Update on Breast Cancer

This article reviews recent advances in the treatment of breast cancer. The goal in selecting these recent articles was to help identify literature that may change the clinical practice of women's health for practitioners in the primary care setting. Articles were identified by reviewing the high-impact medical and women's health journals, national guidelines, ACP JournalWise, and NEJM Journal Watch. In this Clinical Update, we selected recent publications relevant to the treatment and complications of treatment of breast cancer.

Clinical Update in Women's Heart Disease

The goal in selecting these recent articles was to help identify literature that may change the clinical practice of women's health for practitioners in the primary care setting. Articles were identified by reviewing high-impact medical and women's health journals, national guidelines, ACP JournalWise, and NEJM Journal Watch. In this clinical update, we selected recent publications relevant to the prevention, risk assessment, and diagnosis of cardiovascular disease (CVD) in women. Breastfeeding now has data suggesting a robust reduction in subsequent CVD, and migraine with aura and severe and early- and late-onset hot flashes can now be considered risk factors for CVD. The decision to initiate menopausal hormone therapy is influenced by estimation of underlying vascular risk, and new data suggest that CVD risk scores are more accurate in predicting CVD risk than the traditionally used age and years since menopause and should be incorporated into counseling. Finally, new data support the growing belief that breast arterial calcification on mammography is a promising noninvasive marker that can enhance CVD risk prediction in women.

Menopause

This review focuses on the diagnosis and management of menopause, highlighting both hormonal and nonhormonal treatment options. In particular, the article focuses on recent data on the risks and benefits of hormone therapy to help clinicians better counsel their patients about decision making with regard to understanding and treating menopause symptoms.

Correlation of Coping, Mentorship, and Life Events with Burnout in Internal Medicine Residents

Physician burnout is a widespread problem. We examined how coping, mentorship, and life events correlated with burnout in Internal Medicine Residents. We performed a cross-sectional study of survey data collected over multiple time points and used Spearman correlation of coping, mentorship, and life events to emotional exhaustion (EE) and cynicism (CYN). Burnout was assessed using the Maslach Burnout Inventory-General Survey (MBI-GS), coping skills were measured using the Brief COPE, mentorship with an institutional mentoring survey, and life events with a shortened Social Readjustment Rating Scale (SRRS). Two thousand one surveys were distributed to 616 residents from 2010 to 2015. There were 1144 cases of completion of both the Brief COPE and the MBI-GS (58%), 744 of the MBI-GS and the Mentoring survey (47%), and 1138 of the MBI-GS and Life Events Scale (57%). There were correlations between acceptance (ρ 0.1-0.24), denial (ρ 0.13-0.20), substance abuse (ρ 0.15-0.22), behavioral disengagement (ρ 0.18-.037), self-blame (ρ 0.27-0.45), self-distraction (ρ 0.18-0.32) and venting (ρ 0.15-0.47) and EE. There were correlations with acceptance (ρ 0.11-0.15), denial (ρ 0.18-0.26), humor (ρ 0.13-0.20), substance abuse (ρ 0.10-0.29), behavioral disengagement (ρ 0.19-0.40), self-blame (ρ 0.24-0.35), self-distraction (ρ 0.14-0.34) and venting (ρ 0.12-0.38) and CYN. There was a negative correlation between mentorship and EE (ρ - 0.15, - 0.18) and CYN (ρ - 0.30 to - 0.20). There were correlations between life events and EE (ρ 0.15-0.20) and CYN (ρ = 0.14-0.15). Maladaptive coping mechanisms, acceptance, and life stressors correlate with burnout in internal medicine residents and mentoring may be protective.

