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Transitions are a way of life in academic medicine. While much has been written about these changes, less attention has been devoted to a more common shift: the move between academic work and clinical ward time. This gap has important consequences. For example, some faculty dread upcoming ward blocks. When on clinical rotations, they struggle to juggle patient and academic activities—often doing neither well. The resulting perceived lack of efficiency and effectiveness leads to weariness, fatigue, frustration, and symptoms of burnout. Regardless of clinical effort, most faculty will face this problem. Unfortunately, limited guidance on how best to overcome this common challenge exists.

Mentorship takes many forms, from personal and professional counseling to clinical and research guidance. The wisdom and guidance of experienced mentors not only help mentees ascend the academic ladder, but may also prevent burnout. Given the importance of this relationship, it is imperative that mentees put their “best foot forward.” Unfortunately, young physicians are rarely taught what is expected of them as mentees, and mentors vary in discussing “menteeship” with proteges.

CENTRAL VENOUS CATHETERS (CVCS) PROVIDE REliable venous access for tasks as diverse as delivery of medication, laboratory testing, and hemodynamic monitoring and occupy a fundamental role in the management of seriously ill patients. However, despite their many benefits, CVCs are not innocuous and are associated with important complications. Among these, central line–associated bloodstream infection (CLABSI) and venous thromboembolism are significant because they are difficult to detect, increase the cost of care, and are potentially life-threatening adverse events. Consequently, studies to predict and prevent these complications have become a research priority. Because of the frequent use of CVCs in the intensive care unit (ICU), efforts to reduce these unfavorable outcomes have traditionally focused on critically ill patients, a population for which substantial progress has been made. For example, improvements in measurement of infectious episodes by standardized definitions and diffusion of evidence-based practices have led to a 58% decrease in CLABSI in ICUs across the United States. Similarly, evidence-based guidelines emphasizing risk estimation and pharmacological prophylaxis have decreased the risk of CVC-related venous thromboembolism in ICU patients. Important shifts in the epidemiology of CVCs from ICU to non-ICU settings, however, may threaten this progress. For instance, in a survey involving 2459 patients in 6 medical centers, the majority of CVCs (70%) were being used in non-ICU patients. Furthermore, CVCs remain in place for longer durations when inserted in non-ICU settings, theoretically increasing the risk of CLABSI and venous thromboembolism. Recent data confirm this concern: of the 9826 CLABSIs reported by participating National Healthcare Safety Network hospitals in 2010, 31% occurred in non-ICU patients. In a study seeking to simplify the estimation of venous thrombosis risk in hospitalized patients, the presence of a CVC was among 4 of the strongest risk factors associated with venous thromboembolism. These findings are all the more concerning because lack of comprehensive surveillance for CLABSI in some non-ICU settings, absence of a homogenous patient and clinician population in contrast to those within ICUs, and controversies regarding venous thromboembolism prophylaxis represent major barriers to prevention in non-ICU settings. Peripherally inserted central catheters (PICCs) are venous catheters that are inserted peripherally, and terminate in central veins such that they may be categorized as CVCs. For multiple reasons, PICCs have become among the most frequently encountered CVC in non-ICU patients. For instance, these devices are safer to insert than CVCs, eliminate the discomfort associated with phlebotomy and scheduled peripheral intravenous line changes, and provide extended and reliable venous access. Because specially trained nurses commonly place PICCs at the patient’s bedside, ready access to these devices has increased. Furthermore, because PICCs reduce cost by enabling earlier hospital discharge through home intravenous therapy, payers have welcomed and supported the widespread use of these venous catheters. These logistical factors notwithstanding, a key factor contributing to increasing PICC use is the perception that they are safer than CVCs with respect to important complications. Initial studies found PICC-related bloodstream infection rates were significantly lower than rates associated with CVCs. However, accumulating evidence suggests that the risk of PICC-related complications is not uniform. For example, Ajenjo et al reported that PICC-related CLABSI was almost twice as likely for PICCs that were inserted in ICU settings compared with non-ICU settings (4.79 vs 2.79 episodes per 1000 catheter-days, respectively; relative risk, 1.70 [95% CI, 1.10–2.61]). With respect to venous thromboembolism, factors such as site of PICC insertion (right or left arm), number of PICC lumens, the position of the PICC tip, and patient characteristics such as malignancy, prior venous thromboembolism, or both, interact to influence risk of thrombosis. Taken together, these data suggest that the risk of CLABSI and venous thromboembolism associated with PICCs is dynamic and varies according to

