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In medicine, the challenges faced by female faculty members who are attempting to achieve academic advancement have been well described. Various strategies have been proposed to increase academic productivity to aid the promotion of women in medicine. We propose an innovative collaboration strategy that encourages completion of an academic writing project. This strategy acknowledges the challenges inherent in achieving work-life balance and utilizes a collaborative work style with a group of peer physicians. The model is designed to encourage the completion and collation of independently prepared sections of an academic paper within a setting that emphasizes social networking and collaboration. This approach has many similarities to the construction of a quilt during a "quilting bee." [ABSTRACT FROM AUTHOR]

BACKGROUND: Philanthropic contributions to academic medical centers from grateful patients support research, patient care, education, and capital projects. The goal of this study was to identify the ethical concerns associated with philanthropic gifts from grateful patients. METHODS: A qualitative study design was selected. Investigators conducted in-depth semi-structured interviews with 20 Department of Medicine physicians at Johns Hopkins who were identified by Development Office staff as experienced and successful in this realm-those having relationships with multiple patients who have made philanthropic contributions. Interview transcripts were independently coded by two investigators. Content analysis identified several themes related to ethical concerns. RESULTS: Eighteen informants (90 %) were Associate Professors or Professors; two (10 %) were females. Four thematic domains emerged related to ethical concerns associated with philanthropy from grateful patients: (i) impact of gift on the doctor-patient relationship; (ii) gift acquisition considered beyond the physician's professional role; (iii) justice and fairness; and (iv) vulnerability of patients. Despite acknowledging at least one of the aforementioned concerns, eleven physician informants (55 %) expressed the view that there were no ethical issues involved with grateful patient philanthropy. CONCLUSIONS: In this paper, we report that physicians involved in grateful patient philanthropy are aware of, and in some cases troubled by, the ethical concerns related to this activity. Further studies could examine how best to prepare faculty for the challenges that may accompany these gifts so as to help them maintain expected professional and ethical standards when accepting grateful patient philanthropy. [ABSTRACT FROM AUTHOR]

Background: Women remain underrepresented in academic medicine, particularly in leadership positions. This lack of women in leadership has been shown to have negative implications for both patient care and educational outcomes. Similarly, the literature demonstrates that female physicians are less likely to have mentors, despite the proven benefits of mentorship for career advancement. The objective of this review is to identify and describe models of mentorship for women in academic medicine.Methods: We searched PubMed, PsycINFO, Education Resources Information Center, and Cochrane Databases of Systematic Reviews following PRISMA guidelines in June 2017. We included original English language studies that described a mentorship program in the USA that involved academic medical doctorates and that were created for women or provided results stratified by gender.Results: Our search returned 3625 results; 3309 references remained after removal of duplicates. Twenty articles met inclusion criteria. The majority of the programs were designed for junior faculty and used the dyad model of mentoring (i.e., one mentor/one mentee). Frequently cited objectives of these programs were to improve scholarship, promotion, and retention of female faculty. Program evaluations were primarily survey-based, with participant-reported satisfaction being the most frequent measured outcome. Most results showed very high satisfaction. Gender concordance between mentor and mentee did not impact satisfaction. Eight articles reported objective outcomes, including publications, retention, and promotion, and each of these demonstrated an improvement after program implementation.Discussion: Our review suggests that mentorship programs designed for women, regardless of the model, are met with high satisfaction and can help promote and retain women in academic medicine. No clear best practices for mentorship emerged in the literature. Institutions, therefore, can individualize their mentorship programs and models to available resources and goals. These results demonstrate the importance of more widespread implementation of mentorship programs to more effectively facilitate professional development and success of women in academic medicine. [ABSTRACT FROM AUTHOR]

Background: Failed referrals for specialty care are common and often represent medical errors. Technological structures and processes account for many failures. Scheduling appointments for subspecialty evaluation is a first step in outpatient referral and consultation.Objective: We determined whether moving from paper-based referrals to a Web-based system with automated tracking features was associated with greater scheduling of appointments among referred patients.Design: Staggered implementation of a quality-improvement project, with comparison of intervention and control groups.Participants: Patients 21 or more years of age referred from any of 11 primary-care clinics to any of 25 specialty clinics.Interventions: Faxed referrals were replaced by a Web-based application shared by generalists and specialists, with enhanced communications and automated notification to the specialty office.Measurements: We compared scheduling before and after implementation and time from referral to appointment. A logistic regression analysis adjusted for demographics.Main Results: Among 40,487 referrals, 54% led to scheduled specialty visits before intervention, compared to 83% with intervention. The median time to appointment was 168 days without intervention and 78 days with intervention. Scheduling increased more when duplicate referrals were not generated (54% for single orders, 24% for multiple orders). After adjustment, referrals with the intervention were more than twice as likely to have scheduled visits.Conclusions: With a new Web-based referrals system, referrals were more than twice as likely to lead to a scheduled visit. This system improves access to specialty medical services. [ABSTRACT FROM AUTHOR]

