Are Internal Medicine Residency Programs Adequately Preparing Physicians to Care for the Baby Boomers? A National Survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P<or=.001). Internal medicine educators are continuing to improve the training of residents so that, as they become practicing physicians, they will have the knowledge and skills in geriatric medicine to care for older adults.

Haplotype Sharing Analysis Using Mantel Statistics

OBJECTIVE

The potential value of haplotypes has attracted widespread interest in the mapping of complex traits. Haplotype sharing methods take the linkage disequilibrium information between multiple markers into account, and may have good power to detect predisposing genes. We present a new approach based on Mantel statistics for spacetime clustering, which is developed in order to improve the power of haplotype sharing analysis for gene mapping in complex disease.

METHODS

The new statistic correlates genetic similarity and phenotypic similarity across pairs of haplotypes for case-only and case-control studies. The genetic similarity is measured as the shared length between haplotypes around a putative disease locus. The phenotypic similarity is measured as the mean-corrected cross-product based on the respective phenotypes. We analyzed two tests for statistical significance with respect to type I error: (1) assuming asymptotic normality, and (2) using a Monte Carlo permutation procedure. The results were compared to the chi(2) test for association based on 3-marker haplotypes.

RESULTS

The results of the type I error rates for the Mantel statistics using the permutational procedure yielded pointwise valid tests. The approach based on the assumption of asymptotic normality was seriously liberal.

CONCLUSION

Power comparisons showed that the Mantel statistics were better than or equal to the chi(2) test for all simulated disease models.

Real-time gap ligase chain reaction: a rapid semiquantitative assay for detecting p53 mutation at low levels in surgical margins and lymph nodes from resected lung and head and neck tumors

PURPOSE

We have developed a real-time semiquantitative gap ligase chain reaction for detecting p53 point mutations at low level in a background of excess of wild-type DNA.

EXPERIMENTAL DESIGN

This method was validated by direct comparison to a previously validated but cumbersome phage plaque hybridization assay. Forty-one surgical margins and lymph nodes from 10 cases of head and neck squamous cell carcinoma and lung carcinoma were tested for p53 mutant clones.

RESULTS

Both methods detected p53 mutants in margins from 8 of the 10 cases, whereas standard pathology detected cancer cells in only 3 cases. Positive margins included tissue samples with a tumor/normal DNA ratio of up to 1:1000.

CONCLUSIONS

This novel molecular approach can be performed in <5 h facilitating intraoperative use for real-time surgical resection.

An Unfolding Case with a Linked Objective Structured Clinical Examination (OSCE): A Curriculum in Inpatient Geriatric Medicine

As the percentage of time devoted to the care of older adults by internists continues to rise, the need for these physicians to be skilled at their care becomes even more critical. In fact, the Education Committee of the American Geriatrics Society has recommended the development of structured educational curricula to teach the principles of geriatric care. This article describes a comprehensive, evidence-based curriculum for internal medicine house staff in inpatient geriatric medicine. The intervention encompasses a novel instructional method, defined skill and behavioral goals, and a competency-based effectiveness evaluation. Moreover, the principles in this curricular model are those that may affect any hospitalized older adult and so will be important for all house staff taking care of inpatient geriatric patients, regardless of their future subspecialty choice.

Improving geriatrics training in internal medicine residency programs: best practices and sustainable solutions

National surveys indicate a need for additional training in geriatrics during internal medicine residencies. This paper describes 1) "best practices" for integrating geriatrics education into internal medicine residency programs, 2) barriers to implementation of these practices, and 3) possible ways to improve geriatrics training for internal medicine residents. These best practices were determined by a systematic review of the literature and through interviews with leaders of 26 residency and geriatrics programs concerned with geriatrics training for residents. The most successful programs have clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, in the hospital or in ambulatory practice), patient care across sites or transitions of care, and interdisciplinary teamwork. Barriers include attitudes, few faculty, need for relationships with nontraditional training sites, and lack of funding. Local solutions include engaging the internal medicine program director to accomplish a mutual goal--for example, by creating a model geriatrics training experience in which residents demonstrate their skill in a new Accreditation Council of Graduate Medical Education competency (such as systems-based practice). National solutions include reaching consensus on the competencies in geriatrics that should be achieved by board-eligible internists. This may mean increasing the number of questions that test geriatrics competency in the certifying and in-training examinations, increasing numbers of faculty members able to teach and model geriatric care, developing "effective medical resident teaching" courses for nonphysician faculty, and lobbying for improved systems of care.

