Mortality Due to Hyperglycemic Crises in the US, 1999-2022

This study analyzes trends in US mortality attributed to both diabetic ketoacidosis and hyperosmolar hyperglycemic state from 1999-2022.

Connections and older adults

This editorial comments on the article by Neumann et al. in this issue.

Observation tool to measure patient-centered behaviors on rounds in an academic medical center

OBJECTIVE

As part of a quality improvement project, we developed and employed an observation checklist to measure patient-centered behaviors during daily rounds to assess the frequency of patient-centered behaviors among a patient-centered care (PCC) team and standard team (ST) rounds.

PATIENTS AND METHODS

On four general medicine service (GMS) teaching teams at an urban academic medical center in which housestaff rotate, we utilized an observation checklist to assess the occurrence of eight behaviors on inpatient daily rounds. The checklist covered domains of patient-centered communication, etiquette-based behaviors, and shared decision-making. One GMS team is guided by a PCC curriculum that emphasizes patient-centered communication strategies, but not specifically behaviors during bedside rounds.

RESULTS

Between August 2018 and May 2019 a trained observer completed 448 observations of patient rounding encounters using the checklist. Across all teams, 46.0% of the 8 behaviors were performed when possible, with more done on the PCC team (58.0%) than ST (42.0%), p < 0.01.

CONCLUSIONS

Performance of patient-centered behaviors during daily rounds was low overall. Despite having no specific instruction on daily rounds, patient-centered behaviors were more frequent among the teams which were part of a PCC curriculum. However, the frequency of observed behaviors was modest, suggesting that more explicit efforts to change rounding behaviors are needed. Our observational checklist may be a tool to assist in future interventions to improve patient-centered behaviors on daily rounds.

Delivering Personalized Care at a Distance: How Telemedicine Can Foster Getting to Know the Patient as a Person

The promise of precision medicine is based on the use of new technologies to better characterize patients by defining individuals in the areas of genomics, proteomics, metabolomics and other aspects of biologic variability. Wise application of modern technology can similarly transform health visits with patients, allowing for better characterization of the patient's individual life circumstances than possible in a traditional office visit. The use of, and experience with, telemedicine have increased significantly during the COVID-19 pandemic. Patients and clinicians report high satisfaction with telemedicine, and the quality of communication and patient-centeredness experienced in this setting are both rated highly. In this article, we explore the benefits offered by telemedicine in facilitating personalized care with particular focus on telemedicine delivered by video platforms. We propose strategies and skills specific to the effective implementation of personalized telemedicine, drawing on literature in patient-centered communication and home visits. While traditional in-person office visits continue to offer important opportunities such as thorough physical examination and the potential for enhanced non-verbal communication, telemedicine offers many important advantages that can facilitate the process of getting to know the patient as a person.

Internal Medicine Residents' Views About Care Transitions: Results of an Educational Intervention

PROBLEM

Suboptimal care transitions can lead to re-hospitalizations.

INTERVENTION

We developed a 2-week "Transitions of Care Curriculum" to train first-year internal medicine residents to improve their knowledge and skills to deliver optimal transitional care. Our objective was to use reflective writing essays to evaluate the impact of the curriculum on the residents.

METHODS

The rotation included: Transition of Care Teaching modules, Transition Audit, Transitional Care Site Visits, and Transition of Care Conference. Residents performed the above elements of care transitions during the curriculum and wrote reflective essays about their experiences. These essays were analyzed to assess for the overall impact of the curriculum on the residents.Qualitative analysis of reflective essays was used to evaluate the impact of the curriculum. Of the 20 residents who completed the rotation, 18 reflective essays were available for qualitative analysis.

RESULTS

Five major themes identified in the reflective essays for improvement were: discharge planning, patient-centered care, continuity of care, goals of care discussions, and patient safety. The most discussed theme was continuity of care, with following subthemes: fragmentation of the healthcare system, disjointed care to the patients, patient specific factors contributing to lack of continuity of care, lack of primary care provider role as a coordinator of care, and challenges during discharge process. Residents also identified system-based gaps and suggested solutions to overcome these gaps.

CONCLUSIONS

This experiential learning and use of reflective writing enhanced the residents' self-identified awareness of gaps in care transitions and prompted them to generate ideas for systems improvement and personal actions to improve their practice during care transitions.

Effects on Physician Practice After Exposure to a Patient-Centered Care Curriculum During Residency

BACKGROUND

A novel patient-centered curricular experience was implemented in an internal medicine residency program in 2007. There is little published evidence that what is taught in residency affects practice after graduation.

OBJECTIVE

We sought to evaluate whether graduates perceived any long-term effects of participation in this patient-centered curriculum.

METHODS

From July to September 2015, a web-based survey with quantitative and qualitative components was sent to graduates of the program to assess self-reported effects of this curriculum on current practice. Graduates spent 2 to 8 weeks on the intervention team during their training. Responses to open-ended questions were independently coded by 2 investigators, using the editing analysis method. Emergent themes and representative quotes are reported.

RESULTS

Of 150 residents who completed at least 1 year of training from 2007 to 2014, 94 of 110 (85%) with available email addresses responded to this survey. Of respondents, 21 (22%) were still in fellowship training, and 71 (76%) were in full-time practice. The majority responded "a great deal" when asked if the experience was valuable to their training as a physician (72 of 94, 77%) or influenced their practice (59 of 94, 63%). Free-text comments indicate that residents felt the experience enhanced their understanding of social determinants of health, communication skills, relationship building, and ability to tailor treatments to individual patients.