A Multifaceted Intimate Partner Violence Communication Skills Curriculum Increases Screening Among Internal Medicine Residents

Background: Intimate partner violence (IPV) is common, yet physicians do not routinely screen patients for IPV. There are no clear recommendations for best educational practices for physician trainees that improve screening rates. Materials and Methods: We implemented an IPV curriculum combining didactics and communication skills training for internal medicine residents. Didactics included definitions, risk factors, screening recommendations, and documentation; communication skills training included developing unique screening and response phrases; and two simulated patient exercises. The primary outcome was screening documentation rates as measured through pre- and postcurriculum chart review. Secondary outcomes included knowledge, comfort, and attitudes measured through pre- and postcurriculum administration of an adapted Physician Readiness to Manage Intimate partner violence Survey (PREMIS). Postcurriculum semistructured interviews provided further details regarding behaviors and attitudes. Results: Forty residents completed the curriculum. 29/40 (73%) completed both pre- and postsurveys. Fifteen participated in semistructured interviews. Residents demonstrated increased screening documentation postcurriculum (p < 0.05). Residents showed improvement in 80% of objective knowledge questions, and in all perceived knowledge and comfort-based questions (p < 0.01). Statistically significant improvement was noted in many attitudinal domains, including reported screening rates (p < 0.05). In the semistructured interviews, participants reported experiencing both practice-based improvements and ongoing screening barriers. Practice-based improvements included increased screening comfort and frequency, and strengthening of the doctor-patient relationship. Ongoing screening barriers included time, resistance to practice change, competing medical needs, and personal discomfort. Conclusions: A multifaceted IPV curriculum for residents significantly improved documentation rates, knowledge, comfort, and attitudes. Residents reported increased comfort with screening and strengthened patient relationships but acknowledged ongoing barriers to screening.

A Robust Faculty Development Program for Medical Educators: A Decade of Experience

OBJECTIVES

Faculty development programs (FDPs) foster learning communities and enhance professional identity formation for medical educators. Competency-based frameworks for faculty development drive skill development across clinical practice, teaching, and scholarship domains. The aims of this study are to outline the context, content, and evolution of a novel FDP; map the individual conferences that make up the FDP to established faculty development competencies; identify steps to implement similar programming; and demonstrate outcomes to date.

METHODS

The FDP consists of four, 1-hour-long conferences held weekly on a rotating basis since 2007 at the University of Pittsburgh School of Medicine: Academy of Master Educators, Medical Education Research, Medical Education Journal Club, and Medical Education Research Methods and Innovative Design conference. Authors outline the relation of each of these four conferences to faculty development competencies and describe early outcomes for each conference over four consecutive academic years from 2014 to 2018. Participants include attendees and presenters in four consecutive academic years from 2014 to 2018.

RESULTS

The well-attended FDP meets all established competencies for educator faculty. Presenters and attendees were diverse in terms of academic rank and represented a breadth of clinical and basic science specialties.

CONCLUSIONS

This integrated FDP fosters a community of medical educators and develops faculty skills across established medical educator competencies.

Implementation of a clinical reasoning curriculum for clerkship-level medical students: a pseudo-randomized and controlled study

Background The National Academies of Sciences report Improving Diagnosis in Healthcare highlighted the need for better training in medical decision-making, but most medical schools lack formal education in clinical reasoning. Methods We conducted a pseudo-randomized and controlled study to evaluate the impact of a clinical reasoning curriculum in an internal medicine clerkship. Students in the intervention group completed six interactive online modules focused on reasoning concepts and a skills-based workshop. We assessed the impact of the curriculum on clinical reasoning knowledge and skills and perception of education by evaluating: (1) performance on a clinical reasoning concept quiz, (2) demonstration of reasoning in hospital admission notes, and (3) awareness of attending physician utilization of clinical reasoning concepts. Results Students in the intervention group demonstrated superior performance on the clinical reasoning knowledge quiz (67% vs. 54%, p < 0.001). Students in the intervention group demonstrated superior written reasoning skills in the data synthesis (2.3 vs. 2.0, p = 0.02) and diagnostic reasoning (2.2 vs. 1.9, p = 0.02) portions of their admission notes, and reported more discussion of clinical reasoning by their attending physicians. Conclusions Exposure to a clinical reasoning curriculum was associated with superior reasoning knowledge and superior written demonstration of clinical reasoning skills by third-year medical students on an internal medicine clerkship.

The Toxicity of Self-Blame: Sex Differences in Burnout and Coping in Internal Medicine Trainees

BACKGROUND

Burnout is a significant problem facing internal medicine residents contributing to increased risk of depression and suicidal ideation. Coping mechanisms and burnout may differ based on sex.

