Structured interdisciplinary bedside rounds improve interprofessional communication and workplace efficiency among residents and nurses on an inpatient internal medicine unit

Structured Interdisciplinary Bedside Rounds (SIBR) is a standardized, team-based intervention for hospitals to deliver high quality interprofessional care. Despite its potential for improving IPC and the workplace environment, relatively little is known about SIBR's effect on these outcomes. Our study aimed to assess the fidelity of SIBR implementation on an inpatient medicine teaching unit and its effects on perceived IPC and workplace efficiency. We conducted a quasi-experimental study with 88 residents and 44 nurses at a large academic medical center and observed 1308 SIBR encounters over 24 weeks. Of these 1308 encounters, the bedside nurse was present for 96.7%, physician for 97.6%, and care manager for 94.7, and 64.7% occurred at the bedside. Following SIBR implementation, perceived IPC improved significantly among residents (93.3% versus 67.9%, p < .024) and nurses (73.7% versus 36.0%, p < .008) compared to before implementation. Moreover, residents perceived greater workplace efficiency operationalized as being paged less frequently with questions by nurses (20.0% versus 49.1%, p = .01). No statistically significant improvements were reported regarding burnout, meaning at work, and workplace satisfaction. Our implementation of SIBR significantly improved perceived IPC and workplace efficiency, which are two important domains of healthcare quality. Future work should examine the impact of SIBR on patient-centered outcomes such as patient experience.

Implementation of simulation-based health systems science modules for resident physicians

BACKGROUND

Health system science (HSS) encompasses both core and cross-cutting domains that emphasize the complex interplay of care delivery, finances, teamwork, and clinical practice that impact care quality and safety in health care. Although HSS skills are required during residency training for physicians, current HSS didactics have less emphasis on hands-on practice and experiential learning. Medical simulation can allow for experiential participation and reflection in a controlled environment. Our goal was to develop and pilot three simulation scenarios as part of an educational module for resident physicians that incorporated core and cross-cutting HSS domains.  METHODS: Each scenario included a brief didactic, an interactive simulation in small-group breakout rooms, and a structured debriefing. The case scenario topics consisted of educational leadership, quality and safety, and implementation science. Learners from four residency programs (psychiatry, emergency medicine, orthopedics, ophthalmology) participated January - March 2021.

RESULTS

A total of 95 resident physicians received our curricular module, and nearly all (95%) participants who completed a post-session survey reported perceived learning gains. Emotional reactions to the session were positive especially regarding the interactive role-play format. Recommendations for improvement included participation from non-physician professions and tailoring of scenarios for specific disciplines/role. Knowledge transfer included use of multiple stakeholder perspectives and effective negotiation by considering power/social structures.

CONCLUSIONS

The simulation-based scenarios can be feasibly applied for learner groups across different residency training programs. Simulations were conducted in a virtual learning environment, but future work can include in-person and actor-based simulations to further enhance emotional reactions and the reality of the case scenarios.

Hypertensive Urgency: An Emergency Department Pipeline to Primary Care Pilot Study

BACKGROUND

Optimal triage of patients with hypertensive urgency (HU) in the emergency department (ED) is not well established. 2017 ACC/AHA hypertension (HTN) guidelines recommend treatment initiation and follow-up within 1 week. Objectives of our pilot study were to evaluate feasibility and impact of directly connecting ED patients with HU to outpatient HTN management on blood pressure (BP) control and ED utilization.

METHODS

ED patients with HU and no primary care physician were scheduled by a referral coordinator for an initial appointment in a HTN clinic embedded within a primary care practice. BP control and ED utilization over the subsequent 90 days were tracked and compared with BP at time of the referral ED visit, and ED utilization in the 90 days preceding referral.

RESULTS

Data are reported for the first 40 referred patients. Average time to first visit was 7.8 days. Mean age was 51 years (range 28-76), 75% were African-American, and mean pooled 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 20.8%. Mean BP declined from 198/116 mm Hg at ED visit to 167/98 mm Hg at HTN clinic visit 1 to 136/83 by 6 weeks and was sustained at 90 days. Total ED visits for the group decreased from 61 in the 90 days prior to referral, to 18 in the 90 days after the first HTN clinic visit.

CONCLUSIONS

In this pilot study, coordinated referral between the ED and primary care provides safe, timely care for this high ASCVD risk population and leads to sustained reductions in BP and ED utilization.

What's it Worth?: The Costs and Benefits of an Initiative to Decrease Post-Call Fatigued Driving Among Surgery Residents

BACKGROUND

In 2017 the ACGME enacted new regulations requiring sponsoring institutions to ensure "safe transportation options for residents who may be too fatigued to safely return home." We investigate here the impact of a pilot "Safe Ride" program designed to mitigate the risks of fatigued driving.

METHODS

During a 2-month pilot period at a single university-affiliated general surgery residency with four urban clinical sites, all residents (n = 72) were encouraged to hire a rideshare (e.g., Uber, Lyft) to and from 24-h clinical shifts if they felt too fatigued to drive safely. The cost of the rideshare was fully reimbursed to the resident. The impact of this intervention was evaluated using utilization data and a post-intervention resident survey.