CONCLUSIONS

Internal medicine residency graduates reported that exposure to a curriculum focused on knowing patients as individuals had important enduring effects on their practice.

Evaluation and Management of Difficult Symptoms in Older Adults in Primary Care

This article reviews the evaluation of 4 vexing symptoms for elderly patients in primary care: leg cramps, dizziness, insomnia, and weight loss. For each, ideal evaluations are proposed.

COVID-19 Pandemic Response: Development of Outpatient Palliative Care Toolkit Based on Narrative Communication

CONTEXT

The coronavirus disease 2019 (COVID-19) pandemic laid bare the immediate need for primary palliative care education for many clinicians. Primary care clinicians in our health system reported an urgent need for support in advance care planning and end-of-life symptom management for their vulnerable patients. This article describes the design and dissemination of palliative care education for primary care clinicians using an established curriculum development method.

OBJECTIVES

To develop a succinct and practical palliative care toolkit for use by primary care clinicians during the COVID-19 pandemic, focused on 2 key elements: (i) advance care planning communication skills based on the narrative 3-Act Model and (ii) comfort care symptom management at the end of life.

RESULTS

The toolkit was finalized through an iterative process involving a team of end-users and experts in palliative care and primary care, including social work, pharmacy, nursing, and medicine. The modules were formatted into an easily navigable, smartphone-friendly document to be used at point of care. The toolkit was disseminated to our institution's primary care network with practices spanning our state. Early feedback has been positive.

CONCLUSION

While we had been focused primarily on the inpatient setting, our palliative care team at Johns Hopkins Bayview Medical Center pivoted existing infrastructure and curriculum development expertise to meet the expressed needs of our primary care colleagues during the COVID-19 pandemic. Through collaboration with an interprofessional team including end-users, we designed and disseminated a concise palliative care toolkit within 6 weeks.

A Novel Intimate Partner Violence Curriculum for Internal Medicine Residents: Development, Implementation, and Evaluation

INTRODUCTION

Intimate partner violence (IPV) is a prevalent problem with profound health consequences. Research suggests that internal medicine (IM) residents are unprepared to screen for and address IPV. We designed a curriculum to improve IM residents' knowledge, attitudes, and practices in caring for IPV survivors.

METHODS

The curriculum was delivered to first-year IM residents from 2016 to 2017 at Johns Hopkins Bayview. Part 1 was 60 minutes long, with a video, evidence-based didactic teaching, and case-based discussion. Part 2 was 90 minutes long, with evidence-based didactic teaching, role-play of patient-provider conversations about IPV, and debriefing about strategies for discussing IPV. We evaluated knowledge, confidence, and self-reported behaviors pre- and postintervention using two-tailed paired t tests.

RESULTS

Thirty-two residents received IPV training. In comparing precurriculum (n = 29, 91% of total participants) and postcurriculum (n = 28, 88% of total participants) surveys, there was significant improvement in knowledge about IPV (p < .001). Postcurriculum, learners reported greater confidence in detecting IPV (p < .001), documenting IPV (p < .001), and referring to resources (p < .001). Participants reported increased comfort with managing difficult emotions about IPV in patients (p < .01) and themselves (p < .001) and increased comfort in discussing IPV with female (p < .001) and male (p < .001) patients. Postcurriculum, all respondents felt they were more skillful in discussing IPV and would be more likely to screen for IPV.

DISCUSSION

Our curriculum improved residents' knowledge, confidence, comfort, and preparedness in screening for and discussing IPV.

Key Aspects of Neurovascular Control Mediated by Specific Populations of Inhibitory Cortical Interneurons

Inhibitory interneurons can evoke vasodilation and vasoconstriction, making them potential cellular drivers of neurovascular coupling. However, the specific regulatory roles played by particular interneuron subpopulations remain unclear. Our purpose was therefore to adopt a cell-specific optogenetic approach to investigate how somatostatin (SST) and neuronal nitric oxide synthase (nNOS)-expressing interneurons might influence the neurovascular relationship. In mice, specific activation of SST- or nNOS-interneurons was sufficient to evoke hemodynamic changes. In the case of nNOS-interneurons, robust hemodynamic changes occurred with minimal changes in neural activity, suggesting that the ability of blood oxygen level dependent functional magnetic resonance imaging (BOLD fMRI) to reliably reflect changes in neuronal activity may be dependent on type of neuron recruited. Conversely, activation of SST-interneurons produced robust changes in evoked neural activity with shallow cortical excitation and pronounced deep layer cortical inhibition. Prolonged activation of SST-interneurons often resulted in an increase in blood volume in the centrally activated area with an accompanying decrease in blood volume in the surrounding brain regions, analogous to the negative BOLD signal. These results demonstrate the role of specific populations of cortical interneurons in the active control of neurovascular function.

A Call to Bridge Across Silos during Care Transitions

BACKGROUND

Older adults with complex medical conditions are vulnerable during care transitions. Poor care transitions can lead to poor patient outcomes and frequent readmissions to the hospital.

FACTORS CONTRIBUTING TO SUBOPTIMAL CARE TRANSITIONS

Key factors related to ineffective care transitions, which can lead to suboptimal patient outcomes, include poor cross-site communication and collaboration; lack of awareness of patient wishes, abilities, and goals of care; and incomplete medication reconciliation. Fundamental elements for effective care transitions put forth by The Joint Commission for effective care transitions include interdisciplinary coordination and collaboration of patient care in care transitions, shared accountability by all clinicians involved in care transitions, and provision of appropriate support and follow-up after discharge.