METHODS

The study was a retrospective cross-sectional study of reported burnout and coping mechanisms used by internal medicine residents in June 2014 at a large academic center and its community affiliate. Two hundred eighty-five postgraduate year (PGY)-1, 2, 3, and 4 and incoming PGY-1 residents were surveyed. The Maslach Burnout Inventory-General Survey and Brief Coping Orientation to Problems Experienced were given to measure levels of burnout and frequency of use of coping mechanisms. Percentages of residents who met criteria for burnout and high levels on each of the subscales of emotional exhaustion, cynicism and professional efficacy, were calculated and stratified by sex. Chi-squared tests were used for statistical significance. Average frequency of use of each coping mechanism by sex was calculated with statistical significance determined by two sided t-tests.

RESULTS

There was a 69% completion rate (198/285) with 100 men and 98 women. Woman had higher levels of burnout (30% vs. 15%, p = 0.014) and emotional exhaustion (22% vs. 9%, p = 0.005). Women used the adaptive coping mechanisms of emotional support (p = 0.001) and instrumental support (p = 0.018) more frequently but also used the maladaptive coping mechanism of self-blame more frequently (p = 0.022).

CONCLUSIONS

Greater use of self-blame as a coping mechanism may be a major factor in the higher rates of burnout and emotional exhaustion in women resident physicians as compared to men. Educators must pay attention to use of self-blame by female residents and as it may be a red flag for resident distress.

Control of cell mechanics by RhoA and calcium fluxes during epithelial scattering

Epithelial tissues use adherens junctions to maintain tight interactions and coordinate cellular activities. Adherens junctions are remodeled during epithelial morphogenesis, including instances of epithelial-mesenchymal transition, or EMT, wherein individual cells detach from the tissue and migrate as individual cells. EMT has been recapitulated by growth factor induction of epithelial scattering in cell culture. In culture systems, cells undergo a highly reproducible series of cell morphology changes, most notably cell spreading followed by cellular compaction and cell migration. These morphology changes are accompanied by striking actin rearrangements. The current evidence suggests that global changes in actomyosin-based cellular contractility, first a loss of contractility during spreading and its activation during cell compaction, are the main drivers of epithelial scattering. In this review, we focus on how spreading and contractility might be controlled during epithelial scattering. While we propose a central role for RhoA, which is well known to control cellular contractility in multiple systems and whose role in epithelial scattering is well accepted, we suggest potential roles for additional cellular systems whose role in epithelial cell biology has been less well documented. In particular, we propose critical roles for vesicle recycling, calcium channels, and calcium-dependent kinases.

Women's health 2015: an update for the internist

The field of women's health is varied and dynamic. Major studies in 2014 and the first half of 2015 suggest that selective serotonin reuptake inhibitors are not strongly associated with congenital heart defects, that paroxetine 7.5 mg is effective for treating menopausal symptoms, and that women with heart failure may benefit more from cardiac resynchronization therapy than men.

Needs assessment of palliative care education in gynecologic oncology fellowship: we're not teaching what we think is most important

OBJECTIVES

We sought to characterize gynecologic oncology fellowship directors' perspectives on (1) inclusion of palliative care (PC) topics in current fellowship curricula, (2) relative importance of PC topics and (3) interest in new PC curricular materials.

METHODS

An electronic survey was distributed to fellowship directors, assessing current teaching of 16 PC topics meeting ABOG/ASCO objectives, relative importance of PC topics and interest in new PC curricular materials. Descriptive and correlative statistics were used.

RESULTS

Response rate was 63% (29/46). 100% of programs had coverage of some PC topic in didactics in the past year and 48% (14/29) have either a required or elective PC rotation. Only 14% (4/29) have a written PC curriculum. Rates of explicit teaching of PC topics ranged from 36% (fatigue) to 93% (nausea). Four of the top five most important PC topics for fellowship education were communication topics. There was no correlation between topics most frequently taught and those considered most important (rs=0.11, p=0.69). All fellowship directors would consider using new PC curricular materials. Educational modalities of greatest interest include example teaching cases and PowerPoint slides.