RESULTS

A total of 16.6% of trainees utilized a rideshare at least one time. Sixty-three post-call rides were taken, predominantly by junior residents (92.4%) and for commutes greater than 15 miles (91%). The cost for the 60-day pilot was $3030. Comparing pre-intervention to post-intervention data, there was a significant improvement in the reported frequency of falling asleep or nearly asleep while driving (P < 0.001). Trainees nearly unanimously (98%) supported efforts to make the program permanent.

DISCUSSION

Driving while fatigued is common among surgical residents, with increased risk among junior residents, during longer commutes and following longer shifts. A reimbursed rideshare program effectively targets these risk factors and was associated with a significant decrease in rates of self-reported fatigued driving. Future efforts should focus on strategies to promote use of reimbursed rideshare programs while remaining cost efficient.

Collaborative leadership: organisational structure and institutional investment to multiply innovative educational efforts among trainees

Background

Trainees comprise a substantial employee population worldwide and there is increasing perspective of leadership as a foundational skill of physician development. In the USA, the Accreditation Council for Graduate Medical Education mandates a ‘Resident/Fellow Forum’ to facilitate cross-institutional engagement and communication with the Graduate Medical Education Committee.

Interventions

To increase effectiveness, we conceived a ‘Senate’ in place of a forum, incorporating broader housestaff representation and partnerships with faculty and hospital executive leadership. The ‘Yale-New Haven Hospital Resident and Fellow Senate’ was supported by hospital financial resources and faculty mentorship. It provided leadership development, enhanced interdepartmental, connected multiple medical specialties, and improved housestaff engagement with institutional leaders. The Senate comprised an elected Executive Board and five councils in areas of common interest with appointed Chairs and members at large.

Conclusions

We summarise the Senate’s conception, structure, election process, lessons learnt and associated impact. We conclude that the creation of an institutionally supported Senate with interest-specific councils and faculty mentorship leads to qualitatively positive downstream effects on housestaff social interactions, institutional engagement and leadership opportunities.

Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation

IMPORTANCE

Previous studies have shown that medical student mistreatment is common. However, few data exist to date describing how the prevalence of medical student mistreatment varies by student sex, race/ethnicity, and sexual orientation.

OBJECTIVE

To examine the association between mistreatment and medical student sex, race/ethnicity, and sexual orientation.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The questionnaire annually surveys graduating students at all 140 accredited allopathic US medical schools. Participants were graduates from allopathic US medical schools in 2016 and 2017. Data were analyzed between April 1 and December 31, 2019.

MAIN OUTCOMES AND MEASURES

Prevalence of self-reported medical student mistreatment by sex, race/ethnicity, and sexual orientation.

RESULTS

A total of 27 504 unique student surveys were analyzed, representing 72.1% of graduating US medical students in 2016 and 2017. The sample included the following: 13 351 female respondents (48.5%), 16 521 white (60.1%), 5641 Asian (20.5%), 2433 underrepresented minority (URM) (8.8%), and 2376 multiracial respondents (8.6%); and 25 763 heterosexual (93.7%) and 1463 lesbian, gay, or bisexual (LGB) respondents (5.3%). At least 1 episode of mistreatment was reported by a greater proportion of female students compared with male students (40.9% vs 25.2%, P < .001); Asian, URM, and multiracial students compared with white students (31.9%, 38.0%, 32.9%, and 24.0%, respectively; P < .001); and LGB students compared with heterosexual students (43.5% vs 23.6%, P < .001). A higher percentage of female students compared with male students reported discrimination based on gender (28.2% vs 9.4%, P < .001); a greater proportion of Asian, URM, and multiracial students compared with white students reported discrimination based on race/ethnicity (15.7%, 23.3%, 11.8%, and 3.8%, respectively; P < .001), and LGB students reported a higher prevalence of discrimination based on sexual orientation than heterosexual students (23.1% vs 1.0%, P < .001). Moreover, higher proportions of female (17.8% vs 7.0%), URM, Asian, and multiracial (4.9% white, 10.7% Asian, 16.3% URM, and 11.3% multiracial), and LGB (16.4% vs 3.6%) students reported 2 or more types of mistreatment compared with their male, white, and heterosexual counterparts (P < .001).

CONCLUSIONS AND RELEVANCE

Female, URM, Asian, multiracial, and LGB students seem to bear a disproportionate burden of the mistreatment reported in medical schools. It appears that addressing the disparate mistreatment reported will be an important step to promote diversity, equity, and inclusion in medical education.

The Changing Face of HIV Care: Expanding HIV Training in an Internal Medicine Residency Program

PROBLEM

People with HIV/AIDS are living longer and are at an increased risk of comorbidities. A qualified physician workforce is needed to care for this growing population.

APPROACH

In 2012, a novel three-year HIV training track (HIV TT) was implemented as part of the Yale Primary Care Residency Program. To prepare for the implementation of this program, a needs assessment was performed, a web-based curriculum and 12 HIV-specific entrustable professional activities (EPAs) were created, and adequate clinical training opportunities in HIV and primary care were established. Program evaluation included process, learner, and outcome evaluations from 2012 to 2017.