REVIEW OF FOUR EXISTING MODELS OF CARE TRANSITIONS

Consideration of four existing care transitions models representing different health care settings-Care Transitions Intervention® Guided Care, Interventions to Reduce Acute Care Transfers (INTERACT®), Home Health Model of Care Transitions-revealed that they are important but limited in their impact on transitions across health care settings.

PROPOSAL OF THE INTEGRATED CARE TRANSITIONS APPROACH

An innovative approach, Integrated Care Transitions Approach (ICTA), is proposed that incorporates the best practices of the four models discussed in this article and factors identified as essential for an effective care transition while addressing limitations of existing transitional care models. ICTA's four key characteristics and seven key elements are unique and stem from factors that help achieve effective care transitions.

Swallowing Disorders in the Older Population

Swallowing problems, or dysphagia, are common as people age, and are associated with significant negative outcomes, including weight loss, pneumonia, dehydration, shortened life expectancy, reduced quality of life, and increased caregiver burden. In this article, we will discuss the complex process of swallowing in normal circumstances and with healthy aging, then review etiologies that contribute to dysphagia. We will discuss approaches to evaluating and treating dysphagia, providing relevant data where they are available. We highlight the desperate need for high-quality research to guide best practices in treating dysphagia in older adults. J Am Geriatr Soc 67:2643-2649, 2019.

First-Year Internal Medicine Residents' Reflections on Nonmedical Home Visits to High-Risk Patients

PROBLEM

Patients who are high utilizers of care often experience health-related challenges that are not readily visible in an office setting but paramount for residents to learn. A nonmedical home visit performed at the beginning of residency training may help residents better understand social underpinnings related to their patient's health and place subsequent care within the context of the patient's life.

INTERVENTION

First-year internal medicine residents completed a nonmedical home visit to an at-risk patient prior to seeing the patient in the office for his or her first medical visit.

CONTEXT

We performed a thematic analysis of internal medicine interns' (n = 16) written narratives on their experience of getting to know a complex patient in his or her home prior to seeing the patient for a medical visit. Narratives were written by the residents immediately following the visit and then again at the end of the intern year, to assess for lasting impact of the intervention. Residents were from an urban academic residency program in Baltimore, Maryland, USA.

OUTCOME

We identified four themes from the submitted narratives. Residents discussed the visit's impact on future practice, the effect of the community and support system on health, the impact on the depth of the relationship, and the visit as a source of professional fulfillment. Whereas the four themes were present at both time points, the narratives completed immediately following the visit focused more on the themes of impact of future practice and the effect of the community and support system on health. The influence of the home visit on the depth of the relationship was a more prevalent theme in the end-of-the-year narratives.

LESSONS LEARNED

Although there is evidence to support the utility of learners completing medical home visits, this exploratory study shows that a nonmedical home visit can be rewarding and formative for early resident physicians. Future studies could examine the patient's perspective on the experience and whether a nonmedical home visit is a valuable tool in other patient populations.

Medical students' perceptions of the patient-centredness of the learning environment

BACKGROUND

Patient-centred care is an important aspect of quality health care. The learning environment may impact medical students' adoption of patient-centred behaviours.

METHODS

All medical students at a single institution received an anonymous, modified version of the Communication, Curriculum, and Culture instrument that measures patient-centredness in the training environment along three domains: role modelling, students' experience, and support for patient-centred behaviours. We compared domain scores and individual items by class year and gender, and qualitatively analyzed responses to two additional items that asked students to describe experiences that demonstrated varying degrees of patient-centredness.

RESULTS

Year 1 and 2 students reported greater patient-centredness than year 3 and 4 students in each domain: role modelling (p = 0.03), students' experience (p = <0.001), and support for patient-centred behaviours (p < 0.001). Female students reported less support for patient-centred behaviours compared with male students (p = 0.03). Qualitative analysis revealed that explicit patient-centred curricula and positive role modelling fostered patient-centredness. Themes relating to low degrees of patient-centredness included negative role modelling and students being discouraged from being patient-centred.

CONCLUSIONS

Students' perceptions of the patient-centredness of the learning environment decreased as students progressed through medical school, despite increasing exposure to patients. Qualitative analysis found that explicit patient-centred curricula cultivated patient-centred attitudes. Role modelling impacted student perceptions of patient-centredness within the learning environment.

The use of social media to supplement resident medical education - the SMART-ME initiative

BACKGROUND

Residents work at variable times and are often unable to attend all scheduled educational sessions. Therefore, new asynchronistic approaches to learning are essential in ensuring exposure to a comprehensive education. Social media tools may be especially useful, because they are accessed at times convenient for the learner.

OBJECTIVE

Assess if the use of Twitter for medical education impacts the attitude and behavior of residents toward using social media for medical education.

DESIGN

Preintervention and postintervention surveys. Internal medicine resident physicians were surveyed before the launch of a residency-specific Twitter webpage on August 1, 2013, and again 135 days later, to determine their use of the Twitter application and web page, as well as other social media for medical education.

PARTICIPANTS

Residents at an internal medicine urban academic training program.

MAIN MEASURES

All residents within our training program were administered web-based surveys. The surveys assessed resident views and their frequency of use of social media for medical education purposes, and consisted of 10 Likert scale questions. Each answer consisted of a datapoint on a 1-5 scale (1=not useful, 3=useful, 5=very useful). The final survey question was open-ended and asked for general comments.