CONCLUSIONS

Gynecologic oncology fellowship directors prioritize communication topics as the most important PC topics for fellows to learn. There is no correlation between which PC topics are currently being taught and which are considered most important. Interest in new PC curricular materials is high, representing an opportunity for curricular development and dissemination. Future efforts should address identification of optimal methods for teaching communication to gynecologic oncology fellows.

Evaluation of VA Women's Health Fellowships: developing leaders in academic women's health

BACKGROUND

The Department of Veterans Affairs (VA) instituted the VA Women's Health Fellowship (VAWHF) Program in 1994, to accommodate the health needs of increasing numbers of female veterans and to develop academic leaders in women's health. Despite the longevity of the program, it has never been formally evaluated.

OBJECTIVE

To describe the training environments of VAWHFs and career outcomes of female graduates.

DESIGN AND PARTICIPANTS

Cross-sectional web-based surveys of current program directors (2010-2011) and VAWHF graduates (1995-2011).

RESULTS

Responses were received from six of seven program directors (86 %) and 42 of 74 graduates (57 %). The mean age of graduates was 41.2 years, and mean time since graduation was 8.5 years. Of the graduates, 97 % were female, 74 % trained in internal medicine, and 64 % obtained an advanced degree. Those with an advanced degree were more likely than those without an advanced degree to pursue an academic career (82 % vs. 60 %; P<0.01). Of the female graduates, 76 % practice clinical women's health and spend up to 66 % of their time devoted to women's health issues. Thirty percent have held a VA faculty position. Seventy-nine percent remain in academics, with 39 % in the tenure stream. Overall, 94 % had given national presentations, 88 % had received grant funding, 79 % had published in peer-reviewed journals, 64 % had developed or evaluated curricula, 51 % had received awards for teaching or research, and 49 % had held major leadership positions. At 11 or more years after graduation, 33 % of the female graduates in academics had been promoted to the rank of associate professor and 33 % to the rank of full professor.

CONCLUSIONS

The VAWHF Program has been successful in training academic leaders in women's health. Finding ways to retain graduates in the VA system would ensure continued clinical, educational, and research success for the VA women veteran's healthcare program.

Once Is Not Enough

Training in intimate partner violence (IPV) improves health professionals’ knowledge and comfort regarding IPV; the optimal training frequency and format is unknown. We assessed how various types and amounts of IPV education for medical students affected knowledge and attitudes. Medical students at a large, urban university completed a survey concerning IPV-related knowledge and attitudes and participation in didactic and experiential IPV training activities. This was a one-time assessment. Of 586 students, 279 (48%) completed the survey. IPV-related knowledge increased with increased number of training activities. Knowledge and attitude scores were higher ( p < .001) for respondents with experiential, versus only didactic, activities.

A pilot study exploring gender differences in residents' strategies for establishing mentoring relationships

BACKGROUND

Mentoring is important throughout a physician's career and has been noted to be particularly important during residency training. Other studies suggest that women may experience difficulty in finding mentors.

PURPOSE

This study explored gender-specific differences in residents' mentoring experiences.

METHODS

The authors conducted two focus groups at the University of Pittsburgh in July, 2004. One group was composed of 12 female residents; the other was composed of nine male residents. Discussions were audiotaped and transcribed. Two investigators coded the transcripts and identified emerging themes.

RESULTS

Residents of both genders cited multiple barriers to mentoring. Men's strategies for finding mentors were more numerous than women's and included identifying mentors through research, similar interests, friendship, and networking. Female strategies were limited and included identifying mentors through "word of mouth" and work experiences. Women described more passive approaches for finding a mentor than men.

CONCLUSIONS

Female residents may lack strategies and initiatives for finding mentors. Residency programs should create opportunities for residents to develop mentoring relationships, with special attention paid to gender differences.

Teaching internal medicine residents to care for reproductive-age and pregnant women: an effective Web-based curriculum

BACKGROUND

We sought to determine whether a Web-based curriculum could improve internal medicine residents' perceived preparedness and knowledge in the areas of preconception care, infertility evaluation, and management of medical conditions during pregnancy. Training in these areas has been previously identified as inadequate.