OUTCOMES

Since its inception, the HIV TT has enrolled a total of 11 residents (6-7 at a time), with 5 graduating to date. Residents delivered high-quality HIV and primary care for a diverse panel of patients; improved their knowledge and performance in HIV care, including according to the HIV-specific EPAs; and were highly satisfied with the program. All faculty remained with the program, and patients indicated satisfaction.

NEXT STEPS

Next steps include enhanced coordination of residents' schedules, improved EPA documentation, evaluation of residents' HIV and non-HIV competence beyond residency, and monitoring graduates' career trajectories. Expanding HIV training within internal medicine residency programs is feasible and effective and has the potential to alleviate the shortage of physicians trained to provide HIV care and primary care in a single setting.

Minority Resident Physicians' Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace

IMPORTANCE

Black, Hispanic, and Native American physicians remain underrepresented in medicine despite national efforts to increase diversity in the health care workforce. Understanding the unique workplace experiences of minority physicians is essential to inform strategies to create a diverse and inclusive workforce. While prior research has explored the influence of race/ethnicity on the experiences of minority faculty and medical students, there is a paucity of literature investigating how race/ethnicity affects the training experiences of resident physicians in graduate medical education.

OBJECTIVE

To characterize how black, Hispanic, and Native American resident physicians experience race/ethnicity in the workplace.

DESIGN, SETTING, AND PARTICIPANTS

Semistructured, in-depth qualitative interviews of black, Hispanic, and Native American residents were performed in this qualitative study. Interviews took place at the 2017 Annual Medical Education Conference (April 12-17, 2017, in Atlanta, Georgia), sponsored by the Student National Medical Association. Interviews were conducted with 27 residents from 21 residency programs representing a diverse range of medical specialties and geographic locations.

MAIN OUTCOMES AND MEASURES

The workplace experiences of black, Hispanic, and Native American resident physicians in graduate medical education.

RESULTS

Among 27 participants, races/ethnicities were 19 (70%) black, 3 (11%) Hispanic, 1 (4%) Native American, and 4 (15%) mixed race/ethnicity; 15 (56%) were female. Participants described the following 3 major themes in their training experiences in the workplace: a daily barrage of microaggressions and bias, minority residents tasked as race/ethnicity ambassadors, and challenges negotiating professional and personal identity while seen as "other."

CONCLUSIONS AND RELEVANCE

Graduate medical education is an emotionally and physically demanding period for all physicians. Black, Hispanic, and Native American residents experience additional burdens secondary to race/ethnicity. Addressing these unique challenges related to race/ethnicity is crucial to creating a diverse and inclusive work environment.

A Collaborative Initiative to Improve the Care of Elderly Medicare Patients With Hypertension

Qualidigm, the Connecticut Quality Improvement Organization (QIO), collaborated with 17 primary care physicians (PCPs) in private practice to improve the care of elderly patients with hypertension. Patients were identified from Medicare billing data and care was assessed from medical records. Improvement interventions included feedback of baseline performance data and provision of a variety of practice enhancing materials. Care was assessed for 590 patients in 1997 (16-47 patients/PCP) and 547 patients in 1999 (7-51 patients/PCP). Patient characteristics were similar in both periods. Use of recommended therapies and blood pressure control, ie, percent < 140/90 mm Hg, was low and did not improve significantly between the 2 periods (aggregate 39% in 1997 versus 42% in 1999; P = .24). Care of elderly patients with hypertension was not improved with a multifaceted QIO intervention. Additional study is required to determine incentives, barriers, and facilitating factors for quality improvement in the private practice primary care setting.

The residency application abyss: insights and advice

Most medical students apply for residency training upon completion of medical school. The choice of specialty is one of a student's first major career decisions, and the application process often results in considerable anxiety, as it is competitive, unpredictable, and requires a significant investment of time and money. This article, which addresses several important facets of the residency application using both experiential and evidence-based data, is organized chronologically into sections that describe a logical approach to applying for residency: choice of a specialty, the personal statement, the interview day, and developing a rank list. A list of relevant websites is also included. This paper is a resource that provides timely and tangible guidance to medical students applying for residency training.

The association of faculty and residents' gender on faculty evaluations of internal medicine residents in 16 residencies

PURPOSE

Previous studies have found gender bias in the global evaluations of trainees. The purpose of this study was to investigate the association of faculty and residents' gender on the evaluation of residents' specific clinical skills, using direct observation.

METHOD

In 2001-2002, 40 clinician-educators from 16 internal medicine residency programs viewed a series of nine scripted videotapes depicting varying levels of residents' clinical performance in medical interviewing, physical examination, and counseling. Differences in the ratings of women versus men faculty, in relation to differences in the residents' gender, were compared using random-effects regression analysis.

RESULTS

There were no statistically or educationally significant differences in the rating of clinical skills attributable to faculty or residents' gender for medical interviewing, physical examination, or counseling.

CONCLUSIONS

This study suggests that gender bias may be less prevalent in the current era of evaluation of clinical skills, particularly when specific skills are directly observed by faculty. Further work is needed to examine whether the findings of this study translate to the actual training setting.

Medicine residents' understanding of the biostatistics and results in the medical literature

CONTEXT

Physicians depend on the medical literature to keep current with clinical information. Little is known about residents' ability to understand statistical methods or how to appropriately interpret research outcomes.