RESULTS The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I 2 = 0%; τ 2

Objective. —A meta-analysis of randomized trials was performed to estimate the effectiveness of antibiotics in treating exacerbations of chronic obstructive pulmonary disease (COPD). Data Sources. —English-language studies published from 1955 through 1994 were retrieved using MEDLINE,Index Medicus, bibliographies, and consultation with experts. MEDLINE search terms included "COPD," "chronic bronchitis," and "antibiotic(s)." Study Selection. —Only randomized trials that enrolled patients having an exacerbation of COPD, used an antibiotic in the treatment group and placebo in the control group, and provided sufficient data to calculate an effect size were included in the meta-analysis. Data Extraction. —Descriptive and outcome data from each study were independently abstracted by two authors. Data Synthesis. —Overall summary effect size of the nine trials satisfying all inclusion criteria was 0.22 (95% confidence interval [CI], 0.10 to 0.34), indicating a small benefit in the antibiotic-treated group. Similar analysis of the six studies that provided data on peak expiratory flow rate changes revealed a summary effect size of 0.19 (95% CI, 0.03 to 0.35) and a summary change in peak expiratory flow rate of 10.75 L/min (95% CI, 4.96 to 16.54 L/min) in favor of the antibiotic-treated group. Sensitivity analyses did not significantly affect these results. Conclusions. —These analyses suggest a small but statistically significant improvement due to antibiotic therapy in patients with exacerbations of COPD. This antibiotic-associated improvement may be clinically significant, especially in patients with low baseline flow rates. (JAMA. 1995;273:957-960)

ContextThe Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents’ well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents.ObjectiveTo summarize the literature regarding the effect of interventions to reduce resident work hours on residents’ education and quality of life.Data SourcesWe searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings.Study SelectionStudies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States.Data ExtractionFor each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form.Data SynthesisFifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents’ lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents’ quality of life. Many studies had major limitations in their design or conduct.ConclusionsPast interventions suggest that residents’ quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents’ quality of life and quality of patient care.

Symptoms suggestive of acute urinary tract infection (UTI) constitute one of the most common reasons for women to visit clinicians. Although the clinical encounter typically involves taking a history and performing a physical examination, the diagnostic accuracy of the clinical assessment for UTI remains uncertain.To review the accuracy and precision of history taking and physical examination for the diagnosis of UTI in women.We conducted a MEDLINE search for articles published from 1966 through September 2001 and manually reviewed bibliographies, 3 commonly used clinical skills textbooks, and contacted experts in the field.Studies were included if they contained original data on the accuracy or precision of history or physical examination for diagnosing acute uncomplicated UTI in women. One author initially screened titles and abstracts found by our search. Nine of 464 identified studies met inclusion criteria.Two authors independently abstracted data from the included studies. Disagreements were resolved by discussion and consensus with a third author.Four symptoms and 1 sign significantly increased the probability of UTI: dysuria (summary positive likelihood ratio [LR], 1.5; 95% confidence interval [CI], 1.2-2.0), frequency (LR, 1.8; 95% CI, 1.1-3.0), hematuria (LR, 2.0; 95% CI, 1.3-2.9), back pain (LR, 1.6; 95% CI, 1.2-2.1), and costovertebral angle tenderness (LR, 1.7; 95% CI, 1.1-2.5). Four symptoms and 1 sign significantly decreased the probability of UTI: absence of dysuria (summary negative LR, 0.5; 95% CI, 0.3-0.7), absence of back pain (LR, 0.8; 95% CI, 0.7-0.9), history of vaginal discharge (LR, 0.3; 95% CI, 0.1-0.9), history of vaginal irritation (LR, 0.2; 95% CI, 0.1-0.9), and vaginal discharge on examination (LR, 0.7; 95% CI, 0.5-0.9). Of all individual diagnostic signs and symptoms, the 2 most powerful were history of vaginal discharge and history of vaginal irritation, which significantly decreased the likelihood of UTI when present (LRs, 0.3 and 0.2, respectively). One study examined combinations of symptoms, and the resulting LRs were more powerful (24.6 for the combination of dysuria and frequency but no vaginal discharge or irritation). One study of patients with recurrent UTI found that self-diagnosis significantly increased the probability of UTI (LR, 4.0).In women who present with 1 or more symptoms of UTI, the probability of infection is approximately 50%. Specific combinations of symptoms (eg, dysuria and frequency without vaginal discharge or irritation) raise the probability of UTI to more than 90%, effectively ruling in the diagnosis based on history alone. In contrast, history taking, physical examination, and dipstick urinalysis are not able to reliably lower the posttest probability of disease to a level where a UTI can be ruled out when a patient presents with 1 or more symptoms.