A national survey on the current status of general internal medicine residency education in geriatric medicine

OBJECTIVES

The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs.

DESIGN, SETTING, PARTICIPANTS

An original survey was mailed to all the GIM residency directors in the United States (N = 390).

RESULTS

A 53% response rate was achieved (n = 206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education.

CONCLUSIONS

A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.

An evidence-based domestic violence education program for internal medicine residents

BACKGROUND

Domestic violence (DV) is prevalent but often unrecognized, and it is a challenge to teach. This article presents an evidence-based DV education program for medical residents and incorporates it into a women's medicine curriculum.

DESCRIPTION

An initial 3-hr seminar included video and case discussion, literature review, and role play. Participants then actively screened patients for 2 weeks and returned for a follow-up discussion session. The program was well received.

EVALUATION

Six to 12 months after the intervention, key features questions were utilized to measure ability to correctly suspect DV in patient situations. Residents who had not attended the program served as controls. Three of the 8 questions were suspicious for abuse. Fifty-four percent of respondents in the intervention group correctly suspected DV in at least 2 out of 3 questions compared with 20% of controls (p = .02).

CONCLUSIONS

An evidence-based DV education program was well received and helped correctly suspect DV.

An unfolding case with a linked OSCE: a curriculum in inpatient geriatric medicine

OBJECTIVE

This study sought to design, implement, and evaluate a unique educational curriculum in inpatient geriatrics for internal medicine housestaff.

DESCRIPTION

Traditionally the didactic curriculum on an inpatient geriatrics unit varies according to the attending faculty on service, the types of patients admitted, and preferences of the housestaff and students-in-training. However, a more structured educational curriculum would allow for comprehensive attention to, and a detailed exploration of, the principles of geriatric care necessary to effectively treat all hospitalized older adults. We have developed a unique curriculum using an unfolding case that is followed by an OSCE, which assesses the knowledge and skills gained by the learners. An unfolding case is one that evolves over time and is unpredictable to the learners when they begin participating in the curriculum. It is well suited to postgraduate training and assessment since the learner must develop a differential diagnosis, discuss possible work-ups, and use the work-ups' results to reassess the case as it unfolds. Our scripted case, administered by a geriatrics fellow rotating on the unit, follows an ambulatory geriatric patient from her admission throughout her treatment and until the end of her stay. It culminates in a decision-making session about her functional ability and hence her discharge plans. Moreover, several topics relevant to inpatient geriatrics, including dementia, delirium, falls, urinary incontinence, wound care, and depression, are covered in three one-hour sessions. Written examinations or pre- and post-testing after an intervention are better suited to the early years of medical training but provide poor measures of curriculum mastery and clinical competency. Alternatively, our OSCE approach uses "stations" and "interstations" that provide a structured and timed opportunity to test these skills and assess specific areas of knowledge. We have designed a five-station, five-interstation OSCE that is conducted one week after the unfolding case-based conferences have ended. Learners are evaluated by attending physicians and given immediate feedback after each station and interstation.

DISCUSSION

This newly developed project has been implemented as a standardized curriculum on our inpatient geriatrics unit since September 2001. Thus far, it has been extremely well received by housestaff because of real-time assessment and review of the materials covered during the month. In addition, this progressive approach has provided an excellent forum for geriatrics fellows to develop teaching skills. Attending physicians have shown their support, finding the content to be appropriate and relevant to inpatient geriatrics. Finally, this didactic approach will be continued on our unit and a modified version is being developed and piloted for other unit staff.

Geriatric hospital medicine

Over the last decade, there have been dramatic developments in hospital geriatric care. These improved practices have been supported by the development of quality indicators, which allow physicians and other health care professionals to monitor and measure targeted processes and outcomes of care. This new understanding of the clinical complexity and heterogeneity of the hospitalized elderly population should not be perceived as solely the purview of geriatricians. All physicians involved in the hospital care of elderly patients should strive to attain the knowledge and skills described in this article. As the Baby Boom generation approaches 65 years, physicians and those involved in their training must anticipate and prepare for the reality that many of their patients will be elderly. Special expertise will be needed to provide the highest level of hospital care for this population, especially considering the potential negative effects of hospitalization on older adults.