Background: "Sacred moments" are brief periods of time in which people experience a deep interconnectedness that may possess spiritual qualities and emotions. This concept has been shown to have a positive impact on individuals' overall well-being and stress in mental health settings. The concept of sacred moments has not been studied in acute care hospital settings. Objective: To better understand the occurrence of sacred moments among hospitalized patients and their healthcare workers. Design: An exploratory qualitative study that included in-depth interviews with patients and healthcare workers at two academic medical centers in the Midwestern United States. Participants: Hospital healthcare workers (e.g., physicians, nurses, ancillary staff) and discharged patients with a recent hospital stay. Approach: Semi-structured telephone interviews were conducted with 30 participants between August 2020 and April 2021. Interviews were recorded and transcribed before conducting thematic analysis. Key Results: Both healthcare workers and patients reported having experienced at least one sacred moment. Interview findings were organized into three main domains including (1) several common elements described by participants as marking these moments; (2) benefits experienced by both patients and healthcare workers; and (3) suggestions for fostering sacred moments within the hospital setting. Conclusions: Among our participants, sacred moments were extremely common with the vast majority reporting to have experienced at least one in their lifetime. These moments were described as profound and important and shared many common elements. Our findings can be used to help recognize, understand, and promote sacred moments between hospitalized patients and healthcare workers. [ABSTRACT FROM AUTHOR]

A number of fundamental issues must be considered in preparing the education system to produce more primary care physicians. Governmental controls and redirection of resources will force significant changes in the structuring of approaches to both undergraduate and graduate education in primary care. Particularly challenging will be restructuring and funding medical student programs in primary care, given a nearly certain requirement that more than 50% of medical school graduates enter primary care disciplines. Institutions will need to make strategic resource allocations to compete for the funding once the allocation process begins. Educational institutions will also face a cultural adaptation to primary care as an educational priority. This paper presents a model to study costs and funding for residency programs as they move from the traditional inpatient orientation to an outpatient focus. The authors suggest that for medical student education, the development of large academic health care systems may make funding primary care education more feasible. [ABSTRACT FROM AUTHOR]

This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction with work in the group practice was consistently associated with decreased interest in subspecialty training. [ABSTRACT FROM AUTHOR]

Background: Women are underrepresented within internal medicine (IM). Whether women leaders attract women trainees is not well explored. Objective: To characterize leader and trainee gender across US academic IM and to investigate the association of leader gender with trainee gender. Design: Cross-sectional study. Participants: Leaders (chairs, chiefs, program directors (PDs)) in 2018 and trainees (residents, fellows) in 2012–2016 at medical school-affiliated IM and seven IM fellowship programs. Exposure: Leadership (chair/chief and program director; and, for resident analyses, fellow) gender. Main Measures: Our primary outcome was percent women trainees (IM residents and, separately, subspecialty fellows). We used standard statistics to describe leadership and trainee gender. We created separate multivariable linear regressions to evaluate associations of leader gender and percent women fellows with percent women IM residents. We then created separate multivariable multilevel models (site as a random effect) to evaluate associations of leader gender with percent women subspecialty fellows. Key Results: Our cohort consisted of 940 programs. Women were 13.4% of IM chairs and <25% of chiefs in each fellowship subspecialty (cardiology: 2.6%; gastroenterology: 6.6%; pulmonary and critical care: 10.7%; nephrology: 14.4%; endocrinology: 20.6%; hematology-oncology: 23.2%; infectious diseases: 24.3%). IM PDs were 39.7% women; fellowship PDs ranged from nearly 25% (cardiology and gastroenterology) to nearly 50% (endocrinology and infectious disease) women. Having more women fellows (but not chairs or PDs) was associated with having more women residents (0.3% (95% CI: 0.2–0.5%) increase per 1% fellow increase, p<0.001); this association remained after adjustment (0.3% (0.1%, 0.4%), p=0.001). In unadjusted analyses, having a woman PD (increase of 7.7% (4.7%, 10.6%), p<0.001) or chief (increase of 8.9% (4.6%, 13.1%), p<0.001) was associated with an increase in women fellows; after adjustment, these associations were lost. Conclusions: Women held a minority of leadership positions in academic IM. Having women leaders was not independently associated with having more women trainees. [ABSTRACT FROM AUTHOR]

Background: Micro- and macroaggressions are often stereotype threats that can have detrimental effects on the recipients. Survey data shows that these aggressions are happening. However, there are few qualitative studies on trainees and faculty physicians' experiences with such aggressions and their impact.Objective: Explore how micro- and macroaggressions impact physician trainees and faculty.Design, Setting, Participants: Virtual, one-on-one, semi-structured interviews were conducted between February and September 2021, among 14 physicians and trainees (medical students, residents, fellows, and faculty) at a tertiary, urban, US academic medical center and its associated hospitals. Participants shared their experiences with micro- and macroaggressions in training and the workplace, as well as their thoughts on intervention and education.Approach: Qualitative interviews; grounded theory approach KEY RESULTS: A total of 14 physicians and trainees (5 faculty, 2 fellows, 5 residents, 2 students; 11 [79%] women) participated. Four themes with multiple subthemes surfaced: definition, the moment an aggression is experienced, aftereffect of an aggression, and education and training. While general definitions of micro- and macroaggressions were similar among participants, some may have overlooked the inclusion of a marginalized group as central to each term. Both types of aggressions had a range of effects on participants, with faculty noting a cumulative effect. Institutional diversity was identified as a key source of support. Ideas on how to combat such acts included mandatory educational programs and policies, with the acknowledgment that much effort and time are necessary to change mindset and culture.Conclusions: Faculty physicians and medical trainees shared their personal experiences with micro- and macroaggressions during work and training. Participants described various emotions in the moment but also noted that these aggressions often had lasting impacts. They recognized the challenges of finding a solution to micro- and macroaggressions. Institution-wide education was favored by many as a first step. [ABSTRACT FROM AUTHOR]