DESCRIPTION

Three Web-based modules were developed to teach these topics. Seventy residents at one institution were invited to complete the modules and to participate in the curriculum's evaluation over 6 months.

EVALUATION

Paper questionnaires assessed preparedness and comfort level among all participants. Web-based surveys that assessed pre/postknowledge and satisfaction among module completers accompanied each module. Ninety-seven percent completed paper questionnaires, and 59% completed 1 or more modules. At the end of the study period, module completers felt significantly more prepared than noncompleters, and improvement in comfort level was strongly associated with the number of modules completed. Knowledge improved significantly with module completion and curricular satisfaction was high.

CONCLUSIONS

A Web-based approach to teaching these topics to internal medicine residents increased knowledge and perceived preparedness and was well received.

Internal medicine residents' preparedness to care for reproductive-age and pregnant women

BACKGROUND

Research that addresses whether residents are prepared to deliver preconception care and manage medical conditions in pregnant and postpartum women has been scarce since the publication of women's health competency guidelines for internists in 1997.

PURPOSE

To investigate current attitudes, training, and perceived preparedness in these areas and to explore relationships between resident characteristics and preparedness.

METHODS

A 62-item questionnaire was given to 105 internal medicine residents and recent graduates at two affiliated residency programs.

RESULTS

Eighty-five surveys were returned. Most respondents reported that they had minimal training and were unprepared in these areas but felt that learning these topics is important. Perceived preparedness correlated strongly with relevant didactic and clinical training but was not associated with gender, residency track, or career plan.

CONCLUSIONS

In light of published competency guidelines, internal medicine training programs should consider adding or increasing curricular content to improve residents' perceived preparedness to deliver care to reproductive-age and pregnant women.

Ensuring high-quality primary care for women: predictors of success

BACKGROUND

Provider gender, provider specialty, and clinic setting affect quality of primary care delivery for women, but previous research has not examined these factors in combination. The purpose of this study is to determine whether separate or combined effects of provider gender, availability of gynecologic services from the provider, and women's clinic setting improve patient ratings of primary care.

METHODS

Women veterans receiving care in women's clinics or traditional primary care at 10 Veteran's Affair (VA) medical centers completed a mailed questionnaire (N = 1321, 61%) rating four validated domains of primary care (preference for provider, communication, coordination, and accumulated knowledge). For each domain, summary scores were calculated and dichotomized into perfect score (maximum score) versus other. Multiple logistic regressions were used to estimate the probability of a perfect score in each domain while controlling for patient characteristics and site.

RESULTS

Female provider was significantly associated with perfect ratings for communication and coordination. Providing gynecologic care was significantly associated with perfect ratings for male and female providers. Patients who used a women's clinic and had a female provider who gave gynecologic care had perfect or nearly perfect ratings for preference for provider, communication, and accumulated knowledge.

CONCLUSION

Gynecologic services are linked to patient ratings of primary care separate from and in synergy with the effect of female provider. Male and female providers should consider offering routine gynecologic services or working in coordination with a setting that provides gynecologic services. Health care evaluations should assess scope of services for provider and practice.

Patient satisfaction in women's clinics versus traditional primary care clinics in the Veterans Administration

OBJECTIVE

To compare patient satisfaction in women's clinics (WCs) versus traditional primary care clinics (TCs).

DESIGN

Anonymous, cross-sectional mailed survey.

SETTING

Eight Department of Veterans Affairs (VA) medical centers in 3 states.

PATIENTS

A random sample of women stratified by site and enrollment in WC versus TC (total response rate = 61%).

MEASURES

Overall satisfaction and gender-specific satisfaction as measured by the Primary Care Satisfaction Survey for Women (PCSSW).

ANALYSIS

We dichotomized the satisfaction scores (excellent versus all other), and compared excellent satisfaction in WCs versus TCs using logistic regression, controlling for demographics, health status, health care use, and location.

RESULTS

Women enrolled in WCs were more likely than those in TCs to report excellent overall satisfaction (odds ratio, 1.42; 95% confidence interval, 1.00 to 2.02; P = .05). Multivariate models demonstrated that receipt of care in WCs was a significant positive predictor for all 5 satisfaction domains (i.e., getting care, privacy and comfort, communication, complete care, and follow-up care) with the gender-specific satisfaction instrument (PCSSW).