Rehabilitation of the patient with chronic critical illness

Patients with CCI have continuing profound medical needs, poor prognosis for significant functional recovery, and a high mortality rate. Nonetheless, some survive for months or years, but unfortunately, often with functional skills and quality of life lower than need be. Careful evaluation of each patient's medical condition and potential for functional improvement, early involvement of the rehabilitation team, prevention and treatment of medical conditions associated with prolonged bed rest and immobility, reduction of the emotional and financial burden of family members, and establishment of reasonable goals can increase self-sufficiency and quality of life regardless of discharge destination.

Evolution of the simulated data problem

The simulated data problem was designed via an interactive process by the Simulation Problem Organizing Committee and the selected data simulators. Based on discussions at the previous Genetic Analysis Workshop, many of the features of previous simulation problems, such as a complex disease, genome scan, and replication, were retained and in addition, a population genetics model was used to generate the simulated genes. We describe the process that was used to structure the problem and summarize the discussions about many of the scientific issues that were considered.

Genome scan of complex traits by haplotype sharing correlation

We introduce a haplotype-sharing correlation in founder haplotypes for use in genome scanning. The method evaluates the correlation between phenotype similarity and haplotype similarity at each candidate location. When applied to Genetic Analysis Workshop 12 simulated data for disease status, age at onset, and quantitative traits Q1-Q5, we found highly significant signals near four simulated disease loci in genome scans using microsatellite marker data and highly significant gene effects in three casual genes using sequence data.

Bayes estimates of haplotype effects

We describe a Markov chain Monte Carlo implementation of a Bayesian approach to estimating associations of a trait with a large set of haplotypes recently introduced by Clayton and Jones [Am J Hum Genet 65:1161-9, 2000]. The model uses the length of the longest segment in common between any two haplotypes to define the prior correlation structure for the set of haplotype effects, using an intrinsic autocorrelation model. When applied to the Genetic Analysis Workshop 12 data for trait Q1, we found highly significant variation between haplotypes, using either a structured or unstructured covariance matrix.

International Genetic Epidemiology Society: commentary on Darkness in El Dorado by Patrick Tierney

The International Genetic Epidemiology Society (IGES) has examined the charges against James V. Neel and his colleagues contained in the recently published book by Patrick Tierney entitled Darkness in El Dorado: How Scientists and Journalists Devastated the Amazon (W.W. Norton, 2000). The book implicates Neel in causing or promoting an epidemic of measles among the Yanomamö Indians of Venezuela in 1968 leading to "hundreds if not thousands" of deaths by using a "dinosaur" vaccine (Edmonston B) as a deliberate "experiment" to test his "eugenic" theories. Tierney also attempts to link this research, funded by the Atomic Energy Commission (AEC), with a broader tapestry of human radiation experiments. To investigate these serious charges, the IGES undertook a thorough examination of most source documents referenced in Tierney's book, Neel's field logs, notes, first-hand reports, contemporary writings, film sound tracks, etc., and conducted interviews with many relevant persons. The IGES finds that these allegations are false. Neel was not a eugenicist and was in fact highly critical of both the scientific basis of eugenics and its coercive social policies. In this regard, Tierney has grossly misrepresented Neel's views on a wide range of social implications of modern civilization for the long-term health of the gene pool. Far from causing an epidemic of measles, Neel did his utmost to protect the Yanomamö from the ravages of the impending epidemic by a vaccination program using a vaccine that was widely used at the time and administered in an appropriate manner. There was nothing experimental about the vaccination program, which in fact severely hindered the primary scientific objectives of the expedition. Although the research was funded in large part by the AEC, there was no element of radiation research and the work had no connection with the ethical abuses that have been reported from AEC-sponsored radiation research, such as studies of heavy isotopes. Neel's seminal contributions to a broad range of topics in human genetics have been extensively chronicled elsewhere. His research on the Yanomamö in particular has provided unique insights into the evolutionary biology of our species, the role of sociocultural practices, such as kinship relationships and selective pressures in shaping the genetic diversity of primitive population isolates, as well as the general picture of health in such populations. The IGES decries the damage done to the reputation of one of its founders and its first President and the misperception this book may have caused about the conduct of research in genetic epidemiology. Ethical issues about scientific research in primitive populations deserve serious and wide discussion, but the IGES condemns the gross misrepresentation of the facts and demonization of the principal characters in this book.