Background: Most health insurance organizations reimbursed both video and audio-only (i.e., phone) visits during the COVID-19 pandemic, but may discontinue phone visit coverage after the pandemic. The impact of discontinuing phone visit coverage on various patient subgroups is uncertain. Objective: Identify patient subgroups that are more probable to access telehealth through phone versus video. Design: Retrospective cohort. Patients: All patients at a U.S. academic medical center who had an outpatient visit that was eligible for telehealth from April through June 2020. Main Measures: The marginal and cumulative effect of patient demographic, socioeconomic, and geographic characteristics on the probability of using video versus phone visits. Key Results: A total of 104,204 patients had at least one telehealth visit and 45.4% received care through phone visits only. Patient characteristics associated with lower probability of using video visits included age (average marginal effect [AME] −6.9% for every 10 years of age increase, 95%CI −7.8, −4.5), African-American (AME −10.2%, 95%CI −11.4, −7.6), need an interpreter (AME −19.3%, 95%CI −21.8, −14.4), Medicaid as primary insurance (AME −12.1%, 95%CI −13.7, −9.0), and live in a zip code with low broadband access (AME −7.2%, 95%CI −8.1, −4.8). Most patients had more than one factor which further reduced their probability of using video visits. Conclusions: Patients who are older, are African-American, require an interpreter, use Medicaid, and live in areas with low broadband access are less likely to use video visits as compared to phone. Post-pandemic policies that eliminate insurance coverage for phone visits may decrease telehealth access for patients who have one or more of these characteristics. [ABSTRACT FROM AUTHOR]

Background: Care delivered using telemedicine has been steadily growing in the USA but represented a small fraction of overall visits before the COVID-19 pandemic as few clinicians had been providing care using telemedicine. Understanding how experienced clinicians have practiced telemedicine can help guide today's exponential adoption of telemedicine. Objective: The objective of this study was to explore barriers and facilitators to providing effective, high-quality urgent care using telemedicine ("tele-urgent care") from the perspective of clinicians experienced in telemedicine. Approach: We conducted semi-structured interviews between July 2018 and March 2019 of clinicians who had been providing tele-urgent care services to patients as a part of their routine clinical practice. Themes were identified using content analysis with a constant comparative coding approach. Key Results: Among the 20 clinicians interviewed, the majority were female (90%) and nurse practitioners (65%). We identified four themes related to barriers and facilitators to providing effective, high-quality tele-urgent care. Workplace factors such as a strong information technology (IT) infrastructure, real-time IT support, an electronic health record, and a collegial work environment, often virtual, were necessary standards. Communication and exam techniques from in-person encounters were adapted to tele-urgent care including active listening skills and teaching patients to conduct specific exam maneuvers virtually. The convenience of tele-urgent care should be preserved to support improvements in access to care. Finally, patients and clinicians occasionally had mismatched expectations about what could or would be provided during a tele-urgent care encounter. Managing the added tension that can occur during a telemedicine encounter was important. Conclusion: As telemedicine becomes an integral part of the care continuum, incorporating and accounting for these key insights when we train and support clinicians will be necessary to provide effective, high-quality care to patients in the future. [ABSTRACT FROM AUTHOR]

Introduction: Transitions of care experiences leave patients vulnerable to adverse outcomes, including readmissions, worsening symptoms, and reductions in functional status. Aim: To describe and evaluate a primary care transitions clinic that serves patients with medical and/or social needs that must be addressed prior to establishment of primary care. Setting: Brigham Health, an academic medical center in Boston, MA. Program Description: The transitions clinic opened within an existing primary care practice in January 2019. It employs one full-time nurse care coordinator and one full-time medical assistant, and is staffed by one primary care physician (PCP) or nurse practitioner each weekday afternoon. Both medical and social diagnoses that require follow-up post-discharge are addressed. Patients with any insurance are seen as many times as necessary until PCP care is established. Program Evaluation: In the year after its establishment (January 20, 2019, to January 19, 2020), the transitions clinic received 498 referrals (73.2% from the emergency department (ED), 23.3% from inpatient), with 207 patients ultimately seen. Patients were seen 5 (median; IQR 4–6) work days post-discharge, with 2 (median; IQR 1–3) visits per patient. Patients seen in the transitions clinic had significantly fewer ED visits than a comparator cohort referred to Brigham Health Primary Care after ED or hospital discharge in the year prior (January 20, 2018, to January 20, 2019). Patients seen in the transitions clinic additionally had significantly fewer ED visits and hospitalizations in the three months post-referral than in the three months pre-referral. The most common social determinants addressed by the clinic's nurse coordinator were insurance, transportation, and housing. Discussion: A primary care transitions clinic can provide accessible, attentive care post-discharge with positive effects on healthcare utilization. Availability of a multidisciplinary team that can see patients for repeated visits until establishment of PCP care was a key success factor for the transitions clinic. [ABSTRACT FROM AUTHOR]