OBJECTIVE

To evaluate residents' understanding of biostatistics and interpretation of research results.

DESIGN, SETTING, AND PARTICIPANTS

Multiprogram cross-sectional survey of internal medicine residents.

MAIN OUTCOME MEASURE

Percentage of questions correct on a biostatistics/study design multiple-choice knowledge test.

RESULTS

The survey was completed by 277 of 367 residents (75.5%) in 11 residency programs. The overall mean percentage correct on statistical knowledge and interpretation of results was 41.4% (95% confidence interval [CI], 39.7%-43.3%) vs 71.5% (95% CI, 57.5%-85.5%) for fellows and general medicine faculty with research training (P < .001). Higher scores in residents were associated with additional advanced degrees (50.0% [95% CI, 44.5%-55.5%] vs 40.1% [95% CI, 38.3%-42.0%]; P < .001); prior biostatistics training (45.2% [95% CI, 42.7%-47.8%] vs 37.9% [95% CI, 35.4%-40.3%]; P = .001); enrollment in a university-based training program (43.0% [95% CI, 41.0%-45.1%] vs 36.3% [95% CI, 32.6%-40.0%]; P = .002); and male sex (44.0% [95% CI, 41.4%-46.7%] vs 38.8% [95% CI, 36.4%-41.1%]; P = .004). On individual knowledge questions, 81.6% correctly interpreted a relative risk. Residents were less likely to know how to interpret an adjusted odds ratio from a multivariate regression analysis (37.4%) or the results of a Kaplan-Meier analysis (10.5%). Seventy-five percent indicated they did not understand all of the statistics they encountered in journal articles, but 95% felt it was important to understand these concepts to be an intelligent reader of the literature.

CONCLUSIONS

Most residents in this study lacked the knowledge in biostatistics needed to interpret many of the results in published clinical research. Residency programs should include more effective biostatistics training in their curricula to successfully prepare residents for this important lifelong learning skill.

Internal medicine residents' clinical and didactic experiences after work hour regulation: a survey of chief residents

BACKGROUND

Work hour regulations for house staff were intended in part to improve resident clinical and educational performance.

OBJECTIVE

To characterize the effect of work hour regulation on internal medicine resident inpatient clinical experience and didactic education.

DESIGN

Cross-sectional mail survey.

PARTICIPANTS

Chief residents at all accredited U.S. internal medicine residency programs outside New York.

MEASUREMENTS AND MAIN RESULTS

The response rate was 62% (202/324). Most programs (72%) reported no change in average patient load per intern after work hour regulation. Many programs (48%) redistributed house staff admissions through the call cycle. The number of admissions per intern on long call (the day interns have the most admitting responsibility) decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly (12.7 vs 12.4, P = .12), but 56% of programs reported a decrease in intern attendance at educational activities.

CONCLUSIONS

In response to work hour regulation, many internal medicine programs redistributed rather than reduced residents' inpatient clinical experience. Hours allotted to educational activities did not change; however, most programs saw a decrease in intern attendance at conferences, and many reduced third-year elective time.

Transfers of patient care between house staff on internal medicine wards: a national survey

BACKGROUND

Transfer of responsibility for patient care between physicians is a key process in the care of hospitalized patients. Systems of transfer management and transfer frequency may affect clinical outcomes.

METHODS

To characterize the systems by which patient information is transferred ("signed out") between resident physicians in internal medicine residency programs and to determine the impact of recently enacted resident work-hour regulations on the frequency of transfers, we mailed a self-administered survey to chief residents at 324 accredited US internal medicine residency programs outside of New York State. The main outcome measures were sign-out practices, skills training, and transfer frequency.

RESULTS

Surveys were returned from 202 programs (62%). Transfer systems varied among and within institutions: 55% did not consistently require both a written and an oral sign-out at transfers of care, 34% left sign-out to interns alone, and 59% had no means of informing nurses that a transfer had taken place. In addition, 60% of the programs did not provide any lectures or workshops on sign-out skills. After work-hour regulations were instituted, transfers of care for a hypothetical patient increased by a mean of 11% (from 7.0 to 7.8 transfers; P<.001) during a Monday-Friday hospitalization. A member of the primary team was in the hospital for 47% of the hospitalization.

CONCLUSION

Although transfers of care are increasingly frequent, few internal medicine residency programs have comprehensive transfer of care systems in place, and most do not provide formal training in sign-out skills to all residents.

Effects of training in direct observation of medical residents' clinical competence: a randomized trial

BACKGROUND

Faculty observation of residents and students performing clinical skills is essential for reliable and valid evaluation of trainees.

OBJECTIVE

To evaluate the efficacy of a new multifaceted method of faculty development called direct observation of competence training.

DESIGN

Controlled trial of faculty from 16 internal medicine residency programs using a cluster randomization design.

SETTING

Academic medical centers.

PARTICIPANTS

40 internal medicine teaching faculty members: 17 in the intervention group and 23 in the control group.

MEASUREMENTS

Changes in faculty comfort performing direct observation, faculty satisfaction with workshop, and changes in faculty rating behaviors 8 months after completing the training.