The role of interacting determinants in the localization of genes

We describe the potential gains in power for localizing disease genes that can be obtained by allowing for interactions with environmental agents or other genes. The focus is on linkage and association methods in nuclear families with dichotomous phenotypes. A logistic model incorporating various main effects and interactions is used for penetrance, but similar methods apply to censored age-at-onset or continuous phenotypes. We begin by discussing the influence of gene-environment interactions in segregation analysis, illustrated with analysis of smoking as a modifying factor for lung cancer. We then discuss a number of approaches to linkage analysis-model-free and model-based(including generalized estimating equations) incorporating interactions with environmental factors and other genes, either candidate genes or linked loci. We find that a test of heterogeneity in IBD sharing probabilities across strata defined by sharing of environmental factors can offer greater power for detecting linkage than the simple mean test, provided the interaction effect is sufficiently strong; we explore the conditions under which this gain in power occurs. Finally, we describe approaches for testing association and disequilibrium involving interactions, utilizing case-control, case-parent, and pedigree-based approaches. A technical problem that must be addressed in many analyses is the effect of missing data on environmental covariates; we use multiple imputation in an analysis of lung cancer segregation to illustrate an approach to this problem.

Counter-matching in studies of gene-environment interaction: efficiency and feasibility

The interest in studying gene-environment interaction is increasing for complex diseases. However, most methods of detecting gene-environment interactions may not be appropriate for the study of interactions involving rare genes (G:) or uncommon environmental exposures (E:), because of poor statistical power. To increase this power, the authors propose the counter-matching design. This design increases the number of subjects with the rare factor without increasing the number of measurements that must be performed. In this paper, the efficiency and feasibility (required sample sizes) of counter-matching designs are evaluated and discussed. Counter-matching on both G: and E: appears to be the most efficient design for detecting gene-environment interaction. The sensitivity and specificity of the surrogate measures, the frequencies of G: and E:, and, to a lesser extent, the value of the interaction effect are the most important parameters for determining efficiency. Feasibility is also more dependent on the exposure frequencies and the interaction effect than on the main effects of G: and E: Although the efficiency of counter-matching is greatest when the risk factors are very rare, the study of such rare factors is not realistic unless one is interested in very strong interaction effects. Nevertheless, counter-matching appears to be more appropriate than most traditional epidemiologic methods for the study of interactions involving rare factors.

The effects of ambient air pollution on school absenteeism due to respiratory illnesses

We investigated the relations between ozone (O3), nitrogen dioxide (NO2), and respirable particles less than 10 microm in diameter (PM10) and school absenteeism in a cohort of 4th-grade school children who resided in 12 southern California communities. An active surveillance system ascertained the numbers and types of absences during the first 6 months of 1996. Pollutants were measured hourly at central-site monitors in each of the 12 communities. To examine acute effects of air pollution on absence rates, we fitted a two-stage time-series model to the absence count data that included distributed lag effects of exposure adjusted for long-term pollutant levels. Short-term change in O3, but not NO2 or PM10, was associated with a substantial increase in school absences from both upper and lower respiratory illness. An increase of 20 ppb of O3 was associated with an increase of 62.9% [95% confidence interval (95% CI) = 18.4-124.1%] for illness-related absence rates, 82.9% (95% CI = 3.9-222.0%) for respiratory illnesses, 45.1% (95% CI = 21.3-73.7%) for upper respiratory illnesses, and 173.9% (95% CI = 91.3-292.3%) for lower respiratory illnesses with wet cough. The short-term effects of a 20-ppb change of O3 on illness-related absenteeism were larger in communities with lower long-term average PM10 [223.5% (95% CI = 90.4-449.7)] compared with communities with high average levels [38.1% (95% CI = 8.5-75.8)]. Increased school absenteeism from O3 exposure in children is an important adverse effect of ambient air pollution worthy of public policy consideration.