Background: Ensuring equitable care remains a critical issue for healthcare systems. Nationwide evidence highlights the persistence of healthcare disparities and the need for research-informed approaches for reducing them at the local level. Objective: To characterize key contributors in racial/ethnic disparities in emergency department (ED) throughput times. Design: We conducted a sequential mixed methods analysis to understand variations in ED care throughput times for patients eventually admitted to an emergency department at a single academic medical center from November 2017 to May 2018 (n=3152). We detailed patient progression from ED arrival to decision to admit and compared racial/ethnic differences in time intervals from electronic medical record time-stamp data. We then estimated the relationships between race/ethnicity and ED throughput times, adjusting for several patient-level variables and ED-level covariates. These quantitative analyses informed our qualitative study design, which included observations and semi-structured interviews with patients and physicians. Key Results: Non-Hispanic Black as compared to non-Hispanic White patients waited significantly longer during the time interval from arrival to the physician's decision to admit, even after adjustment for several ED-level and patient demographic, clinical, and socioeconomic variables (Beta (average minutes) (SE): 16.35 (5.8); p value=.005). Qualitative findings suggest that the manner in which providers communicate, advocate, and prioritize patients may contribute to such disparities. When the race/ethnicity of provider and patient differed, providers were more likely to interrupt patients, ignore their requests, and make less eye contact. Conversely, if the race/ethnicity of provider and patient were similar, providers exhibited a greater level of advocacy, such as tracking down patient labs or consultants. Physicians with no significant ED throughput disparities articulated objective criteria such as triage scores for prioritizing patients. Conclusions: Our findings suggest the importance of (1) understanding how our communication style and care may differ by race/ethnicity; and (2) taking advantage of structured processes designed to equalize care. [ABSTRACT FROM AUTHOR]

Background: Although social factors influence uptake of preventive services, the association between social needs and influenza vaccination has not been comprehensively evaluated for adults seeking primary care in the USA. Objective: To determine the association between unmet social needs and influenza vaccination. Design: Retrospective, cross-sectional, multivariable logistic regression. Participants: Persons completing ambulatory visits in a primary care department at a midwestern, urban, multispecialty, academic medical center between July 2017 and July 2019 (N = 7955 individuals included). Main Measures: Completion of influenza vaccination in the 2018–2019 influenza season (primary outcome) or any year (secondary outcome) against 11 essential social needs (childcare, companionship, food security, health literacy, home safety, neighborhood safety, housing, health care provider costs, prescription costs, transportation, and utilities). Demographics, diabetic status, COPD, smoking status, office visit frequency, and hierarchical condition category risk scores were included as covariates. Key Results: Individuals with transportation vulnerability were less likely to be vaccinated against influenza (current-year aOR 0.65, 95% CI: 0.53–0.78, p < 0.001; any-year aOR 0.58, 95% CI: 0.47–0.71, p < 0.001). Poor health literacy promoted any-year, but not current-year, influenza vaccination (any-year aOR 1.30, 95% CI: 1.01–1.69, p = 0.043). Older age, female sex, diabetes, more comorbidities, and more frequent primary care visits were associated with greater influenza vaccination. Persons with Black or other/multiple race and current smokers were less frequently vaccinated. Conclusions: Transportation vulnerability, health literacy, smoking, age, sex, race, comorbidity, and office visit frequency are associated with influenza vaccination. Primary care–led interventions should consider these factors when designing outreach interventions. Trial Registration: Not applicable [ABSTRACT FROM AUTHOR]

Introduction: As the U.S. population ages, primary care clinicians (PCCs) will encounter more patients with geriatric syndromes, such as urinary incontinence (UI) and falls. Yet, current evidence suggests that care of these conditions does not meet expected standards and that PCCs would benefit from tools to improve care of these conditions. Little is known about the role of computerized condition-specific templates for improving care of geriatric syndromes.Aim: We sought to develop and assess the usefulness of condition-specific computerized templates in a primary care setting.Setting: A large academic Veterans Affairs medical center.Program Description: We developed and tested the usefulness of 2 condition-specific computerized templates (UI and falls) that could be added on to an existing electronic health record system.Program Evaluation: Semistructured interviews were used to identify barriers to use of computerized templates. Usefulness and usability were assessed through a randomized-controlled trial involving standardized patients.Discussion: Use of condition-specific templates resulted in improved history and physical exam assessment for both UI and falls (P < .05). Our computerized, condition-specific templates are a promising method for improving care of geriatric conditions in a primary care setting, but require improvement in usability before widespread implementation. [ABSTRACT FROM AUTHOR]

Background: There are currently no evidence-based guidelines that provide standardized criteria for the discharge of COVID-19 patients from the hospital.Objective: To address this gap in practice guidance, we reviewed published guidance and collected discharge protocols and procedures to identify and synthesize common practices.Design: Rapid review of existing guidance from US and non-US public health organizations and professional societies and qualitative review using content analysis of discharge documents collected from a national sample of US academic medical centers with follow-up survey of hospital leaders SETTING AND PARTICIPANTS: We reviewed 65 websites for major professional societies and public health organizations and collected documents from 22 Academic Medical Centers (AMCs) in the US participating in the HOspital MEdicine Reengineering Network (HOMERuN).Results: We synthesized data regarding common practices around 5 major domains: (1) isolation and transmission mitigation; (2) criteria for discharge to non-home settings including skilled nursing, assisted living, or homeless; (3) clinical criteria for discharge including oxygenation levels, fever, and symptom improvement; (4) social support and ability to perform activities of daily living; (5) post-discharge instructions, monitoring, and follow-up.Limitations: We used streamlined methods for rapid review of published guidance and collected discharge documents only in a focused sample of US academic medical centers.Conclusion: AMCs studied showed strong consensus on discharge practices for COVID-19 patients related to post-discharge isolation and transmission mitigation for home and non-home settings. There was high concordance among AMCs that discharge practices should address COVID-19-specific factors in clinical, functional, and post-discharge monitoring domains although definitions and details varied. [ABSTRACT FROM AUTHOR]

