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Objective To determine whether internists’ initial specialty certification and the maintenance of that certification (MOC) is associated with lower in-hospital mortality for their patients with acute myocardial infarction (AMI) or congestive heart failure (CHF).Design Retrospective cohort study of hospitalisations in Pennsylvania, USA, from 2012 to 2017.Setting All hospitals in Pennsylvania.Participants All 184 115 hospitalisations for primary diagnoses of AMI or CHF where the attending physician was a self-designated internist.Primary outcome measure In-hospital mortality.Results Of the 2575 physicians, 2238 had initial certification and 820 were eligible for MOC. After controlling for patient demographics and clinical characteristics, hospital-level factors and physicians’ demographic and medical school characteristics, both initial certification and MOC were associated with lower mortality. The adjusted OR for initial certification was 0.835 (95% CI 0.756 to 0.922; p

Objective Diagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors.Setting/participants 1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 ‘index’ outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke).Outcome measures 90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations.Design Using retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics.Results Rates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI −5.0 to −0.7, p=0.008), 4.1 fewer hospitalisations (95% CI −6.9 to −1.2, p=0.006) and 4.9 fewer ED visits (95% CI −8.1% to −1.6%, p=0.003) per 1000 visits.Conclusion Higher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

Burnout is prevalent in residency training and practice and is linked to medical error and suboptimal patient care. However, little is known about how burnout affects clinical reasoning, which is essential to safe and effective care. The aim of this study was to examine how burnout modulates brain activity during clinical reasoning in physicians. Using functional Magnetic Resonance Imaging (fMRI), brain activity was assessed in internal medicine residents (n=10) and board-certified internists (faculty, n=17) from the Uniformed Services University (USU) while they answered and reflected upon United States Medical Licensing Examination and American Board of Internal Medicine multiple-choice questions. Participants also completed a validated two-item burnout scale, which includes an item assessing emotional exhaustion and an item assessing depersonalization. Whole brain covariate analysis was used to examine blood-oxygen-level-dependent (BOLD) signal during answering and reflecting upon clinical problems with respect to burnout scores. Higher depersonalization scores were associated with less BOLD signal in the right dorsolateral prefrontal cortex and middle frontal gyrus during reflecting on clinical problems and less BOLD signal in the bilateral precuneus while answering clinical problems in residents. Higher emotional exhaustion scores were associated with more right posterior cingulate cortex and middle frontal gyrus BOLD signal in residents. Examination of faculty revealed no significant influence of burnout on brain activity. Residents appear to be more susceptible to burnout effects on clinical reasoning, which may indicate that residents may need both cognitive and emotional support to improve quality of life and to optimize performance and learning. These results inform our understanding of mental stress, cognitive control as well as cognitive load theory.