KEY RESULTS

Thirty-five of 50 residents (70%) completed the presurvey and 40 (80%) participated in the postsurvey. At baseline, 34 out of 35 residents used social media and nine specifically used Twitter. Twenty-seven (77%) used social media for medical education; however, only three used Twitter for educational purposes. After the establishment of the Twitter page, the percentage of residents using social media for educational purposes increased (34 of 40 residents, 85%), and 22 used Twitter for this purpose (p<0.001 for the change). The percentage of residents using the application at least once a week also increased from 11.4 to 60.0% (p<0.001). Almost all residents (38 of 40) felt that social media could be useful as a medical education tool, which slightly increased from 30 out of 35 in the preintervention survey (p=0.01).

CONCLUSION

Residents believe social media could be used for medical education. After we launched a Twitter page for medical education, there was a significant increase in the use and frequency of Twitter for resident medical education over the ensuing 6 months. Further research should be performed to see if social media can impact overall medical knowledge and patient care, and whether longer term use is maintained.

The Lay Health Educator Program: Evaluating the Impact of this Community Health Initiative on the Medical Education of Resident Physicians

Resident physicians receive little training designed to help them develop an understanding of the health literacy and health concerns of laypersons. The purpose of this study was to assess whether residents improve their understanding of health concerns of community members after participating in the Lay Health Educator Program, a health education program provided through a medical-religious community partnership. The impact was evaluated via pre-post surveys and open-ended responses. There was a statistically significant change in the residents' (n = 15) understanding of what the public values as important with respect to specific healthcare topics. Findings suggest participation in a brief, formal community engagement activity improved medical residents' confidence with community health education.

Telephone calls to patients after discharge from the hospital: an important part of transitions of care

BACKGROUND

Teaching interns patient-centered communication skills, including making structured telephone calls to patients following discharge, may improve transitions of care.

OBJECTIVE

To explore associations between a patient-centered care (PCC) curriculum and patients' perspectives of the quality of transitional care.

METHODS

We implemented a novel PCC curriculum on one of four inpatient general medicine resident teaching teams in which interns make post-discharge telephone calls to patients, contact outpatient providers, perform medication adherence reviews, and engage in patient-centered discharge planning. Between July and November of 2011, we conducted telephone surveys of patients from all four teaching teams within 30 days of discharge. In addition to asking if patients received a call from their hospital physician (intern), we administered the 3-Item Care Transitions Measure (CTM-3), which assesses patients' perceptions of preparedness for the transition from hospital to home (possible score range 0-100).

RESULTS

The CTM-3 scores (mean±SD) of PCC team patients and standard team patients were not significantly different (82.4±17.3 vs. 79.6±17.6, p=0.53). However, regardless of team assignment, patients who reported receiving a post-discharge telephone call had significantly higher CTM-3 scores than those who did not (84.7±16.0 vs. 78.2±17.4, p=0.03). Interns exposed to the PCC curriculum called their patients after discharge more often than interns never exposed (OR=2.78, 95% CI [1.25, 6.18], p=0.013).

CONCLUSIONS

The post-discharge telephone call, one element of PCC, was associated with higher CTM-3 scores--which, in turn, have been shown to lessen patients' risk of emergency department visits within 30 days of discharge.

Systematic review of self-expanding stents in the management of benign colorectal obstruction

AIM

Colorectal obstruction due to benign disease is likely to become more prevalent. Self-expanding stents have been shown to be effective in reducing morbidity and allowing one-stage resection or improved palliation in colorectal cancer. This review assessed the use of self-expanding stents in benign colorectal obstruction.

METHOD

A systematic review was performed using PubMed, Embase and the Cochrane Library. Keywords included: 'benign disease' 'colorectal obstruction', 'stent', 'endoprosthesis' and 'prosthesis' Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. The main outcome measures assessed were technical and clinical success, perforation, reobstruction and stoma avoidance in the bridge to surgery population.

RESULTS

The search strategy identified 130 articles; the 21 included studies yielded a pooled analysis of 122 patients. Diverticulitis was the predominant aetiology (66/122, 54%). Technical success was achieved in 115/122 (94%) and clinical success in 108/120 (87%) patients. Overall, the perforation rate was 12% (15/122) and the reobstruction rate was 14% (17/122). A stoma was avoided in 48% (23/48) of bridge to surgery patients. Perforation and stoma avoidance in the bridge to surgery group were worse with an aetiology of diverticulitis.

CONCLUSION

Complication rates in stenting for benign colorectal obstruction are higher than for malignant obstruction. On the basis of limited published evidence, stenting cannot be recommended for benign colorectal obstruction.

Getting out of silos: an innovative transitional care curriculum for internal medicine residents through experiential interdisciplinary learning

BACKGROUND

Care transitions are common and highly vulnerable times during illness. Physicians need better training to improve care transitions. Existing transitional care curricula infrequently involve settings outside of the hospital or other health care disciplines.

INTERVENTION

We created a curriculum to teach internal medicine residents how to provide better transitional care at hospital discharge through experiential, interdisciplinary learning in different care settings outside of the acute hospital, and we engaged other health care disciplines frequently involved in care transitions.

SETTING/PARTICIPANTS

Nineteen postgraduate year-1 internal medicine trainees at an academic medical center in an urban location completed experiences in a postacute care facility, home health care, and outpatient clinics.

PROGRAM DESCRIPTION

The 2-week required curriculum involved teachers from geriatric medicine; physical, occupational, and speech therapy; and home health care, with both didactic and experiential components and self-reflective exercises.

PROGRAM EVALUATION

The curriculum was highly rated (6.86 on a 9-point scale) and was associated with a significant increase in the rating of the overall quality of transitional care education (from 4.09 on a 5-point scale in 2011 to 4.53 in 2012) on the annual residency program survey. Learners reported improved knowledge in key curricular areas and that they would change practice as a result of the curriculum.