Background: Workplace discrimination negatively affects physicians of color personally and professionally. Although the occurrence of discrimination from patients has been visible in social media, popular press, and personal essays, scant research exists on patients as a source of discrimination directed at physicians of color.Objective: To explore practicing general internists' experiences observing or interacting with patients exhibiting discriminatory behavior directed at physicians of color.Design: A qualitative study with in-depth, semi-structured, one-on-one telephone interviews conducted and recorded between May and September 2019.Participants: A purposive sample of 24 general internists practicing at 12 academic health centers in the USA: 14 self-identified as White and 10 as a physician of color, which included Asian, Black, Native American, and self-identified other race.Approach: Four coders analyzed the transcribed and verified interview text; thematic analysis was used to inductively identify cohesive themes and subthemes.Key Results: Analyses revealed four major themes: (1) assumption that a legitimate doctor is White, male, and able-bodied; (2) legacy of the Black experience; (3) working through the struggle of discrimination; and (4) ethical dilemma of providing care to discriminatory patients. In addition to discrimination from patients based on a physician's race or ethnicity, participants described experiencing or observing discrimination based on a physician's gender and disability status. Participants generally expressed a need for greater support from colleagues and more guidance from institutional policies.Conclusions: General internists practicing in academic settings reported observing or experiencing discrimination from patients based on the physician's race, ethnicity, gender (or their intersection), and disability status and the ethical dilemma of providing care to such patients. These results contribute to growing evidence of the need for institutions to better support an increasingly diverse physician workforce with policies and specific guidance to help physicians respond to discrimination from patients while still providing quality care. [ABSTRACT FROM AUTHOR]

Third-year clerkships, organized around clinical experiences, may provide students with an uneven or narrowly focused fund of clinical knowledge. This paper describes the results of a comparative trial in which a structured curriculum, based on learning objectives, was introduced into an internal medicine clerkship at one of three teaching hospitals of a single medical school; the other two hospitals, providing similar patient care experiences, were used for comparison purposes. Students who did their clerkship at the hospital using the structured curriculum scored significantly higher on the Medicine section of the National Board Part II examination when scores were adjusted for past academic performance. The structured curriculum was very well received and, according to student perceptions, achieved the goal of expanding their basic clinical knowledge beyond that derived from reading only in connection with patient care. These results support the use of curricular guidelines and objectives as a means of enhancing students' cognitive experience during clinical clerkships. [ABSTRACT FROM AUTHOR]

Background: Advancing health equity entails reducing disparities in care. African-American patients with chronic kidney disease (CKD) have poorer outcomes, including dialysis access placement and transplantation. Estimated glomerular filtration rate (eGFR) equations, which assign higher eGFR values to African-American patients, may be a mechanism for inequitable outcomes. Electronic health record–based registries enable population-based examination of care across racial groups. Objective: To examine the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and care delivery. Design: Cross-sectional study Setting: Two large academic medical centers and affiliated community primary care and specialty practices. Participants: A total of 56,845 patients in the Partners HealthCare System CKD registry in June 2019, among whom 2225 (3.9%) were African-American. Measurements: Exposures included race, age, sex, comorbidities, and eGFR. Outcomes were transplant referral and dialysis access placement. Results: Of 2225 African-American patients, 743 (33.4%) would hypothetically be reclassified to a more severe CKD stage if the race multiplier were removed from the CKD-EPI equation. Similarly, 167 of 687 (24.3%) would be reclassified from stage 3B to stage 4. Finally, 64 of 2069 patients (3.1%) would be reassigned from eGFR > 20 ml/min/1.73 m2 to eGFR ≤ 20 ml/min/1.73 m2, meeting the criterion for accumulating kidney transplant priority. Zero of 64 African-American patients with an eGFR ≤ 20 ml/min/1.73 m2 after the race multiplier was removed were referred, evaluated, or waitlisted for kidney transplant, compared to 19.2% of African-American patients with eGFR ≤ 20 ml/min/1.73 m2 with the default CKD-EPI equation. Limitations: Single healthcare system in the Northeastern United States and relatively small African-American patient cohort may limit generalizability. Conclusions: Our study reveals a meaningful impact of race-adjusted eGFR on the care provided to the African-American CKD patient population. [ABSTRACT FROM AUTHOR]

