Teaching Models in the Ambulatory Care Setting

mat is a cohost with molyho bline on the medad show, s jem. He shares some of his tips and tricks for teaching in an ambulatory care setting. Mat: "Practice changing knowledge to my medad friends out there"

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Fill up with delicious practice-changing knowledge food from #SGIM22 as The Curbsiders team discusses breast cancer survivorship, sexual dysfunction, How climate change will affect health, Are PT consults necessary in the hospital?, Do we need antibiotics for aspiration events?, bias in note writing, Are plant-based meats a healthy?, complications after breast implantation, how to get breast reduction approved, doxycycline for chlamydia, the metronidazole and alcohol myth, pearls for clinician-educators, telehealth, TEACHIM.org, CGMs help lower a1c, PT for rotator cuff disease, Is it safe to taper antidepressants? and how to treat methamphetamine use disorder!

Note: There is no CME for this episode, but claim CME for prior episodes at curbsiders.vcuhealth.org!

Credits

Written and Hosted by: Nora Taranto MD, Beth Garbitelli (about to be an MD!), Era Kryzhanovskaya MD, Justin Berk MD, MPH, MBA, Shreya Trivedi MD, Chris Chiu MD, Paul Williams MD, Matthew Watto MD
Show Notes and Cover Art: Matthew Watto MD, FACP
Showrunner: Matthew Watto MD, FACP
Technical Production: Pod Paste

Show Segments

Intro
A few ambulatory teaching models include the One Minute Preceptor, SNAPS (summarize, narrow, analyze, probe, plan, and select), PIPP (precepting in the presence of the patient) [see Community Preceptor Toolbox]
Ikigai is a Japanese term indicating a motivational force or reason for living. It is associated with decreased mortality [Tanno, 2009]. Explore your ikigai here (PositivePsychology.com).
Listening to podcasts while driving does not affect knowledge retention (Gottleib et al. 2021)
Treatment of Hot flashes: Avoid paroxetine, fluoxetine, and sertraline in breast cancers survivors taking tamoxifen. Instead use venlafaxine (or another SNRI), citalopram, or escitalopram. Gabapentin given at bedtime is also an option. (Clinical Update 2019: Tamoxifen and Antidepressants)
Distress in patients with cancer can be measured using the NCCN screening tool [NCCN Distress Thermometer]
Don’t forget to ask for a Cancer Survivorship Plan from oncology [CDC Cancer Survivorship Care Plans]
Ask about sexual dysfunction in cancer survivors.
How will climate change impact our patient’s health? NIH framework; CH2OPD2 environmental screening tool [CH2OPD2 ]; and the 15 steps of climate communication.
Use the AM-PAC score cutoff of >18 to avoid a PT consult in hospitalized patients (Martinez 2021).
Early antibiotics after an aspiration event do not improve outcomes (Aga 2021).
Biased language is more common in notes about Black patients (Beach 2021). Be thoughtful about what you write and role model good behavior.
While plant-based meats are more eco-friendly than animal-sourced meats, they are heavily processed foods (van Vliet 2021) and may have high sodium.
Silicone breast implant rupture can be insidious. Guidelines recommend screening with MRI after 6 years, then every 2-3 years (FDA 2020, More FDA info) (Note: FDA’s most recent guidance also recommends ultrasound as an alternative screening method, so always check with the patient's insurance about which modality will be covered)
Document a trial of NSAIDs, physical therapy, attempted weight loss, and supportive bra usage before breast reduction surgery for macromastia.
Doxycycline is now first line for chlamydia rather than azithromycin [STI Treatment Guidelines Update], BUT the most effective treatment is the one your patient will take!
Metronidazole does not cause a disulfiram-like reaction and is no longer recommended by the guidelines [STI Treatment Guidelines Update]
More clinician-educator pearls from Era: Don’t be afraid to brand yourself! Network with like-minded individuals (e.g. interest groups).
BST mode: bite-sized teaching pearls can help reduce extrinsic load and improve retention [Manning, 2021]
A guided discussion based on Scrubs episodes can improve resident wellness [Holtzclaw 2021]
Chris recaps some posters (click links to see them on Twitter!): Telehealth disparities and tech equity (poster 1, poster 2); TeachIM.org (poster)
Continuous glucose monitors can help lower a1c in patients on basal insulin [Martens 2021]
A single session of PT improved shoulder pain. The benefits of steroid injections were limited to 8 weeks in the GRASP trial [Hopewell 2021]
There is a high risk of recurrence after tapering antidepressants [Lewis 2021]
Methamphetamine use disorder can be treated with IM naltrexone every 3 weeks, plus oral bupropion 450 mg daily [Trivedi 2021]. Limitations include cost and co-use of opioids.
Outro

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