Insights on Residency Training

Recent advances and discussions in medicine are the cornerstone of Journal Watch. Here’s the fifth installment of the articles that made the biggest impression on me in the past 2 weeks. I hope you enjoy the articles I selected.

Please feel free to leave a comment on the articles — Do you like them? Dislike them? Agree, disagree, state your opinion, and participate in the discussion. And if you know of another recent interesting article, post a link to it. I would love to read it.

Greg Bratton, MD

Articles of Interest:

• Physicians Recommend Different Treatments for Patients Than They Would Choose for Themselves – This interesting article brings the dreaded question, “What would you do, Doc?” to the forefront. We have all been asked how we would proceed in a given situation. This article suggests that our answers are not always truthful. A group of primary care physicians were presented one of two hypothetical clinical scenarios. One scenario involved choosing between two treatment options for colon cancer, and the other asked about two treatment options for avian flu. For the two treatment options in each scenario, one had a high rate of side effects but low risk for death, and the other had a low rate of side effects but a higher risk for death. In analyzing the data, in both scenarios, a large percentage of physicians chose treatments with higher risk for death for themselves, but only offered them to their patients between 25% and 50% of the time. Which begs the question, “Are we, in fact, treating our patients like we would our mother??”
• Cardiac Troponin: Lowering the Threshold, Improving the Outcome – In an attempt to make sense of mildly elevated troponins in the ER, researchers examined plasma troponin concentrations (<0.05 ng/mL, 0.05–0.19 ng/mL, and 0.20 ng/mL) and the clinical outcomes of those with suspected acute coronary syndrome. When the diagnostic threshold for troponin was lowered to 0.05 ng/mL from 0.20ng/mL, the rate of death or MI decreased. Ultimately, I believe if ERs adopt a lower troponin threshold for ACS criteria, we might improve morbidity and mortality, but at a cost of more interventions and hospital admissions and greater patient risk.
• Treating Sepsis in the Emergency Department Is Cost-Effective – This study hits home for me, as our ICU attendings at JPS Hospital currently are investigating sepsis and early goal-directed therapy (EGDT). Seeing that EGDT was associated with a gain of 1.3 quality-adjusted life-years (QALY) per patient at a cost of about $5400 per QALY suggests that EGDT was cost-effective (probability, >98%). And, with sepsis being one of the most serious and fatal diagnoses among patients admitted to hospitals, having a protocol to identify and treat it expediently will revolutionize emergency medicine centers.