This Perspective presents a case study of multidimensional clinical transformation in an academic general internal medicine practice. In the face of increasing internal and external pressures, health systems and individual medical practices have pursued multiple strategies to improve quality, patient experience, and efficiency, while reducing staff and provider stress and burnout. We describe a Lean-informed approach that emphasizes the importance of organizational alignment in goals, evidence-based problem solving, and leadership behaviors to support a culture of continuous improvement. Our aim in this Perspective is to provide a real-world example of a feasible process for the planning, preparation, and execution of effective transformation, and to present lessons that may be useful to other academic health center practices seeking to develop innovative models to achieve the quadruple aim. [ABSTRACT FROM AUTHOR]

Importance: The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood.Objective: To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults.Design: Retrospective analysis of overall means and clinician-level variation in performance on three new measures.Subjects: Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017.Measures: Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication.Results: Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively.Conclusions: Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined. [ABSTRACT FROM AUTHOR]

Background: Gender inequities are documented in academic medicine. Within General Internal Medicine (GIM), there are fewer female division directors and first and last authors on publications. With gender parity in US medical school graduates and with Academic Hospital (AH) medicine being a relatively newer discipline, one might postulate that AH would have less gender inequity.Design: A national survey of AH programs was developed via literature review and expert recommendations. Domains included program and faculty information. Gender of the leader was determined via website or telephone call.Participants: Leaders of AH programs associated with the American Association of Medical Colleges (AAMC). Programs without a primary teaching hospital or hospitalist program and those not staffed by university-affiliated physicians were excluded.Main Measures: Description and characteristics of leaders and programs including a multivariable analysis of gender of hospitalist leaders and the portion of female faculty.Key Results: 59% response rate (80 of 135); there were no differences between responders/non-responders in NIH funding (p = 0.12), type of institution (p = 0.09), geographic region (p = 0.15), or year established (p = 0.86). Reported number of female and male faculty were approximately equal. 80% of hospitalist leaders were male; 37% of male hospitalist leaders were professors, no female leaders were professors. In univariate and multivariate analysis only the number of hospitals staffed was a significant predictor of having a female hospitalist leader. There were no significant predictors of having fewer female faculty.Conclusion: This study demonstrated gender inequality in academic hospital medicine regarding leadership and rank. Though there was equal gender distribution of faculty, among leaders most were men and all "full professors" were men. As diversity benefits the tripartite mission research on methods, initiatives and programs that achieve gender equity in leadership are needed. [ABSTRACT FROM AUTHOR]

Background: There have been no large-scale studies to date of patients' experiences with electronic consultation (eConsult) between primary and specialty care.Objective: Compare experiences with eConsult and referral for in-person specialist consultation.Design: Online survey 2-6 weeks following eConsult or referral at 9 US academic medical centers.Participants: Adult patients with no more than one eConsult or referral order from a primary care provider (PCP) in the prior month. Over 9 months, 29,291 email invitations were sent (88% referral; 12% eConsult).Main Measures: Trust in and satisfaction with PCP; consult type awareness; agreement with decision to seek specialist input; timeliness of care; mode of PCP-patient eConsult communication; satisfaction with specialist's recommendations; future preference for eConsult or referral.Key Results: A 27.6% response rate yielded 8087 respondents (88.4% referral; 11.6% eConsult). Many did not know that their PCP had placed a referral (32.8% unaware) or eConsult (52.9%), and eConsult awareness was significantly higher among patients reporting better health (OR 1.62, 95% CI 1.18-2.23). Most (81.4% eConsult; 82.0% referral) were satisfied with the specialist's recommendations. Those who had a good primary care experience were more likely to be satisfied (eConsult: OR 10.63, 95% CI 2.95-38.32; referral: OR 2.87, 95% CI 1.86-4.44). For a similar problem in the future, 78% of eConsult and 32% percent of referral patients preferred eConsult.Conclusions: This multisite study demonstrates that many patients find virtual consultation to be an acceptable strategy for the management of their medical condition and that trust and confidence in one's PCP are crucial ingredients for a satisfying eConsult experience. The lack of awareness of eConsult among many patients who were beneficiaries of the service warrants an increased effort to include patients in eConsult decision-making and communication. Further research is needed to assess eConsult acceptability and satisfaction in more diverse patient populations. [ABSTRACT FROM AUTHOR]

Background: Older adults often take multiple medications, leading to a myriad of medication-related problems. Addressing these problems requires thoughtful approaches that align with patients' perspectives and experiences. Objective: To (1) identify and categorize medication-related problems from the patient perspective and (2) understand patient and clinician attitudes toward these problems and experiences with addressing these problems. Design: Qualitative, semi-structured interviews with patients and focus groups with physicians and pharmacists. Participants: Twenty older adults recruited from an academic medical center and from a community senior center; 14 primary care physicians and 6 pharmacists affiliated with an academic medical center. Approach: Hybrid deductive-inductive thematic analysis. Key Results: Older adults identified a variety of medication-related problems that could be classified into four broad categories: (1) obtaining medications (e.g., problems with cost and insurance coverage); (2) taking medications (e.g., organization and remembering to take pills); (3) medication effects, including side effects and concerns over lack of effectiveness; and (4) communication and care coordination, including information related to medications. Many of the problems described by older adults were framed within the person's socioemotional context, including the impact of medications on interpersonal relationships, emotional wellbeing, and activities that add meaning and quality to life. In contrast, clinicians almost exclusively focused on discrete medication issues without reference to this larger context and expressed relatively little interest in learning more about their patients' perspectives. Conclusions: Older adults experience medication-related problems as inseparable from their broader life context. Incorporating the social and emotional context of medications and related communication into a problem-focused framework can guide clinicians in specific actions and interventions to address medication-related problems from the patient perspective. [ABSTRACT FROM AUTHOR]