INTERVENTION

The direct observation of competence workshop combines didactic mini-lectures, interactive small group and videotape evaluation exercises, and evaluation skill practice with standardized residents and patients.

RESULTS

37 faculty members (16 in the intervention group and 21 in the control group) completed the study. Most of the faculty in the intervention group (14 [88%]) reported that they felt significantly more comfortable performing direct observation compared with control group faculty (4 [19%]) (P = 0.04), and all intervention faculty rated the training as outstanding. For 9 videotaped clinical encounters, intervention group faculty were more stringent than controls in their evaluations of medical interviewing, physical examination, and counseling; differences in ratings for medical interviewing and physical examination remained statistically significant even after adjustment for baseline rating behavior.

LIMITATIONS

The study involved a limited number of residency programs, and faculty did not rate the performance of actual residents.

CONCLUSION

Direct observation of competence training, a new multifaceted approach to faculty development, leads to meaningful changes in rating behaviors and in faculty comfort with evaluation of clinical skills.

Teaching and learning in an 80-hour work week: a novel day-float rotation for medical residents

The 80-hour workweek limit for residents provides an opportunity for residency directors to creatively innovate their programs. Our novel day-float rotation augmented both the educational structure within the inpatient team setting and the ability for house staff to complete their work within the mandated limits. Descriptive evaluation of the rotation was performed through an end-of-rotation questionnaire. The average length of the ward residents' work week was quantified before and after the rotation's implementation. Educational portfolios and mentored peer-teaching opportunities enriched the rotation. As measured by our evaluation, this new rotation enhanced learning and patient care while reducing work hours for inpatient ward residents.

Feedback and the mini clinical evaluation exercise

We studied the nature of feedback given after a miniCEX. We investigated whether the feedback was interactive; specifically, did the faculty allow the trainee to react to the feedback, enable self-assessment, and help trainees to develop an action plan for improvement. Finally, we investigated the number of types of recommendations given by faculty. One hundred and seven miniCEX feedback sessions were audiotaped. The faculty provided at least 1 recommendation for improvement in 80% of the feedback sessions. The majority of the sessions (61%) involved learner reaction, but in only 34% of the sessions did faculty ask for self-assessment from the intern and only 8% involved an action plan from the faculty member. Faculty are using the miniCEX to provide recommendations and often encourage learner reaction, but are underutilizing other interactive feedback methods of self-assessment and action plans. Programs should consider both specific training in feedback and changes to the miniCEX form to facilitate interactive feedback.

Physician leadership: enhancing the career development of academic physician administrators and leaders

As the health care environment grows more complex, there is greater opportunity for physician administrative and management leadership. Although physicians in general, and academic physicians in particular, view management as outside their purview, the increased importance of physician administrative leadership represents an opportunity for academic physicians interested in working at the interface of clinical medicine, health care, finance, and management. These physicians are called academic physician administrators and leaders (APALs). APALs are clinician-administrators whose academic contributions include both scholarly work related to their administrative duties and administrative leadership of academically important programs. However, existing academic career development infrastructure, such as academic promotions, is oriented toward traditional clinician-educator and clinician-researcher faculty. The APAL career path differs from traditional academic pathways because APALs require unique skills, different mentors, and a more expansive definition of academic productivity. This article describes how academic medical institutions could enhance the career development of academic physicians in administrative and leadership positions.

The development and implementation of a curriculum to improve clinicians' self-directed learning skills: a pilot project

BACKGROUND

Clinicians need self-directed learning skills to maintain competency. The objective of this study was to develop and implement a curriculum to teach physicians self-directed learning skills during inpatient ward rotations.

METHODS

Residents and attendings from an internal medicine residency were assigned to intervention or control groups; intervention physicians completed self-directed learning curricular exercises.

RESULTS

Among the 43 intervention physicians, 21 (49%) completed pre- and post-curriculum tests; and 10 (23%) completed the one-year test. Immediately after exposure to the curriculum, the proportion of physicians defining short- and long-term learning goals increased [short-term: 1/21 (5%) to 11/21 (52%), p = 0.001; long-term: 2/21 (10%) to 15/21 (71%), p = 0.001]. There were no significant changes post-curriculum in the quantity or quality of clinical question asking. The physicians' mean self-efficacy (on a 100-point scale) improved for their abilities to develop a plan to keep up with the medical literature (59 vs. 72, p = 0.04). The effects of the curriculum on self-reported learning behaviors was maintained from the immediate post-curriculum test to the one-year post curriculum test: [short-term learning goals: 1/21 (5%) pre-, 11/21 (52%) immediately post-, and 5/10 (50%) one-year after the curriculum (p = 0.0075 for the pre- vs one-year comparison); long-term learning goals: 2/21 (10%) pre-, 15/21 (71%) immediately post-, and 7/10 (70%) one-year (p = 0.0013 for the pre- vs one-year comparison). At one-year, half of the participants reported changed learning behaviors.

CONCLUSIONS

A four-week curriculum may improve self-directed learning skills.

Utility of captopril renal scans for detecting renal artery stenosis

BACKGROUND

Captopril renal scanning (CRS) is commonly recommended as a noninvasive method for detecting renal artery stenosis (RAS), based on performance characteristics determined in research settings. Scant data are available, however, regarding the utility of CRS in clinical practice.

