Speaking up: using OSTEs to understand how medical students address professionalism lapses

Background: Objective-structured teaching encounters (OSTEs) are used across many disciplines to assess teaching ability. The OSTE detailed in this paper assesses 191 fourth-year medical students’ (M4) ability to identify and address lapses in professionalism based on Association of American Medical Colleges’ professionalism competencies. The research questions addressed are: How frequently do M4s address professionalism lapses observed during an OSTE? What factors influence whether M4s provide feedback when they observe professionalism lapses in an OSTE? Methods: Standardized patients (SPs) and standardized learners (SLs) were recruited and trained to participate in a standardized encounter with specific cognitive, social, and behavioral errors, including professionalism lapses. M4s viewed this encounter and then offered feedback to the SL, while remotely observed by faculty. Post-encounter, the SL and faculty completed identical checklists to assess both teaching readiness and ability to address professionalism concerns. Results: An analysis of frequencies showed that six of the Association of American Medical Colleges’ nine professional competencies were addressed in the checklist and/or discussed in the focus group. Analysis of transcribed debriefing sessions confirmed that M4s did not consistently address professionalism lapses by their peers. Conclusions: In focus groups, M4s indicated that, while they noticed professionalism issues, they were uncomfortable discussing them with the SLs. Findings of the current study suggest how medical educators might support learners’ ability to address lapses in professionalism as well as topics for future research

Case Report Graves' Disease and Treatment Effects on Warfarin Anticoagulation

Background. Hyperthyroidism causes an increased hypoprothrombinemic response to warfarin anticoagulation. Previous studies have demonstrated that patients with hyperthyroidism require lower dosages of warfarin to achieve a therapeutic effect. As hyperthyroidism is treated and euthyroidism is approached, patients may require increasing warfarin dosages to maintain appropriate anticoagulation. We describe a patient's varying response to warfarin during treatment of Graves' disease. Case Presentation. A 48-year-old African American female presented to the emergency room with tachycardia, new onset bilateral lower extremity edema, gradual weight loss, palpable goiter, and generalized sweating over the prior 4 months. She was admitted with Graves' disease and new onset atrial fibrillation. Primary stroke prophylaxis was started using warfarin; the patient developed a markedly supratherapeutic INR likely due to hyperthyroidism. After starting methimazole, her free thyroxine approached euthyroid levels and the INR became subtherapeutic. She remained subtherapeutic over several months despite steadily increasing dosages of warfarin. Immediately following thyroid radioablation and discontinuation of methimazole, the patient's warfarin dose and INR stabilized. Conclusion. Clinicians should expect an increased response to warfarin in patients with hyperthyroidism and close monitoring of the INR is imperative to prevent adverse effects. As patients approach euthyroidism, insufficient anticoagulation is likely without vigilant follow-up, INR monitoring, and increasing warfarin dosages

Graves’ Disease and Treatment Effects on Warfarin Anticoagulation

Background. Hyperthyroidism causes an increased hypoprothrombinemic response to warfarin anticoagulation. Previous studies have demonstrated that patients with hyperthyroidism require lower dosages of warfarin to achieve a therapeutic effect. As hyperthyroidism is treated and euthyroidism is approached, patients may require increasing warfarin dosages to maintain appropriate anticoagulation. We describe a patient’s varying response to warfarin during treatment of Graves’ disease. Case Presentation. A 48-year-old African American female presented to the emergency room with tachycardia, new onset bilateral lower extremity edema, gradual weight loss, palpable goiter, and generalized sweating over the prior 4 months. She was admitted with Graves’ disease and new onset atrial fibrillation. Primary stroke prophylaxis was started using warfarin; the patient developed a markedly supratherapeutic INR likely due to hyperthyroidism. After starting methimazole, her free thyroxine approached euthyroid levels and the INR became subtherapeutic. She remained subtherapeutic over several months despite steadily increasing dosages of warfarin. Immediately following thyroid radioablation and discontinuation of methimazole, the patient’s warfarin dose and INR stabilized. Conclusion. Clinicians should expect an increased response to warfarin in patients with hyperthyroidism and close monitoring of the INR is imperative to prevent adverse effects. As patients approach euthyroidism, insufficient anticoagulation is likely without vigilant follow-up, INR monitoring, and increasing warfarin dosages

Adolescent Bipolar Disorder: A Clinical Vignette

Adolescence is a vulnerable developmental phase marked by physical, psychological, and social changes that rapidly expose young people to a wide range of new stressors. When differentiating between bipolar disorder and teenage “acting out,” a careful history is important. Adolescent bipolar disorder is a psychiatric illness characterized by fluctuating episodes of mood elevation and depression that is frequently neither recognized nor formally diagnosed. Adolescents with bipolar disorder often manifest a more nonepisodic, chronic course with continuous rapid-cycling patterns than do adults. Pharmacologic treatment of adolescent bipolar disorder is difficult and often requires combination therapy to address comorbidities like attention-deficit/hyperactivity disorder and anxiety disorder. Adjuncts to pharmacologic treatment of bipolar disorder can be beneficial. Psychosocial treatments include family education, enhanced parenting techniques, stress management, and the development of effective coping strategies