Background: Mutual support groups (MSGs) are support systems for patients with substance use disorders (SUDs), yet medical residents lack awareness in the role MSGs play in addiction treatment.Aim: We developed an educational intervention to expose residents to MSGs and improve attitudes toward patients with SUD.Setting: The study took place from October 2017 to March 2018 within a large academic medical center.Participants: First- to third-year internal medicine residents participated.Program Description: Residents attended a MSG meeting. They completed surveys pre- and post-meeting and attended a focus group debrief session. Focus group transcripts were coded and thematically analyzed.Program Evaluation: Sixty-eight residents participated in the curriculum, 54 attended the focus group and 47 completed the pre- and post-survey. Qualitative themes included (1) appreciation for the sense of community at meetings, (2) improved perspective taking of patients with SUDs, (3) concern regarding religion, and (4) improved confidence in MSG referrals. Post-intervention, residents had more positive attitudes toward patients with SUD (p < 0.05 for 9 of 14 questions) and toward MSGs (p < 0.05 for 2 of 4 questions).Discussion: Implementing an educational intervention on MSGs gives residents an experience that impacts attitudes toward patients with SUD and confidence with MSG referrals. [ABSTRACT FROM AUTHOR]

Background: Risk communication is a core aspect of a physician's work and a fundamental prerequisite for successful shared decision-making. However, many physicians are not able to adequately communicate risks to patients due to a lack of understanding of statistics as well as inadequate management of conflicts of interest (COI).Objective: To evaluate the effects of an integrated curriculum encompassing COI and shared decision-making on the participants' risk communication competence, that is, their competence to advise patients on the benefits and harms of diagnostic or therapeutic interventions.Design: A rater-blind randomized controlled trial with a 30 (± 1)-week follow-up conducted from October 2016 to June 2017 at two German academic medical centers.Participants: Sixty-three medical students in their fourth or fifth year.Interventions: Participants received either a newly developed 15-h curriculum or a course manual adapted from teaching as usual.Main Measures: Primary outcome: change in risk communication performance in a video-observed structured clinical examination (VOSCE).Key Results: Participants were 25.7 years old on average (SD 3.6); 73% (46/63) were female. Increase in risk communication performance was significantly higher in the intervention group with post-intervention Cohen's d of 2.35 (95% confidence interval (CI) 1.62 to 3.01, p < 0.01) and of 1.83 (CI 1.13 to 2.47, p < 0.01) 30 (± 1) weeks later. Secondary outcomes with the exception of frequency of interactions with the pharmaceutical industry also showed relevant improvements in the intervention as compared with the control group (d between 0.91 and 2.04 (p < 0.001)).Conclusions: Our results show that an integrated curriculum encompassing COI and risk communication leads to a large and sustainable increase in risk communication performance. We interpret the large effect sizes to be a result of the integration of topics that are usually taught separately, leading to a more effective organization of knowledge.Trial Registration: The trial is registered in the International Clinical Trials Registry with the trial number DRKS00010890. [ABSTRACT FROM AUTHOR]

Background: The transition from pediatric to adult care is a critical period for young adults with childhood-onset conditions. General internists are tasked with participating in the care of this vulnerable population. Existing guidelines regarding transition do not fully address structural or organizational characteristics of practices that facilitate transition. Moreover, literature regarding transition has focused on pediatric subspecialty settings, leaving internists with little guidance after transfer.Objectives: To better understand post-transfer transitional care by describing care models that primary care providers have implemented, and examining common features of generalist physicians' experiences providing transitional care.Design: Qualitative methods, semi-structured interviews.Participants: Nineteen generalist-trained physicians from across the USA, engaged in transition-focused and/or ongoing care of adolescents and young adults with childhood-onset conditions.Approach: Content and grounded theory analyses.Key Results: Participants included nineteen physicians from seventeen institutions. Most (89%) were from academic medical centers. About 80% had completed a combined internal medicine-pediatrics residency. About 70% worked with clinic staff who were dedicated to transition. Practice structures fell into four main care models: (1) primary care in adult settings; (2) transition support and primary care in pediatric settings; (3) a blend of pediatric and adult care elements forming a bridge during transition; and (4) a transition consultative service. Most provided primary care for adults with childhood-onset conditions within larger adult-oriented primary care practices. Common features across interviews included taking extra time with patients both during and between visits and an interdisciplinary team-based approach. Shared practice strategies and philosophies emphasized care coordination, focus on the whole patient beyond immediate health concerns, and willingness to learn from practice and from families.Conclusions: Participants used disparate care models. Common features and strategies among interviews highlight key functions and attributes of transitional care across settings, suggest important elements of care post-transfer, and clarify the role of generalists. [ABSTRACT FROM AUTHOR]

