2/23/2017 A CLINICAL PEARL IS • A distillation of clinical knowledge that is useful for solving every day medical problems • It may be a tip, a way to remember something, a framing CLINICAL PEARLS of a problem FACULTY AND AUDIENCE • May be evidence-based or experience-based APPROACH SOCIAL ISSUES WITH MEDICAL FRAMEWORK CLINICAL PEARL: WHY IS THE DNR DISCUSSION HARD? SO: Think differential, risk, prevention…. • What is the differential diagnosis of homelessness? • BECAUSE ( it’s just hard) BUT ALSO… • What does homelessness put you at risk for? The DNR discussion is really 3 discussions— OR • 1: THE PROBLEM • Being imprisoned is bad for your health. How can it be • 2. THE GOALS prevented? • What puts a person at risk for incarceration? • 3. THE METHODS– resuscitation is one method • What does incarceration put a person at risk for? • Try it on the issue of your choice!!! 1
2/23/2017 END OF LIFE DISCUSSION PEARLS: USEFUL WORDS DEPRESCRIBE: IMPROVE OUTCOMES! • The Problem “ There are three kinds of diseases: disease we can cure; diseases that we can’t cure but we can help people live longer; and diseases where we can’t cure or prolong life but where we can help people feel better. You have …..” • Goals “ Let’s hope for the best and plan for the worst. What would are your hopes? What would be important for you to plan for? GO TOGETHER LIKE PEANUT BUTTER AND JELLY: THE AMPUTATION IN DIABETICS YOU FORGOT TO PREVENT? OPIATE SCRIPTS AND NARCAN • THE TEETH: • Diabetics 2x more likely than non-diabetics to lose their teeth • Refer to Denti-Cal while you can • Emphasize brushing, flossing, nutrition • Glycemic control improves dental outcomes • Good dental hygiene may improve glycemic control! 2
2/23/2017 AUDIENCE: SHARE YOUR CLINICAL TEACH-BACK FOR EVERYONE PEARLS • Patients remember less than 50% of what their doctors tell • Email to Margaret.Wheeler@ucsf.edu them • We will collate them on to slides for presentation Thursday and • Literacy depends on content Friday and context • TOP TEN will win a copy of Medical Care of Vulnerable and • Assessing for understanding Underserved Population s improves recall • Teach-Back IMMIGRANTS ARE OUR HIGHEST RISK TRAVELERS INSULIN AND HOMELESSNESS: KNOW YOUR OPTIONS • If you have immigrant patients you • Common misconception: Insulin must be kept should be practicing travel in refrigerator medicine • Truth! Insulin can be kept at room • Vaccinate temperature for up to one month. Can be carried with belongings, taken to shelters, etc. • Prophylax • Common misconception: Pens require a PA • Anticipatory Guidance and are hard to obtain • Remember people go home for • Truth! Pens are increasingly covered as first- medical care line treatment, are more portable and less • CDC Travel section for recs likely to be stolen than bottles and syringes, and have auditory clues for the visually impaired 3
2/23/2017 NOACS OR DOACS AND ATRIAL FIBRILLATION DIABETES AND HOMELESSNESS • Remember food insecurity and discussing strategies for taking meds, especially insulin • Needle exchange for needles and • Switching appropriate patients off • Point of care HgA1c disposal Warfarin and onto NOAC can benefit • Tolerate higher A1cs • Med-Alert bracelets patients who are low literacy and/or • Foot care: Try to put feet up; change socks have inconsistent Vitamin K intake due • Give rx sugar tablets and discuss and inspect feet; foot care supplies in clinic to food insecurity hypoglycemia • Brush teeth or at least rinse after eating • Get way to contact! • Hand out tooth brushes/toiletries • Same day eye exams PICK PATIENT-CENTERED GLUCOSE TARGETS IT’S FLU SEASON: REMEMBER • Healthy folk, no treatment if >48 hr sx • Remember to ask about • High risk treatment even if more than 48 • Annals September 2016: Yet more hrs sx: PG, young, old, DM, lung disease, work, who is in the family evidence that intensive glucose immunosuppressed, pregnant, sickle cell, lowering can be risky in high-risk etc. for all patients with ESRD, ESLD, Native ethnicity, nursing home individuals! and flu–HR need post- • Especially with older patients, CKD, • CAD :Getting the flu risk for MI exposure prophylaxis and comorbid conditions…. • Obesity predisposes severe disease vaccination • VACCINATE 4
2/23/2017 COMPASSION SATISFACTION & “THE GOOD LIFE” YOUTUBE IN YOUR OFFICE • Pleasure that comes from • Great for teaching yourself new techniques but also for patients • What is meaningful in what helping others • Use of inhalers, discus you do? • Increases connection • Exercises • What are you grateful for in • Epley maneuver • Protects against burn-out your work? • SVT reverse maneuver at home • The “ Good Life” full of • What core values are meaning, aimed at greater expressed through your work? good rather than ease. AUDIENCE: SHARE YOUR CLINICAL MOST POWERFUL THING WE DO TO DECREASE MORTALITY & MORBIDITY? SMOKING CESSATION PEARLS • One evidence-based step toward cessation? • Email to Margaret.Wheeler@ucsf.edu • Smoke-free homes –voluntary no smoking at home • We will collate them on to slides for presentation Thursday and • Associated with: Friday � Reduced secondhand smoke exposure • TOP TEN will win a copy of Medical Care of Vulnerable and � Decreased consumption Underserved Population s � Increased cessation � Reduced relapse to smoking 5
2/23/2017 MUSCULAR-SKELETAL INJURIES: MAXIMIZE FUNCTION CELLULITIS: IS OVER DIAGNOSED. WHAT ELSE COULD IT BE? • Venous stasis and resulting dermatitis (lipodermatosclerosis) - Generate a differential based on mechanism of injury (e.g. acute traumatic, chronic, overuse • type) and anatomy • contact dermatitis; • acute inflammatory edema • Use PE maneuvers as you would use tests (e.g. an MRI) to confirm /refute a • In people who inject drugs, stasis may appear more complex because of venous differential. Only do tests you execute well: avoid generating extra diagnostic noise changes (asymmetrical, with depressed skin scars, etc.) • Avoid imaging unless changes management (see Choosing Wisely campaign) • Cellulitis is not bilateral. If bilateral, go back to the differential. • Maximizing function • If it is cellulitis: look at the feet for a portal of entry (often tinea pedis) and then • Ergonomics, training, behavioral approaches treat the primary problem • Low cost complementary rx– tennis ball massage; ice in the bottle; taping • Massage/acupuncture at low cost/teaching clinics • Home exercise programs with handouts from familydoctor.org or AAOS.org, THANKS TO • Era Kryzhanovskaya • Dean Schillinger • Claire Horton • Jack Chase • Diana Coffa • Claudia Diaz Mooney 6
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