CONCLUSIONS

This study is the first to consistently show higher satisfaction in WCs versus TCs despite age and race differences and comparable health status. Since these WCs show better quality in terms of satisfaction, other quality indicators should be evaluated. If WCs reduce fragmentation and improve health care delivery, the model will be applicable in VA and non-VA outpatient settings.

Alcohol, dementia, and Alzheimer's disease: comparison of neuropsychological profiles

Thirty-nine detoxified elderly alcoholics (mean age = 65.85) completed a comprehensive assessment designed to identify individuals meeting DSM-IV criteria for alcohol-related dementia. Ten subjects meeting criteria (mean age = 69.8; mean Mini-Mental State Examination [MMSE] = 25.1) were compared to the 29 nondemented alcoholics (mean age = 64.5; mean MMSE = 27.8), 9 patients with Alzheimer's disease (mean age = 73.4; mean MMSE = 22.3), and 15 control subjects (mean age = 70.8; mean MMSE = 28). Comparison of neuropsychological test scores revealed several statistically significant differences. Furthermore, the overall pattern of test performance between the two demented groups was different. Alzheimer's patients were more impaired on confrontation naming, recognition memory, animal fluency, and orientation. Alcohol dementia subjects were more impaired than controls on initial letter fluency, fine motor control, and free recall. However, alcohol dementia subjects did not differ from controls on tests of verbal recognition memory. This study suggests that it is possible to clinically differentiate the cognitive deficits of alcohol-related dementia from typical Alzheimer's disease. However, the results are preliminary and are based on small sample sizes so should be interpreted with caution.

Salary equity among male and female internists in Pennsylvania

BACKGROUND

Women constitute an increasing proportion of physicians in the United States. Historically, inequities have existed between male and female physicians in professional advancement, but evidence has suggested that disparities in salary are resolving.

OBJECTIVE

To examine the current state of salary equity among male and female internists.

DESIGN

Population-based survey mailed to all Board-certified female internists and a matched group of male internists who had graduated from medical school 10 to 30 years ago and were currently practicing.

SETTING

Pennsylvania.

PARTICIPANTS

232 male and 213 female internists for whom data were complete.

MEASUREMENTS

Respondents answered questions about demographic characteristics, training, practice type and setting, status within the practice, family life, and salary.

RESULTS

Women were more likely to be involved in the least lucrative practice arrangements. They were more likely to be in low-paying specialties, to not be a partner in the practice, and to be salaried employees; they also spent fewer hours per week seeing patients. Even after adjustment for these differences, hourly earnings were significantly higher (14%) among men than among their female colleagues. Men's earnings significantly exceeded women's earnings among physicians with no academic affiliation, those in high-earning specialties, and those in general internal medicine.

CONCLUSIONS

Significant salary differentials exist between male and female internists overall and in various medical practice settings.

A method for assessing the impact of a computer-based decision support system on health care outcomes

The wide variation in utilization of diagnostic resources has not been decreased by the proliferation of new diagnostic technologies. We wish to test the hypothesis that the introduction of a medical decision support system into clinical practice could potentially lead to more efficient use of diagnostic information, and therefore lead to a reduction in overall laboratory use and cost of care. We have devised and are currently implementing a randomized controlled trial of a computer based decision support system, the University of Pittsburgh version of Quick Medical Reference (QMR). The main purpose of the study is to determine the effect of the QMR program on specific outcome measures: length of hospital stay, number and types of diagnostic tests ordered, and overall charges. An important part of this evaluation is relating the initial level of diagnostic uncertainty expressed by the admitting housestaff team to utilization of diagnostic resources. The purpose of this paper is to describe the methodology for carrying out this controlled trial, and to describe our initial experiences with its implementation.