ContextA recent randomized controlled trial and meta-analysis indicated that central venous catheters impregnated with an antiseptic combination of chlorhexidine and silver sulfadiazine are efficacious in reducing the incidence of catheter-related bloodstream infection (CR-BSI); however, the ultimate clinical and economic consequences of their use have not been formally evaluated.ObjectiveTo estimate the incremental clinical and economic outcomes associated with the use of antiseptic-impregnated vs standard catheters.DesignDecision analytic model using data from randomized controlled trials, meta-analyses, and case-control studies, as well as safety data from the US Food and Drug Administration.Setting and PatientsA hypothetical cohort of hospitalized patients at high risk for catheter-related infections (eg, patients in intensive care units, immunosuppressed patients, and patients receiving total parenteral nutrition) requiring use of a central venous catheter.InterventionShort-term use (2-10 days) of chlorhexidine–silver sulfadiazine–impregnated multilumen central venous catheters and nonimpregnated catheters.Main Outcome MeasuresExpected incidence of CR-BSI and death attributable to antiseptic-impregnated and standard catheter use; direct medical costs for both types of catheters.ResultsIn the base-case analysis, use of antiseptic-impregnated catheters resulted in a decrease in the incidence of CR-BSI of 2.2% (5.2% for standard vs 3.0% for antiseptic-impregnated catheters), a decrease in the incidence of death of 0.33% (0.78% for standard vs 0.45% for antiseptic-impregnated), and a decrease in costs of $196 per catheter used ($532 for standard vs $336 for antiseptic-impregnated). The decrease in CR-BSI ranged from 1.2% to 3.4%, the decrease in death ranged from 0.09% to 0.78%, and the costs saved ranged from $68 to $391 in a multivariate sensitivity analysis.ConclusionOur analyses suggest that use of chlorhexidine–silver sulfadiazine–impregnated central venous catheters in patients at high risk for catheter-related infections reduces the incidence of CR-BSI and death and provides significant saving in costs. Use of these catheters should be considered as part of a comprehensive nosocomial infection control program.

ContextCentral venous catheters impregnated with chlorhexidine and silver sulfadiazine have recently been introduced for the prevention of catheter-related infections. However, there remains some uncertainty regarding the efficacy of these catheters because of conflicting reports in the literature.ObjectiveTo evaluate the efficacy of chlorhexidine–silver sulfadiazine–impregnated central venous catheters in the prevention of catheter-related bloodstream infection.Data SourcesStudies identified from a computerized search of the MEDLINE database from January 1966 to January 1998, reference lists of identified articles, and queries of principal investigators and the catheter manufacturer.Study SelectionRandomized trials comparing chlorhexidine–silver sulfadiazine–impregnated central venous catheters with nonimpregnated catheters were included. The outcomes assessed were catheter colonization and catheter-related bloodstream infection confirmed by catheter culture.Data ExtractionTwelve studies met the inclusion criteria for catheter colonization and included a total of 2611 catheters. Eleven studies with a total of 2603 catheters met the inclusion criteria for catheter-related bloodstream infection. Most patients in these studies were from groups considered to be at high risk for catheter-related infections. Summary statistics were calculated using Mantel-Haenszel methods under a fixed-effects model.Data SynthesisThe summary odds ratio for catheter colonization was 0.44 (95% confidence interval [CI], 0.36-0.54; P