CONCLUSIONS

Our transitional care curriculum for internal medicine residents provides exposure to care settings and health care disciplines that patients frequently encounter. The curriculum has shown positive, short-term effects on learners' perceived knowledge and behavior.

A memorial service to provide reflection on patient death during residency

BACKGROUND

Patient death can be emotionally and psychologically stressful for clinicians, particularly clinicians in training.

OBJECTIVE

We describe an annual memorial service as a novel approach to help internal medicine residents cope with and reflect on the experiences of patient death.

METHODS

We created a memorial service in 2010 for patients who had died under the care of the internal medicine residents in our institution. Residents, medical students, and medicine faculty attended the 1-hour service. The memorial service was repeated in 2011, and a 10-question survey was sent to evaluate its impact.

RESULTS

Twenty-two participants in either the 2010 or 2011 memorial service responded to the survey. Most of the respondents thought that reflection on patient death was important (95%) and that the memorial service was helpful in facilitating such reflection and bringing closure (95%).

CONCLUSIONS

An annual memorial service helps trainees cope with the emotional impact of patient death. It can be easily adopted by other residency programs. The long-term impact of this experience on trainees' well-being and professional development is unknown.

Resident satisfaction with continuity clinic and career choice in general internal medicine

BACKGROUND

The quality of the continuity clinic experience for internal medicine (IM) residents may influence their choice to enter general internal medicine (GIM), yet few data exist to support this hypothesis.

OBJECTIVE

To assess the relationship between IM residents' satisfaction with continuity clinic and interest in GIM careers.

DESIGN

Cross-sectional survey assessing satisfaction with elements of continuity clinic and residents' likelihood of career choice in GIM.

PARTICIPANTS

IM residents at three urban medical centers.

MAIN MEASURES

Bivariate and multivariate associations between satisfaction with 32 elements of outpatient clinic in 6 domains (clinical preceptors, educational environment, ancillary staff, time management, administrative, personal experience) and likelihood of considering a GIM career.

KEY RESULTS

Of the 225 (90 %) residents who completed surveys, 48 % planned to enter GIM before beginning their continuity clinic, whereas only 38 % did as a result of continuity clinic. Comparing residents' likelihood to enter GIM as a result of clinic to likelihood to enter a career in GIM before clinic showed that 59 % of residents had no difference in likelihood, 28 % reported a lower likelihood as a result of clinic, and 11 % reported higher likelihood as a result of clinic. Most residents were very satisfied or satisfied with all clinic elements. Significantly more residents (p ≤ 0.002) were likely vs. unlikely to enter GIM if they were very satisfied with faculty mentorship (76 % vs. 53 %), time for appointments (28 % vs. 11 %), number of patients seen (33 % vs. 15 %), personal reward from work (51 % vs. 23 %), relationship with patients (64 % vs. 42 %), and continuity with patients (57 % vs. 33 %). In the multivariate analysis, being likely to enter GIM before clinic (OR 29.0, 95 % CI 24.0-34.8) and being very satisfied with the continuity of relationships with patients (OR 4.08, 95 % CI 2.50-6.64) were the strongest independent predictors of likelihood to enter GIM as a result of clinic.

CONCLUSIONS

Resident satisfaction with most aspects of continuity clinic was high; yet, continuity clinic had an overall negative influence on residents' attitudes toward GIM careers. Targeting resources toward improving ambulatory patient continuity, workflow efficiency and increasing pre-residency interest in primary care may help build the primary care workforce.

Case discussion: large volume blood loss and delirium in a patient with subtrochanteric fracture, dementia, and multiple comorbidities

This case presents a discussion of a 92-year-old man with multiple comorbidities, who presents with a subtrochanteric fracture. His course is complicated by large volume blood loss intraoperatively, requiring intensive care unit (ICU) monitoring postoperatively. His course is also complicated by delirium.

The Donald W. Reynolds Consortium for Faculty Development to Advance Geriatrics Education (FD~AGE): a model for dissemination of subspecialty educational expertise

PURPOSE

Most U.S. medical schools and training programs lack sufficient faculty expertise in geriatrics to train future physicians to care for the growing population of older adults. Thus, to reach clinician-educators at institutions and programs that have limited resources for enhancing geriatrics curricula, the Donald W. Reynolds Foundation launched the Faculty Development to Advance Geriatrics Education (FD~AGE) program. This consortium of four medical schools disseminates expertise in geriatrics education through support and training of clinician-educators. The authors conducted this study to measure the effects of FD~AGE.

METHOD

Program leaders developed a three-pronged strategy to meet program goals: FD~AGE offers (1) advanced fellowships in clinical education for geriatricians who have completed clinical training, (2) mini-fellowships and intensive courses for faculty in geriatrics, teaching skills, and curriculum development, and (3) on-site consultations to assist institutions with reviewing and redesigning geriatrics education programs. FD~AGE evaluators tracked the number and type of participants and conducted interviews and follow-up surveys to gauge effects on learners and institutions.

RESULTS

Over six years (2004-2010), FD~AGE trained 82 fellows as clinician-educators, hosted 899 faculty scholars in mini-fellowships and intensive courses, and conducted 65 site visits. Participants taught thousands of students, developed innovative curricula, and assumed leadership roles. Participants cited as especially important to program success expanded knowledge, improved teaching skills, mentoring, and advocacy.

CONCLUSIONS

The FD~AGE program represents a unique model for extending concentrated expertise in geriatrics education to a broad group of faculty and institutions to accelerate progress in training future physicians.

Effects of a focused patient-centered care curriculum on the experiences of internal medicine residents and their patients

BACKGROUND

Traditional residency training may not promote competencies in patient-centered care.