METHODS

We evaluated the performance characteristics (sensitivity, specificity, and predictive values) of CRS in a consecutive series of 90 patients who underwent both CRS and renal arteriography within a 6-month period (January 1, 1991, through December 31, 1995) at a university hospital.

RESULTS

Among 86 eligible patients (and 169 kidneys), the prevalence of RAS was 43%. The sensitivity of CRS was 74% (95% confidence interval [CI], 62%-83%); the specificity was 59% (95% CI, 49%-69%); the positive predictive value was 58% (95% CI, 47%-68%); and the negative predictive value was 75% (95% CI, 64%-84%). Also, there was evidence of spectrum bias, because the sensitivity and specificity (as well as the positive and negative predictive values) were different for groups with and without vascular disease.

CONCLUSIONS

The results of CRS were substantially worse in a clinical practice setting than previously reported in research settings, despite a similar prevalence of RAS. Captopril renal scanning should not be used as an initial screening test for diagnosing RAS, even among patients with high clinical likelihood of disease.

Cardiovascular disease in neurofibromatosis 1: report of the NF1 Cardiovascular Task Force

PURPOSE

Patients with neurofibromatosis 1 (NF1) are at increased risk for a variety of cardiovascular disorders, but the natural history and pathogenesis of these abnormalities are poorly understood.

METHODS

The National Neurofibromatosis Foundation convened an expert task force to review current knowledge about cardiovascular manifestations of NF1 and to make recommendations regarding clinical management and research priorities related to these features of the disease.

RESULTS

This report summarizes the NF1 Cardiovascular Task Force's current understanding of vasculopathy, hypertension, and congenital heart defects that occur in association with NF1. Recommendations are made regarding routine surveillance for cardiovascular disease and diagnostic evaluation and management of cardiovascular disorders in individuals with NF1.

CONCLUSION

Our understanding of the natural history and pathogenesis of cardiovascular disease in NF1 has improved substantially in the past few years, but many clinically important questions remain unanswered.

Developing an Internet-based communication system for residency training programs

Administrative communication is increasingly challenging for residency programs as the number of training sites expands. The Internet provides a cost-effective opportunity to address these needs. Using the World Wide Web, we developed a single, reliable, accurate, and accessible source of administrative information for residents, faculty, and staff in a multisite internal medicine residency at reduced costs. Evaluation of the effectiveness of the website was determined by tracking website use, materials and personnel costs, and resident, staff, and faculty satisfaction. Office supply and personnel costs were reduced by 89% and personnel effort by 85%. All users were highly satisfied with the web communication tool and all reported increased knowledge of program information and a greater sense of "connectedness." We conclude that an internet-based communication system that provides a single, reliable, accurate, and accessible source of information for residents, faculty, and staff can be developed with minimum resources and reduced costs.

An organizational innovation: the Yale Primary Care Residency Program's experience with a firm system

BACKGROUND

Integrated inpatient-outpatient firms developed in residencies with single institutions may not be applicable to residency programs with multiple inpatient and outpatient training sites. Our objective was to develop a firm in a multisite residency program that improved education and patient care.

DESCRIPTION

One ward team was restructured into a firm that included two interns, three residents, and four private practice internists whose patients were admitted to the firm. Educational impact, length of stay, hospital charges, and in-hospital mortality were evaluated.

EVALUATION

The firm experience increased outpatient training, fostered mentoring relationships, and increased attending availability. Mean length of stay (5.7 vs. 6.5 days, p = .2) and mean hospital charges ($10,888 vs. $12,316, p = .8) for firm and nonfirm patients, respectively, were not different. In-hospital mortality was lower for firm patients (9 of 348, 3%, vs. 87 of 1,565, 6%; p = .02).

CONCLUSIONS

Firm structures with educational and patient care advantages can be instituted in multisite residencies.

Metabolic complications of urinary diversions: an overview

Patients with urinary diversions present unique challenges to internists who have an important role in their long-term management. Advances in surgical techniques over the past 30 years have given rise to a number of urinary diversion procedures that use various intestinal segments. In its normal function, the intestine absorbs water and solutes. When placed in contact with the urinary stream, the intestine can create numerous metabolic abnormalities. These include bone disease, hepatobiliary disease, infection, malignancy, neurologic complications, nutritional deficiencies, and a number of electrolyte and acid-base disorders. An overview of these metabolic abnormalities and their causes is provided, as well as recommendations for screening and management of patients.