Effect of a computer-assisted general medicine diagnostic consultation service on housestaff diagnostic strategy

Quick Medical Reference (QMR) is a microcomputer-based decision support system designed to provide diagnostic assistance in the field of internal medicine. In addition to providing plausible diagnostic hypotheses based upon patient specific findings, the program highlights history, physical and laboratory items which are potentially useful in discriminating among the diagnoses under consideration. We have evaluated the impact of a computer-assisted diagnostic consultation service on the diagnostic and management strategy of a housestaff in a university internal medicine training program. Differential diagnoses were obtained before and after the use of the program, and a questionnaire was used to assess the educational value of the service and the effect of the service on the diagnosis and planned management. Over an eight week period, 31 cases were identified which met inclusion criteria. The QMR consultation added a diagnosis to the original list in 14 out of 31 cases. The consultation reordered the diagnosis in an additional 7 cases, and in 8 cases a diagnosis was ruled out by the use of the program. After the use of the program the housestaff reported they would obtain an additional lab test in 10 cases, change the order of planned tests in two cases and eliminate a lab test in one case. The use of the program was rated as helpful educationally in 81% of the cases, and helpful with respect to management in also 81% of the cases.

A computer-assisted medical diagnostic consultation service. Implementation and prospective evaluation of a prototype

STUDY OBJECTIVE

To evaluate the accuracy of a computer-aided consultation service using academic general internists and the Quick Medical Reference (QMR) diagnostic program: and to study the impact of the consultation on the diagnostic behavior of physicians caring for patients.

DESIGN

Prospective study of the diagnostic accuracy of computer-aided consultation in 31 cases, as well as a prospective study of ward team diagnoses and opinions before and after consultation.

SETTING

General medicine wards of two tertiary care centers.

PARTICIPANTS

Thirty-one patients identified as posing a diagnostic challenge and meeting eligibility criteria, as well as the housestaff caring for these patients.

MEASUREMENTS AND MAIN RESULTS

After 6 months follow-up, diagnoses were established in 20 of 31 cases. The diagnostic sensitivity of the computer-assisted diagnoses, 85% (95% CI, 56% to 97%), was similar to that of the consult service physicians, 80% (95% CI, 55% to 94%), but better than that of the ward teams, 60% (95% CI, 33% to 81%; P = 0.03 using the binomial test). The consultation influenced the postconsultation differential diagnoses of the ward teams in 26 of the 31 cases (95% CI, 92% to 95%). House officers rated the consultation service as being educationally helpful in 25 of the 31 cases (95% CI, 62% to 94%).

CONCLUSIONS

Computer-aided diagnostic consultation, when provided by physicians familiar with the limitations of the system and capable of overriding inappropriate suggestions, was both accurate and educationally helpful in most cases. The system provided reasonable diagnostic suggestions not previously considered by the ward teams and these suggestions were valued sufficiently to cause alteration of the original differential diagnoses.

The INTERNIST-1/QUICK MEDICAL REFERENCE project--status report

INTERNIST-1 and its successor, QUICK MEDICAL REFERENCE (QMR), are computer programs designed to provide health care professionals with diagnostic assistance in general internal medicine. Both programs rely on the INTERNIST-1 computerized knowledge base, which comprehensively describes 570 diseases in internal medicine. The philosophies behind the development of each program differ. Whereas INTERNIST-1 functions solely as a high-powered diagnostic consultant program, the QMR program acts more as an information tool, providing users with multiple ways of reviewing and manipulating the diagnostic information in the program's knowledge base. At the lowest level, the program can be viewed as an electronic textbook of medicine. In addition, the QMR program has the ability to assist users with generating hypotheses in complex patient cases. The QMR program has not been evaluated formally as an information tool for practicing physicians. A preliminary study indicates that QMR's case-analysis capabilities are of potential benefit in most patients in internal medicine admitted for diagnostic evaluation.

Hearing loss and erythromycin pharmacokinetics in a patient receiving hemodialysis

A left upper lobe pneumonia developed in a patient who was receiving hemodialysis; he was treated intravenously with 1 g of erythromycin lactobionate every six hours. After five doses, hearing loss was noted; this was later documented by audiogram. Erythromycin serum concentrations as high as 100 mg/L and a half-life more than three times longer than normal were observed. To our knowledge, this represents the first report of reversible hearing loss associated with elevated serum erythromycin concentrations and prolonged serum half-life.