AIM

To improve residents' competencies in delivering patient-centered care.

SETTING/PARTICIPANTS

Internal medicine residents at a university-based teaching hospital in Baltimore, Maryland.

PROGRAM DESCRIPTION

One inpatient team admitted half the usual census and was exposed to a multi-modal patient-centered care curriculum to promote knowledge of patients as individuals, improve patient transitions of care, and reduce barriers to medication adherence.

PROGRAM EVALUATION

Annual resident surveys (N = 40) revealed that the intervention was judged as professionally valuable (90%) and important to their training (90%) and offered experiences not available during other rotations (88%). Compared to standard inpatient rotation evaluations (n = 163), intervention rotation evaluations (n = 51) showed no differences in ratings for traditional medical learning, but higher ratings for improving how housestaff address patient medication adherence, communicate with patients about post-hospital transition of care, and know their patients as people (all p < 0.01). On post-discharge surveys, patients from the intervention team (N = 177, score 90.4, percentile ranking 97%) reported greater satisfaction with physicians than patients on standard teams (N = 924, score 86.1, percentile ranking 47%) p < 0.01).

DISCUSSION

A patient-centered inpatient curriculum was associated with higher satisfaction ratings in patient-centered domains by internal medicine residents and with higher satisfaction ratings of their physicians by patients. Future research will explore the intervention's impact on clinical outcomes.

Update in geriatric medicine

INTRODUCTION

With an aging population, internists will provide care to a growing number of older adults, a population at risk of developing multiple chronic medical conditions and geriatric syndromes. For this update in geriatric medicine, we highlight recent key articles focused on preventive strategies and lifestyle changes that reduce the burden of disease and functional decline in older adults.

METHODS

We identified English-language articles published between March 1, 2010 and March 31, 2011 by review of the contents of major geriatrics/general medicine journals and journal watch services including: New England Journal of Medicine, Annals of Internal Medicine, Journal of the American Medical Association, Lancet, Archives of Internal Medicine, British Medical Journal, Journal of the American Geriatrics Society, and the Journals of Gerontology. We also reviewed updates to the Cochrane database of systematic reviews and articles highlighted by the ACP Journal Club and Journal Watch. Inclusion criteria included (1) randomized controlled trials, (2) conditions exclusive or common to older adults, and (3) commonly seen in generalist practices. After abstract review, each author selected five articles, and these were reviewed again by all authors. Through multiple discussions, consensus was reached on the final articles selected for inclusion based on their quality and potential to improve the health of older patients cared for by generalists.

The intersection between clinical excellence and role modeling in medicine

BACKGROUND

Role modeling is an integral component of medical education. The literature suggests that being a clinically excellent academic physician and serving as a role model for trainees are integrally related.

PURPOSE

To explore the relationship between being considered clinically excellent and being considered an effective role model.

METHODS

Two independent surveys were administered to clinically active faculty (asked to name clinically excellent colleagues) and internal medicine residents (asked to name faculty role models). We compared frequency counts of clinically excellent faculty mentioned and frequency counts of role models mentioned by respondents. Spearman correlations and odds ratios with 95% confidence intervals were used to assess the relationship between the responses.

RESULTS

A total of 39 of 66 faculty (59%) and 45 of 50 residents (90%) responded. There were 31 faculty members judged to be clinically excellent and 67 faculty identified as role models. Thirty faculty members appeared on both lists. There was a moderately high correlation between these groups (Spearman correlation coefficient  =  0.54, P < .001). Faculty members who were among those named as clinically excellent by their peers were more likely to be named 3 or more times as a role model by trainees (odds ratio, 24.6; confidence interval, 2.9-207).

CONCLUSIONS

This study tested and confirmed the correlation between clinical excellence and role modeling, illustrating the value of these faculty members at teaching hospitals.

Rallying the troops: a four-step guide to preparing a residency program for short-term weather emergencies

BACKGROUND

Weather emergencies present a multifaceted challenge to residents and residency programs. Both the individual trainee and program may be pushed to the limits of physical and mental strain, potentially jeopardizing core competencies of patient care and professionalism. Although daunting, the task of preparing for these events should be a methodical process integrated into every residency training program.

SUMMARY

The core elements of emergency preparation with regard to inpatient services include identifying and staffing critical positions, motivating residents to consider the needs of the group over those of the individual, providing for basic needs, and planning activities in order to preserve team morale and facilitate recovery. The authors outline a four-step process in preparing a residency program for an anticipated short-term weather emergency. An example worksheet for emergency planning is included.

CONCLUSION

With adequate preparation, residency training programs can maintain the highest levels of patient care, professionalism, and esprit de corps during weather emergencies. When managed effectively, emergencies may present an opportunity for professional growth and a sense of unity for those involved.

Creating an academy of clinical excellence at Johns Hopkins Bayview Medical Center: a 3-year experience

Academic health centers (AHCs) are committed to the tripartite missions of research, education, and patient care. Promotion decisions at many AHCs focus predominantly on research accomplishments, and some members of the community remain concerned about how to reward clinicians who excel in, and spend a majority of their time, caring for patients. Many clinically excellent physicians contribute substantively to all aspects of the mission by collaborating with researchers (either through intellectual discourse or enrolling participants in trials), by serving as role models for trainees with respect to ideal caring and practice, and by attracting patients to the institution. Not giving fair and appreciative recognition to these clinically excellent faculty places AHCs at risk of losing them. The Center for Innovative Medicine at Johns Hopkins set out to address this concern by defining, measuring, and rewarding clinical excellence. Prior to this initiative, little attention was directed toward the "bright spots" of excellence in patient care at Johns Hopkins Bayview. Using a scholarly approach, the authors launched a new academy; this manuscript describes the history, creation, and ongoing activities of the Miller-Coulson Academy of Clinical Excellence at Johns Hopkins University Bayview Medical Center. While membership in the academy is honorific, the members of this working academy are committed to influencing institutional culture as they collaborate on advocacy, scholarship, and educational initiatives.