Medical Grand Rounds: refractory hypertension and renal insufficiency in a patient with renal artery stenosis

Renal artery stenosis has become increasingly common as a cause of refractory hypertension and renal insufficiency. There is a high prevalence of bilateral disease and the lesions tend to progress over time. Newer, less invasive, imaging modalities such as doppler ultrasound, magnetic resonance angiography, and spiral CT scanning are evolving technologies in the diagnosis of renal artery stenosis. Advances in surgical technique, particularly the development of extra-anatomical procedures such as spleno-renal and hepato-renal by pass, have significantly lowered surgical morbidity and mortality and provides revascularization options for patients with complex vascular disease that would previously not have been considered because of their high surgical risk. Improvements in angioplasty technique and the use of stents are broadening the types of lesions that can be successfully approached with these techniques and may be particularly helpful for patients with more severe cardiac or cerebrovascular disease. The benefits of revascularization may be even greater for preservation of renal function than for control of blood pressure in properly selected patients. It is difficult to predict which patients will benefit from surgical revascularization versus medical management of RAS. Knowledge of the progressive nature of RAS, the high prevalence of bilateral disease, and the clinical characteristics that correlate with progression (e.g., decreasing renal size) are helpful in guiding clinical decisions regarding intervention. Additional studies to determine the predictive value of non-invasive tests such as CRS, doppler ultrasound before and after administration of angiotensin converting enzyme inhibitors, and other tests, are needed to assist the clinician in identifying who will benefit most from revascularization both in terms of renal function and blood pressure control.

Na(+)-H+ exchanger and its role in essential hypertension and diabetes mellitus

The Na(+)-H+ exchanger is a ubiquitous transport system that is involved in the regulation of intracellular pH, cell growth and proliferation, cell volume regulation, and transepithelial absorption of Na+, Cl-, and HCO3-. Altered activity of the Na(+)-H+ exchanger has been implicated as a mechanism contributing to the development of high blood pressure in subgroups of patients with essential hypertension and in various animal models of hypertension. Many of these studies measured Na(+)-Li+ exchange rather than Na(+)-H+ exchange, hypothesizing that Na(+)-Li+ exchange represents a functional mode of the Na(+)-H+ exchanger. However, this is a controversial assumption. Several studies have also shown an association between erythrocyte Na(+)-Li(+)-exchange rate and predisposition to nephropathy in patients with insulin-dependent diabetes mellitus. The recent cDNA cloning of at least one isoform of the Na(+)-H+ exchanger will help clarify the cellular mechanisms of regulation of the exchanger and its possible role in pathophysiological states such as hypertension.

Humoral Na+-K+ pump inhibitory activity in essential hypertension and in normotensive subjects after acute volume expansion

Plasma from black male patients with essential hypertension was bioassayed for vascular Na+-K+ pump inhibitory activity. Halves of the same rat tail artery were incubated for two hours in boiled plasma supernates from a hypertensive patient and a paired age-, sex-, and race-matched normotensive subject and then ouabain-sensitive 86Rb uptake was measured. Ouabain-sensitive 86Rb uptake by their leukocytes was also measured. Eighteen pairs of subjects were studied. The uptakes were not significantly different in the hypertensive patients and control subjects. However, when we selected from the eighteen hypertensive patients, nine with low plasma renin activity on the day of the study, uptakes were reduced in the hypertensive patients relative to the paired control subjects. We also assayed plasma supernates from normotensive black and white male subjects before and after acute volume expansion (2.5 L saline IV + 1.5 L distilled water orally over a three-hour period) and from paired normotensive subjects before and after sham volume expansion and obtained a positive bioassay in the expanded subjects both on intraindividual and interindividual comparisons. These studies demonstrate increased vascular Na+-K+ pump inhibitory activity in the plasma of black male patients with low renin essential hypertension and in the plasma of normotensive subjects after acute volume expansion. The findings suggest that the inhibitory activity in the hypertensive subjects' plasma is related to volume expansion, relative or absolute.

Identification and purification of a renal amiloride-binding protein with properties of the Na+-H+ exchanger

The aim of this study was to identify and purify the Na+-H+ exchanger from rabbit renal brush border membranes by use of affinity chromatography. Triton-solubilized membranes were equilibrated with an affinity matrix consisting of the amiloride analogue A35 (5-N-(3-aminophenyl)amiloride) covalently coupled to Sepharose CL-4B beads through a triglycine spacer arm. The matrix was then washed extensively with buffer and sequentially eluted with buffer, buffer containing 5 mM amiloride, and 1% sodium dodecyl sulfate (SDS). Eluates were concentrated and subjected to SDS-polyacrylamide gel electrophoresis. The silver-stained gel revealed a 25-kDa protein that was not visible in the initial solubilized brush border membrane extract, was not eluted from the affinity matrix by buffer alone, but was eluted with 5 mM amiloride. A subsequent elution with 1% SDS did not release any more of the 25-kDa protein, indicating that it had been completely eluted from the affinity matrix by amiloride. The presence of 5 mM amiloride during equilibration of the solubilized brush border extract with the affinity matrix completely blocked adsorption of the 25-kDa protein. The relative abundance of this protein correlated closely with Na+-H+ exchange activity when preparations of cortical brush border membrane vesicles, outer medullary brush border membrane vesicles, and cortical basolateral membrane vesicles were compared. Moreover, binding of the protein to the affinity matrix was inhibited by amiloride and amiloride analogues with a rank order identical to that for inhibition of Na+-H+ exchange activity. These findings strongly suggest that the 25-kDa protein is a structural component of the Na+-H+ exchanger.

