Wednesday, September 5, 2012

Teaching About A Tough Case

The highlight today was watching Benard (yep, that's how he spells it), the head clinical officer, lead a continuing medical education activity about a patient that had been at the hospital. Every week this small hospital has a CME activity, and the staff all come, from the nurses to the pharmacist tech to the peer educator. And the free Coke that you get at the end of the session is only a small reason that people show up. They really want to learn and be involved in a multidisciplinary approach to care and learning. I'm especially amazed at the clinical involvement by the non-clinicians. For example, Benson, the executive officer, was raising great points about the need to check for multidrug resistant TB (MDRTB) and to follow-up on records from other clinics to get a better idea of the past treatment history of the patient. And at a previous CME meeting, the laboratory technician was giving treatment advice on a patient.

Today the discussion led by Benard was a mixture of teaching and group discussion on how to best care for this patient. She is HIV positive, and while she had been on the life saving antiretroviral drugs (ARVs) in the past, she had stopped them because she thought they were causing her serious side effects (in retrospect, they were unlikely responsible). Her CD4 count, a measure of how strong her immune system is, was a mere 66 to start with (adults without HIV have CD4 counts typically between 500-1500), and now after being off of her ARVs, it's likely even below that.  And when someone comes off of their ARVs, they are at risk for the virus developing resistance to those medications as their concentrations slowly drop in their blood. Additionally she has a history of tuberculosis that wasn't cured after a round of treatment, and then she stopped taking her second round of treatment. She may very well have MDRTB, as Benson was rightly concerned about. And the third major challenge that she's facing is that she's pregnant. Managing her illnesses and pregnancy in the US would be a huge endeavor. Trying to treat her and prevent her baby from getting HIV and TB in Kenya is an even greater feat. But Benard did an excellent job of listing the issues, the challenges, and what needs to be done to help her.

What was most impressive about the presentation was his teaching style. He is a natural in front of a group, appearing at ease and confident. He repeats the questions that the audience asks him and is respectful of opinions offered up by them. The presentation was case-based, which is shown to be a better way to teach adults than just hitting them with lists of information. He knew his audience, he asked open ended questions, he summarized his talk, and he had an action plan of what the next steps will be after the lecture.

Tomorrow I'm leading a small group discussion on a patient with cryptococcal meningitis. He'll be a tough act to follow.

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