspected CR-BSI.

The paired quantitative blood culture is not a test without drawbacks. Some organisms do not survive the lysis-centrifugation process (e.g., Streptococcus pneumoniae). It is also labor-intensive at the laboratory level, requiring several manipulations, and therefore the potential exists for contamination. It is expensive and not widely used in hospitals with heavy workloads and few technical staff members.

A practical approach to diagnosing CR-BSI in situ while taking advantage of the differential in organism load between the catheter and peripheral blood is the differential time to positivity. Most automated blood culture systems continuously monitor growth and now report positive readings every 10 to 20 minutes. If the differential time between the blood drawn through the catheter and the blood drawn peripherally is > 2 hours for each to turn positive, it is a sign that the organism load is higher in the catheter and that the catheter is probably the source of bacteremia. Using this method instead of quantitative cultures adds no additional laboratory cost, has similar sensitivity albeit lower specificity, and uses a blood culture system that is already in place at most centers.

Naomi P. O’Grady, MD National Institutes of Health Bethesda, Maryland, USA

References

1. Ryan JA Jr., Abel RM, Abbott WM, et al. Catheter complications in total parenteral nutrition. A prospective study of 200 consecutive patients. N Engl J Med. 1974;290:757-61.

2. Brun-Buisson C, Abrouk F, Legrand P, et al. Diagnosis of central venous catheter-related sepsis. Critical level of quantitative tip cultures. Arch Intern Med. 1987;147:873-7.

Announcing a New Activity for Medical Students at the Herbert S. Waxman Learning Center During Annual Session 2006 in Philadelphia

Students can prepare for the USMLE Step 2 Clinical Skills Examination by using the Learning Center’s professional teaching patients and receive feedback on their performance from expert faculty. To find out about Annual Session 2006 and to register, go here. All Learning Center activities are free to Annual Session attendees, but onsite advance registration is required.

MKSAP Question 1

A 20-year-old woman is evaluated because of a lower abdominal pain and a heavy, yellowish vaginal discharge 3 weeks after having unprotected intercourse with a new partner. Speculum examination shows a reddened, friable cervix with yellow discharge emanating from the os. A Gram stain of the discharge is obtained:

What is the most likely diagnosis?

( A ) Chlamydia
( B ) Bacterial vaginosis
( C ) HIV
( D ) Gonorrhea
( E ) Syphilis

MKSAP Question 2

A healthy 35-year-old woman is planning to travel to rural Mexico in 2 weeks on a 7-day trip and seeks advice regarding prophylaxis against viral hepatitis. She denies any prior history of liver disease or use of illicit drugs and has a monogamous heterosexual relationship. She is asymptomatic, and her physical examination is normal. Serologic testing for antibody to hepatitis A virus (anti-HAV) (both IgG and IgM) is negative.

Administration of which of the following options is the most appropriate?

( A ) Immune serum globulin
( B ) Immune serum globulin (ISG) and hepatitis B immune globulin (HBIG)
( C ) Hepatitis A vaccine
( D ) Hepatitis A and B vaccines

MKSAP Answer 1

Answer: D

Educational Objective: Recognize gonorrhea on Gram stain.

Gonorrhea causes a mucopurulent cervicitis that is characterized by an increased yellow or creamy vaginal discharge. Gynecologic examination will show an inflamed cervix that is very friable, with a purulent secretion emanating from the os. The Gram stain shows the intracellular gram-negative diplococci that are diagnostic of Neisseria gonorrhoeae. The patient should be screened for other sexually transmitted diseases and should be treated for Chlamydia infection also. Her partner or partners should also be screened and treated.

References

• Emmert DH, Kirchner JT. Sexually transmitted diseases in women. Gonorrhea and syphilis. Postgrad Med. 2000;107:189-90,193-7.

MKSAP Answer 2

Answer: A

Educational Objective: Identify the most appropriate prophylaxis for travelers to developing countries.

This patient should receive immune serum globulin (ISG). She is traveling to a region of the world that is endemic for hepatitis A, and prophylaxis is indicated. Most of the populated areas of the world should be considered to be high prevalence relative to the United States. Prophylaxis is not required for travelers to low-prevalence areas such as Canada and northern or western Europe. Currently, there are two choices for prophylaxis against hepatitis A: ISG and hepatitis A vaccine. Rapid, passive transfer of immunity to hepatitis A is achieved with intramuscular injection of ISG. Although 0.02 mL/kg is the standard dose, current preparations of ISG may have low titers of antibody to hepatitis A virus (anti-HAV), and larger doses (0.06 mL/kg) may be required to confer immunity. Vaccination actively stimulates antibody production in more than 95% of patients, but development of antibody is delayed and may not be protective against HAV infection within the first month after vaccination. This patient is planning to travel in 2 weeks, and ISG would be the most effective prophylaxis. Hepatitis A vaccine should be given to all travelers to endemic regions when there is sufficient time to allow development of antibody in response to vaccine or for travelers who plan repeated trips to the region.

In the absence of high-risk behavior, such as illicit substance abuse or homosexual activity, the risk of acquiring hepatitis B is not significantly increased. It is not necessary to test the traveler for hepatitis B and prophylactically treat with either hepatitis B immune globulin (HBIG) or hepatitis B vaccine.

References

• Fujiyama S, Iino S, Odoh K, Kuzuhara S, Watanabe H, Tanaka M, et al. Time course of hepatitis A virus antibody titer after active and passive immunization. Hepatology. 1992;15:983-8.
• Lemon SM, Thomas DL. Vaccines to prevent viral hepatitis. N Engl J Med. 1997;336:196-204.

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