Advantages and challenges of working as a clinician in an academic department of medicine: academic clinicians' perspectives

BACKGROUND

The provision of high-quality clinical care is critical to the mission of academic and nonacademic clinical settings and is of foremost importance to academic and nonacademic physicians. Concern has been increasingly raised that the rewards systems at most academic institutions may discourage those with a passion for clinical care over research or teaching from staying in academia. In addition to the advantages afforded by academic institutions, academic physicians may perceive important challenges, disincentives, and limitations to providing excellent clinical care. To better understand these views, we conducted a qualitative study to explore the perspectives of clinical faculty in prominent departments of medicine.

METHODS

Between March and May 2007, 2 investigators conducted in-depth, semistructured interviews with 24 clinically excellent internal medicine physicians at 8 academic institutions across the nation. Transcripts were independently coded by 2 investigators and compared for agreement. Content analysis was performed to identify emerging themes.

RESULTS

Twenty interviewees (83%) were associate professors or professors, 33% were women, and participants represented a wide range of internal medicine subspecialties. Mean time currently spent in clinical care by the physicians was 48%. Domains that emerged related to faculty's perception of clinical care in the academic setting included competing obligations, teamwork and collaboration, types of patients and productivity expectations, resources for clinical services, emphasis on discovery, and bureaucratic challenges.

CONCLUSIONS

Expert clinicians at academic medical centers perceive barriers to providing excellent patient care related to competing demands on their time, competing academic missions, and bureaucratic challenges. They also believe there are differences in the types of patients seen in academic settings compared with those in the private sector, that there is a "public" nature in their clinical work, that productivity expectations are likely different from those of private practitioners, and that resource allocation both facilitates and limits excellent care in the academic setting. These findings have important implications for patients, learners, and faculty and academic leaders, and suggest challenges as well as opportunities in fostering clinical medicine at academic institutions.

Implications of academic medicine's failure to recognize clinical excellence

OBJECTIVE

To better understand the implications of inadequately recognizing clinical excellence in academia by exploring the perspectives of clinically excellent faculty within prominent American departments of medicine.

DESIGN

Qualitative study.

SETTING

8 academic institutions.

PARTICIPANTS

24 clinically excellent department of medicine physicians.

METHODS

Between March 1 and May 31, 2007, investigators conducted in-depth semi-structured interviews with 24 clinically excellent physicians at leading academic institutions. Interview transcripts were independently coded by two investigators and compared for agreement. Content analysis identified themes related to clinical excellence in academia.

RESULTS

Twenty informants (83%) were Associate Professors or Professors, 8 (33%) were females, and the physicians hailed from a wide range of internal medicine specialties. The mean percent effort spent in clinical care by the physicians was 48%. The five domains that emerged related to academic medicine's failure to recognize clinical excellence were: (1) low morale and prestige among clinicians, (2) less than excellent patient care, (3) loss of talented clinicians, (4) a lack of commitment to improve patient care systems, and (5) fewer excellent clinician role models to inspire trainees.

CONCLUSIONS

If academic medical centers fail to recognize clinical excellence among its physicians, they may be doing a disservice to the patients that they pledge to serve. It is hoped that initiatives aiming to measure clinical performance in our academic medical centers will translate into meaningful recognition for those achieving excellence such that outstanding clinicians may feel valued and decide to stay in academia.

Intensive insulin therapy confers a similar survival benefit in the burn intensive care unit to the surgical intensive care unit

BACKGROUND

In contrast to the benefits of intensive insulin therapy (IIT) in the surgical intensive care unit (SICU), its benefits in the burn ICU (BICU) remain unclear. Furthermore, IIT and tight glycemic control has received little attention in elderly ICU patients.

METHODS

We evaluated the normalization of blood glucose level with IIT in BICU and SICU patients. From October 2006 to July 2007, 970 patients were admitted to our BICU and our SICU. A total of 79 of these patients met criteria for initiation of IIT, 37 of who required IIT for at least 72 hours. Data were analyzed to determine if tight glycemic control (blood glucose < or =150 mg/dL by day 3) is associated with reduced morbidity and mortality.

RESULTS

Tight control was better achieved in SICU patients (45%) than in BICU patients (33%). Daily insulin requirements were approximately 2-fold greater in SICU patients compared with BICU patients (P < .05). Tight control in both SICU and BICU patients was associated with a decreased incidence of sepsis compared with poor glycemic control (10% vs 58% and 60% vs 70%, respectively) and a decreased mortality rate (0 vs 58% and 20% vs 50%; SICU vs BICU, respectively). The percentage of total body surface area burned in BICU patients was 10% and 45% in the < or =150 and >150 mg/dL groups. Mortality rate in the poor control group was >10-fold greater than that of the tight control group; for patients > or =65 years of age, mortality was nearly double than that of patients <65 years of age. The greatest mortality rate (62%) was seen in patients >65 years of age with poor control.

CONCLUSION

Tight control with IIT is associated with an increased survival rate in both BICU and SICU patients. Age is associated with survival, with patients older than 65 years of age having the greatest mortality rate.

