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Learning issues are focused questions generated by the medical student about the diagnosis, pathogenesis, treatment, prognosis, or prevention of a patient's health problem. Students are expected to select and research learning issues regularly. Students are required to submit one (1) formal report on a learning issue to be discussed with the campus clerkship director.
We anticipate that the process of selecting, researching, and reporting learning issues will aid in the development of the student's self-directed, lifelong learning skills in addition to building general medical knowledge. The focus of these issues, however, is for the student to acquire information useful for patient care.
Selecting a Learning Issue
- For each item on a patient's problem list, ask yourself:
- What is the differential diagnosis? How are the possible diagnoses differentiated from each other?
- What is the pathogenesis?
- What are the treatment options? What are the potential benefits and risks of the various options relative to other options?
- What is the prognosis?
- Questions you can't answer are potential learning issues.
- Select a question for formal study if it is of great importance to the patient, and/or if it is related to a high priority learning objective for the course.
- DO NOT BRING an UPTODATE ARTICLE
Researching a Learning Issue
- Format your issue as a question about your patient.
- Select and find appropriate references.
- Textbooks are best for very general questions.
- Original literature sources are best for specific, focused questions, i.e. foreground questions.
- Read with your question(s) in mind.
Format for Learning Issues
- Necessary as the evaluator doesn’t receive the H&P.
- Summarize, don’t regurgitate. Briefly identify the patient issues prompting the question.
- Should be a valid question-not a review topic
- Example: Heparin vs Enoxaparin for DVT prophylaxis
- Example: Steroids vs No steroids in acute alcoholic hepatitis
- Example: IV Albumin vs No albumin in SBP
- Example: Evidence for serial BNP in CHF
- Be brief and focused on the question and issues specific for your patient.
- Contact campus librarian if you need help searching literature.
- Connect what you learned to the patient. Based on what you learned, what is the patient’s prognosis? Should an MRI have been obtained? Should treatment x have been used rather than treatment y? A summary of what happened is not a reconnection. Commit to whether you think what happened was appropriate or would have an alternative process been more appropriate for patient.
- Original research article from a major clinical database (PubMed etc.)
Critical Review of Literature
- This addresses the quality of the supporting literature, e.g., the patient population selection, study design, selection of outcome variables, data analysis, and study interpretation. (Generally, above expectation for third-year IM clerks.)
Evaluation of Learning Issues
- Each student is required to submit one Learning Issue to the campus clerkship director and discuss it at the mid-clerkship feedback session or at another time arranged by clerkship director or coordinator.
Example of a learning issue completed by a UNDSM&HS graduate who is also an endocrinologist, done in real-time, when the issue arose.
The patient is a 31-year-old female who is seven months postpartum and breast-feeding. She has the classic symptoms, signs, and laboratory features of thyrotoxicosis. While differentiating between postpartum thyroiditis and Graves' disease, symptom control with a beta-blocker is desired. She wishes to continue breast-feeding.
Which is the optimal beta-blocker for use in the breast-feeding female?
Atenolol is generally not recommended for use in breast-feeding women because of the potential risk of hypotension and bradycardia in the nursing infant; neonates whose mothers are receiving atenolol during breast-feeding have an increased risk of hypoglycemia. Premature infants or infants with impaired renal function, may be more likely to develop adverse effects. Atenolol is excreted in human breast milk at a ratio of 1.5 to 6.8 when compared to the concentration in maternal plasma. The American Academy of Pediatrics lists atenolol as a beta-blocker which should be given to nursing mothers with caution due to the risk for fetal cyanosis and bradycardia. Because of the potential for serious reactions in nursing infants, a decision should be made to discontinue breast-feeding or to discontinue the atenolol, taking into account the importance of the drug to the mother.
Metoprolol is excreted into breast milk in very small quantities. According to the manufacturer, an infant consuming 1 liter per day of breast milk would ingest < 1 mg of metoprolol. Caution is advised and the infant should be monitored for signs of beta-blockade according to the manufacturer. The AmericanAcademy of Pediatrics considers metoprolol to be generally compatible with breast-feeding, but also notes that the drug is concentrated in breast milk.
The patient was contacted and metoprolol was initiated for thyrotoxicosis symptomatic control until the results of testing for the differentiation between postpartum thyroiditis and Graves' disease arrived.
First Consult – Drugs – Contraindications/Adverse Effects