Decreased myocardial Na+K+ATPase activity in rats with reduced renal mass-saline hypertension

Inhibition of cardiovascular Na,K-pump activity has been shown to promote an increase in the contractile activity of myocardial and vascular smooth muscle and a consequent rise in blood pressure (BP). It has also been shown that vascular Na,K-pump activity and myocardial Na+K+ATPase activity [the energy source for active sodium (Na) and potassium (K) transport] are decreased in rats with various forms of low renin hypertension including rats with reduced renal mass-saline (RRM-saline) hypertension. In the present study, left ventricular Na+K+ATPase activity from rats with RRM-saline hypertension was found to be decreased in membranes prepared by two independent methods: deoxycholate, sodium iodide (Nal)-treated microsomal fractions (method 1) and membranes prepared by the hypotonic, lithium bromide (LiBr) method (method 2). Relative to RRM normotensive control rats which drank distilled water, myocardial Na+K+ATPase activity from RRM-saline drinking rats was decreased by 18.2% in membranes prepared by method 1 and 33.6% in membranes prepared by method 2. The apparent affinities of Na+K+ATPase for K and for ouabain were unaltered relative to controls in membranes prepared from these hypertensive rats by method 1, and the sialic acid content and 5'-nucleotidase activity (two putative sarcolemmal markers) were unaltered in membranes from the hypertensive rats, prepared by methods 1 and 2 respectively. The Mg2+ATPase activity of membranes prepared by method 1 was increased in the RRM-saline hypertensive rats but because it was not increased in membranes prepared by method 2 the former observation does not appear to be of any pathophysiological importance. In other experiments, hypertension was reversed in RRM-saline hypertensive rats by restricting their salt intake (substitution of distilled water for drinking).(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial (Na+,K+)-ATPase activity in Dahl salt-sensitive and resistant rats

Vascular (Na+,K+)-pump activity (ouabain-sensitive 86Rb+ uptake) and myocardial (Na+,K+)-ATPase activity are reduced in animals with various forms of low renin, experimental hypertension. On the other hand, vascular (Na+,K+)-pump activity is increased in Dahl salt-sensitive relative to resistant rats (a genetic model of hypertension), regardless of salt intake or blood pressure and it is also increased in Dahl salt-sensitive rats on high salt (8% NaCl) relative to low salt (0.4% NaCl) diets. It has been suggested that this increase in vascular (Na+,K+)-pump activity may be secondary to an increase in the vascular sarcolemmal permeability to Na+ in these salt-sensitive rats. In the present study, (Na+,K+)-ATPase activity of left ventricular microsomal fractions, was increased in Dahl salt-sensitive relative to resistant rats on low salt diets; however, this difference disappeared when these salt-sensitive and resistant rats were placed on high salt diets. In contrast, myocardial (Na+,K+)-ATPase activity was decreased in Dahl salt-sensitive rats on high relative to low salt diets. Evidence that this decrease in (Na+,K+)-ATPase activity is not secondary to myocardial hypertrophy in the hypertensive salt-sensitive rats, and mechanisms by which decreased cardiovascular (Na+,K+)-pump activity, increased sarcolemmal permeability or both, might contribute to elevated blood pressure, are discussed.

Studies on the role of a humoral sodium-transport inhibitor and the anteroventral third ventricle (AV3V) in experimental low-renin hypertension

1. Recent studies in our laboratory suggest that Na+,K+-dependent-ATPase and Na+—K+ pump activities are reduced in cardiovascular muscle of animals with experimental low-renin hypertension.

2. We here show that these abnormalities are associated with a heat-stable ouabain-like agent in the plasma.

3. In the volume-expanded rat, an anteroventral third ventricle (AV3V) lesion decreases the level of the ouabain-like humoral factor and increases vascular Na+—K+ pump activity. These findings suggest that the humoral ouabain-like factor originates in or is influenced by the AV3V area of the brain and may help to explain why the AV3V lesion prevents or reverses one-kidney renal and one-kidney, DOCA—salt hypertension in rats.

Effect of prolonged dietary administration of vanadate on blood pressure in the rat

Vanadate, a potent naturally occurring Na+,K+-ATPase inhibitor thought to have a role in regulating Na+-K+ pump activity, was fed to uninephrectomized rats drinking tap water or a 1% solution of sodium chloride for as long as 56 weeks. Feeding was achieved by adding sodium orthovanadate to normal rat chow equivalent to 100 or 200 ppm vanadium by weight. In the rats drinking tap water, systolic pressure gradually increased over a period of several weeks and then was sustained in a dose-related manner for the duration of the treatment. The increased pressure was not associated with changes in water intake, urine output, or urinary sodium excretion but correlated positively with plasma vanadium levels ranging from 0.04 to 0.27 microgram/ml. Increased pressure was associated with increased heart-to-body-weight ratio but did not appear to occur in a small group of animals drinking the 1% solution of sodium chloride. These findings, considered in the light of others, indicate that vanadate deserves continued study in relation to hypertension.

Vascular sodium-potassium pump activity in various models of experimental hypertension

1. Ouabain-sensitive 86Rb uptake was used to assess sodium-potassium pump activity in vascular smooth muscle of animals with various types of experimental hypertension. 2. The findings suggest that pump activity is suppressed in the non-genetic low renin, presumably volume-expanded forms of hypertension. 3. By contrast, pump suppression does not appear to be involved in spontaneously hypertensive rats or in salt-induced hypertension in Dahl's salt-sensitive rats. In these genetic models the primary defect may be increased cell membrane permeability.