The seventh competency

BACKGROUND

Disclosure of error is gaining acceptance as an ethical imperative in health care. Despite this, residency training programs do not commonly address this in their curricula, and competence in the identification and disclosure of adverse events and medical error is typically not assessed.

SUMMARY

Although aspects of the identification, disclosure, and apology for medical error can be subsumed under existing competencies, the skills required in this area are in many ways fundamentally different from anything else physicians are taught.

CONCLUSIONS

We propose that the identification of medical error recognition and disclosure be recognized as a seventh core competency and we suggest that residency program directors be invited to develop innovative approaches to teaching and assessing competence in this area. This will benefit training programs, residents, and ultimately society and the patients that we serve.

House calls and the ACGME competencies

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) "core competencies" (patient care, medical knowledge, interpersonal and communication skills, practice-based learning, and systems-based practice) are challenging to achieve in today's complex, high-acuity, hospital-based setting. House calls provide unique clinical exposure to opportunities for learning the ACGME competencies in a single integrated experience. We review the medical literature on the educational value of house calls and describe a pilot questionnaire of housestaff perceptions of the value of house calls in addressing all of the competencies.

DESCRIPTION

Focused literature review and questionnaire.

EVALUATION

A substantial body of literature supports our hypothesis that house calls expose residents to all of the ACGME competency domains. Residents actively engaged in house call training perceive that their experiences allow them to fulfill all of the ACGME competencies.

CONCLUSION

House calls provide an ideal and highly valued opportunity for internal medicine residents to learn the ACGME competencies.

Clinical excellence in academia: perspectives from masterful academic clinicians

OBJECTIVE

To better understand and characterize clinical excellence in academia by exploring the perspectives of clinically excellent faculty in the top American departments of medicine.

PARTICIPANTS AND METHODS

Between March 1 and May 31, 2007, 2 investigators conducted in-depth semistructured interviews with 24 clinically excellent Department of Medicine physicians at 8 academic institutions. Interview transcripts were independently analyzed by 2 investigators and compared for agreement. Content analysis identified several major themes that relate to clinical excellence in academia.

RESULTS

Physicians hailed from a range of internal medicine specialties; 20 (83%) were associate professors or professors and 8 (33%) were women. The mean percentage of time physicians spent in clinical care was 48%. Eight domains emerged as the major features of clinical excellence in academia: reputation, communication and interpersonal skills, professionalism and humanism, diagnostic acumen, skillful negotiation of the health care system, knowledge, scholarly approach to clinical care, and passion for clinical medicine.

CONCLUSION

Understanding the core elements that contribute to clinical excellence in academia represents a pivotal step to defining clinical excellence in this setting. It is hoped that such work will lead to initiatives aimed at measuring and rewarding clinical excellence in our academic medical centers such that the most outstanding clinicians feel valued and decide to stay in academia to serve as role models for medical trainees.

Perspective: transforming chronic care for older persons

The size and impending morbidity of the aging baby boom generation could soon overwhelm the U.S. health care system. Transforming chronic care for older persons to avert this calamity will require rapid increases in the number of physicians who are skilled in providing chronic care and prompt adoption of new models for providing high-quality, cost-effective chronic care. The authors propose a new approach for attaining these objectives, recommending that today's leaders of academic medicine help transform geriatrics into a collaborative discipline of clinicians with advanced skills in leading educational, organizational, and research-related initiatives; that they support the collaboration of geriatrics with primary care and specialty disciplines in preparing physicians to practice effectively in new models of chronic care for older persons; and that they energetically promote rigorous training in chronic care at all levels of medical education. Implementing this strategy would require firm commitment by the Association of American Medical Colleges, specialty boards, accrediting organizations, academic institutions, the Centers for Medicare and Medicaid Services, legislators, and business leaders. Although garnering such support would be challenging and controversial, this approach could leverage the expertise of geriatric educator-leaders to help transform chronic care in the United States and to make high-quality, cost-effective chronic care accessible to most chronically ill Americans within 20 years.

A model intensive course in geriatric teaching for non-geriatrician educators

INTRODUCTION

Because of the aging demographics nearly all medical specialties require faculty who are competent to teach geriatric care principles to learners, yet many non-geriatrician physician faculty members report they are not prepared for this role.

AIMS

To determine the impact of a new educational intervention designed to improve the self-efficacy and ability of non-geriatrician clinician-educators to teach geriatric medicine principles to medical students and residents.

DESCRIPTION

Forty-two non-geriatrician clinician-educator faculty from 17 academic centers self-selected to participate in a 3-day on-site interactive intensive course designed to increase knowledge of specific geriatric medicine principles and to enhance teaching efficacy followed by up to a year of mentorship by geriatrics faculty after participants return to their home institutions. On average, 24% of their faculty time was spent teaching and 57% of their clinical practices involved patients aged over 65 years. Half of all participants were in General Internal Medicine, and the remaining were from diverse areas of medicine.

EVALUATION

Tests of geriatrics medical knowledge and attitudes were high at baseline and did not significantly change after the intervention. Self-rated knowledge about specific geriatric syndromes, self-efficacy to teach geriatrics, and reported value for learning about geriatrics all improved significantly after the intervention. A quarter of the participants reported they had achieved at least one of their self-selected 6-month teaching goals.

DISCUSSION

An intensive 3-day on-site course was effective in improving self-reported knowledge, value, and confidence for teaching geriatrics principles but not in changing standardized tests of geriatrics knowledge and attitudes in a diverse group of clinician-educator faculty. This intervention was somewhat associated with new teaching behaviors 6 months after the intervention. Longer-term investigations are underway to determine the sustainability of the effect and to determine which factors predict the faculty who most benefit from this innovative model.