MED-TED Teaching Competition

The inaugural MED-TED teaching competition saw seven contestants compete against each other to teach a topic in under eight minutes. This innovative session included attending hospitalists with fewer than five years of experience out of residency. A panel of judges scored each presentation to determine who should come out of the competition victorious. If any contestant went over eight minutes, a point was deducted.

The first contestant, Dr. Arges, discussed “Pulmonary Complications of Cirrhosis.” Dr. Arges had the audience running down to the emergency department on a busy admitting shift to take care of patients with hepatic hydrothorax, portopulmonary hypertension, and hepatopulmonary syndrome. Take-home points included consideration of diaphragmatic repair via video-assisted thoracic surgery for patients with intractable hepatic hydrothorax; the importance of obtaining a right-heart catheterization in those with cirrhosis and signs of elevated pulmonary artery pressures on echocardiogram, so that pulmonary arterial hypertension therapies can be started if portopulmonary hypertension is suspected; and in those with platypnea orthodeoxia the value of obtaining arterial blood gases (alveolar-arterial gradient should be over 15 mmHg) and contrast-enhanced echocardiogram (for shunt detection) in diagnosis of hepatopulmonary syndrome. The importance of early diagnosis of all these conditions was emphasized, as early pursual of liver transplant is vital in caring for patients with these high-mortality conditions.

Next up was Dr. Brawley-Wang who presented on “Inpatient Gender Affirming Care.” First, Dr. Brawley-Wang went over some vocabulary, including defining gender dysphoria as “feelings, usually intense, of gendered discomfort with parts of one’s body.” Next, strategies to mitigate inpatient risks for dysphoria based on which dysphoria triggers were presented. Examples of strategies included: introducing oneself with preferred pronouns, avoiding honorifics (i.e., Mr. and Mrs.), using the electronic health record to find the patient’s preferred name and pronouns, continuing hormone treatments unless contraindicated, and getting your patient with gender dysphoria a private room or at least a shared room with the gender as which they self-identify. Overall, realizing that mistakes happen and that approaching the patient with compassion, curiosity, and a humble growth mindset will go a long way toward mitigating inpatient gender dysphoria.

Using the innovative presentation style, PechaKucha, Dr. El-Din gave an overview of “Acute Pancreatitis.” The presentation style PechaKucha uses 20 slides, allowing only 20 seconds per slide for the presenter, automatically advancing the slides as the presenter speaks. The PechaKucha format originated in 2003 and means “chit chat” in Japanese. Dr. El-Din used a combination of clinical images and memes to illustrate his points to the audience. A large chunk of the pearls presented were regarding management. Examples included: enteral feeding using a low-fat rather than clear liquid diet as soon as possible; using a more restrictive intravenous fluid strategy (the WATERFALL trial), and same-admission cholecystectomy for mild gallstone pancreatitis (the PONCHO trial).

The fourth contestant, Dr. Larsen, used an image-based approach to presentation in the aptly titled presentation “Teaching Snapshots: Leveraging Clinical Images to Improve Physical Diagnosis.” Initially, the audience was shown a rash from a patient and they were asked to discuss at their tables possible differentials. One objective of the presentation was being able to recognize that clinical images in the electronic health record can be used as a strategy for physical-examination teaching on busy, inpatient, teaching services. The audience was taught how to do this by using the 3 Ds of image review: Describe, Diagnosis, and Differential. The rash was described as widespread, hyperpigmented, and scaling patches and plaques. The working diagnosis was mycosis fungoides with differential eczema, psoriasis, cutaneous lupus, and lichen planus. The case was wrapped up with the patient’s biopsy showing mycosis fungoides, the most common type of cutaneous T-cell lymphoma.

Next up was Dr. Lipten with “A Visual Method to Teach SIADH Physiology and Treatment.” Dr. Lipten was clear up front that we would not be doing calculations or covering an exhaustive review of hyponatremia; simplifying this presentation into essentially one animation. While time-consuming, the creation of the animation was able to properly illustrate the differences in normal versus syndrome of inappropriate antidiuretic hormone secretion (SIADH) kidney physiology. Essentially, while normal kidney physiology can create a wide range of urine concentrations, SIADH can only make one concentration of urine so any additional water intake will lead to hyponatremia via dilution. Once this pathophysiology was clearly illustrated, the three methods of correction of hyponatremia in SIADH became clear: decrease water intake (i.e., fluid restriction), increase the renal solute load (i.e., salt tabs), or restore the kidney’s ability to dilute the urine (i.e., loop diuretic).

Dr. Mahmooth presented “Into and Out of Ketoacidosis.” The importance of differentiating the etiology of ketoacidosis was emphasized, as this determined the appropriate treatment. The different pathophysiologies of each type of ketoacidosis were illustrated to the audience using an animation that included the (often dreaded) Krebs Cycle. Dr. Mahmooth shared with us that it is estimated that half of all euglycemic diabetic ketoacidosis (DKA) patients’ diagnoses are delayed. The importance of obtaining a good patient history, particularly in these patients, was demonstrated by showing that while the lab values look similar between starvation ketoacidosis, alcoholic ketoacidosis, and euglycemic DKA, the treatment can be drastically different (glucose alone for starvation ketoacidosis, glucose then thiamine for alcoholic ketoacidosis, glucose and insulin for euglycemic DKA). While the importance of history was made clear, one helpful lab value is the presence of glucosuria in determining the effect of Sodium-glucose cotransporter-2 drugs in euglycemic DKA.

Finally, Dr. Suarez described how buprenorphine and methadone are life-saving medications with his presentation titled, “Buprenorphine and Methadone: More Life-saving Than Aspirin, Statins, et al.” The number needed to treat (NNT) to save a life for the full opioid receptor agonist methadone is 42, while the NNT for the partial agonist buprenorphine is 53; comparatively the NNT for secondary prevention of cardiovascular disease for aspirin and statins is 333 and 83 respectively. Dr. Suarez emphasized that prescribing buprenorphine is an essential skill all hospitalists need, given the rise of opioid-related admissions and the undertreatment of opioid use disorder (only 22% of patients with opioid use disorder receive treatment). Finally, the inpatient initiation of low-dose buprenorphine was strongly advocated for as it minimizes withdrawal symptoms and avoids an opioid-free period.

Once all contestants had presented, the panel of judges announced that Dr. Larsen’s image-based presentation on improving physical exam teaching through clinical images was the winner of the inaugural MED-TED teaching competition. 

Dr. Calderhead

Dr. Calderhead is a hospitalist at Corewell Health West in Grand Rapids, Mich. He is a physician informaticist as well as core faculty for the Michigan State internal medicine residency program at Corewell Health.