Genetic epidemiology with a capital "E"

Three characteristics of genetic epidemiology that distinguish it from its parent disciplines are a focus on population-based research, a focus on the joint effects of genes and the environment, and the incorporation of the underlying biology of the disease into its conceptual models. These principles are illustrated by a review of the genetic epidemiology of breast and ovarian cancer. Descriptive and mechanistic models for the joint effects of genes and "environmental" risk factors such as hormones and reproductive events are compared to illustrate the need to understand the biology. The contribution of population-based research to the development of the evidence for the involvement of major genes, the discovery of BRCA1 and BRCA2, and their characterization is reviewed. Interactions of major susceptibility genes, metabolic genes, and hormones are also discussed. I conclude with some suggestions for future directions for the field, the journal, and the Society, including recent bioethics initiatives. I believe that the Society should reach out more to the epidemiology community and that the journal should shift its emphasis from pure methodology to also include more substantive papers that illustrate these principles.

Performance of Markov chain-Monte Carlo approaches for mapping genes in oligogenic models with an unknown number of loci

Markov chain-Monte Carlo (MCMC) techniques for multipoint mapping of quantitative trait loci have been developed on nuclear-family and extended-pedigree data. These methods are based on repeated sampling-peeling and gene dropping of genotype vectors and random sampling of each of the model parameters from their full conditional distributions, given phenotypes, markers, and other model parameters. We further refine such approaches by improving the efficiency of the marker haplotype-updating algorithm and by adopting a new proposal for adding loci. Incorporating these refinements, we have performed an extensive simulation study on simulated nuclear-family data, varying the number of trait loci, family size, displacement, and other segregation parameters. Our simulation studies show that our MCMC algorithm identifies the locations of the true trait loci and estimates their segregation parameters well-provided that the total number of sibship pairs in the pedigree data is reasonably large, heritability of each individual trait locus is not too low, and the loci are not too close together. Our MCMC algorithm was shown to be significantly more efficient than LOKI (Heath 1997) in our simulation study using nuclear-family data.

Morbid hypocalcemia associated with phosphate enema in a six-week-old infant

A 6-week-old premature infant who was born at 29 weeks of gestation presented to the emergency department with a several-hour history of stiffness and increased alarms on his apnea monitor at home. On arrival he was noted to have generalized seizures, apnea, and bradycardia. He was intubated and required cardiopulmonary resuscitation including chest compressions and medications. After stabilization he was transferred to the neonatal intensive care unit for further management. His initial laboratory tests revealed a serum calcium level of 2.4 mg/dL (normal range: 8.4-10.2 mg/dL) and a serum phosphorus level of 28.5 mg/dL (normal range: 2.4-4.5 mg/dL). During the first week of admission, the infant's mother reported that she had administered a full pediatric Fleets enema (CB Fleet Company Inc, Lynchburg, VA) to him. The infant was discharged after 12 days of hospitalization. Anticipatory guidance on the stool patterns and behavior of infants can prevent misconceptions about constipation that are especially prevalent in new parents. Proper management of constipation, should it arise, should be addressed with all parents at early well-child visits to avoid hazardous complications of treatments. hypocalcemia, seizures, premature infants, enema.

Multistage sampling for disease family registries

BACKGROUND

The objectives of a family-based disease registry range from characterizing measured genetic factors and gene-environment interaction effects to detecting novel susceptibility genes. Gathering complete information on exposure and disease status in all family members for a sample of affected subjects (probands) to address these diverse objectives would be prohibitively expensive.

METHODS

Multistage sampling can be used to design an efficient family-based disease registry. At each stage, the probands are classified on the basis of previously collected data, and a subsample is selected for more detailed observation. The design can be optimized to minimize the variance of any of the model parameter estimates, subject to a constraint on the total sample size.

RESULTS

We describe the basic statistical theory and its application to a four-stage sampling scheme proposed for the Cooperative Family Registry for Epidemiologic Studies of Colorectal Cancer at the University of Southern California.