Background: Greater than 60% of adults have overweight or obesity. Self-weighing is an effective weight loss and weight maintenance tool. However, little is known about self-weighing habits among the primary care patient population. Our objective was to examine the frequency of patient-reported self-weighing, and to evaluate the associations of self-weighing with demographic characteristics and self-monitoring behaviors.Methods: We conducted an analysis of survey data collected as part of the PaTH Clinical Data Research Network, which recruited a cohort of 1,021 primary care patients at 4 academic medical centers. Patients of all body mass index (BMI) categories were included.Results: Response rate of 6-month survey was 727 (71%). The mean age was 56 years, and most were female (68%), White (78%), college graduates (66%), and employed/retired (85%). The mean BMI was 30.2 kg/m2, 80% of participants had a BMI ≧ 25 kg/m2. Of patients with BMI ≧ 25 kg/m2, 35% of participants self-weighed weekly and 23% daily. Participants who reported self-weighing at least weekly were more likely to be older (59 vs 54 years, p < 0.01), married (p = 0.01), college graduates (p = 0.03), White (p < 0.01), and employed vs disabled/unemployed (p < 0.01). Patients who self-weighed daily had a lower BMI (29 kg/m2 vs 31 kg/m2, p = 0.04). Patients who tracked exercise or food intake were more likely to self-weigh daily (p < 0.01), as were patients wanting to lose or maintain weight (p < 0.01).Conclusions: Despite its potential for primary and secondary obesity prevention, only 35% of primary care patients with overweight or obesity engage in self-weighing weekly and less than a quarter (23%) self-weigh daily. Socioeconomic status appears to be a factor influencing regular self-weighing in this population, potentially contributing to greater health disparities in obesity rates. Patients who self-weighed daily had a lower BMI, suggesting that it may play a role in primary prevention of obesity. More work is needed to explore self-weighing among patients. [ABSTRACT FROM AUTHOR]

Background: Outpatient primary care experience is vital to internal medicine resident training but may impact quality and equity of care delivered in practices that include resident physicians. Understanding whether quality differences exist among resident and staff primary care physicians (PCPs) may present an opportunity to address health disparities within academic medical centers.Objective: To determine whether there are differences in the quality of primary care provided by resident PCPs compared to staff PCPs.Design: A retrospective cohort study with a propensity-matched analysis.Participants: 143,274 patients, including 10,870 patients managed by resident PCPs, seen in 16 primary care practices affiliated with an academic medical center.Main Measures: Guideline-concordant chronic disease management of diabetes (HbA1c, LDL) and coronary artery disease (LDL), preventive breast, cervical, and colorectal cancer screening, and resource utilization measures including emergency department (ED) visits, hospitalizations, high-cost imaging, and patient-reported health experience.Key Results: At baseline, there were significant differences in sociodemographic and clinical characteristics between resident and staff physician patients. Resident patients were less likely to achieve chronic disease and preventive cancer screening outcome measures including LDL at goal (adjusted OR [aOR] 0.77 [95% CI 0.65, 0.92]) for patients with coronary artery disease; HbA1c at goal (aOR 0.73 [95% CI 0.62, 0.85]) for patients with diabetes; breast (aOR 0.56 [95% CI 0.49, 0.63]), cervical (aOR 0.66 [95% CI 0.60, 0.74]), and colorectal (aOR 0.72 [95% CI 0.65, 0.79] cancer screening. Additionally, resident patients had higher rates of ED visits and hospitalizations but lower rates of high-cost imaging. Resident patients reported lower rates of satisfaction with certain access to care and communication measures. Similar outcomes were noted in propensity-matched sensitivity analyses.Conclusion: After controlling for differences in sociodemographic and clinical factors, resident patients were less likely to achieve chronic disease and preventive cancer screening outcomes compared to staff patients. Further efforts to address ambulatory trainee education and primary care quality along with novel approaches to the management of the disproportionately disadvantaged resident patient panels are needed. [ABSTRACT FROM AUTHOR]

Background: Few programs train residents in recognizing and responding to distressed colleagues at risk for suicide.Aim: To assess interns' ability to identify a struggling colleague, describe resources, and recognize that physicians can and should help colleagues in trouble.Setting: Residency programs at an academic medical center.Participants: One hundred forty-five interns.Program Design: An OSCE case was designed to give interns practice and feedback on their skills in recognizing a colleague in distress and recommending the appropriate course of action. Embedded in a patient "sign-out" case, standardized health professionals (SHP) portrayed a resident with depressed mood and an underlying drinking problem. The SHP assessed intern skills in assessing symptoms and directing the resident to seek help.Program Evaluation: Interns appreciated the opportunity to practice addressing this situation. Debriefing the case led to productive conversations between faculty and residents on available resources. Interns' skills require further development: while 60% of interns asked about their colleague's emotional state, only one-third screened for depression and just under half explored suicidal ideation. Only 32% directed the colleague to specific resources for his depression (higher among those that checked his emotional state, 54%, or screened for depression, 80%).Discussion: This OSCE case identified varying intern skill levels for identifying and assessing a struggling colleague while also providing experiential learning and supporting a culture of addressing peer wellness. [ABSTRACT FROM AUTHOR]

Background: Prior cross-sectional research has found that generalists have lower rates of academic advancement than specialists and basic science faculty.Objective: Our objective was to examine generalists relative to other medical faculty in advancement and academic productivity.Design: In 2012, we conducted a follow-up survey (n = 607) of 1214 participants in the 1995 National Faculty Survey cohort and supplemented survey responses with publicly available data.Participants: Participants were randomly selected faculty from 24 US medical schools, oversampling for generalists, underrepresented minorities, and senior women.Main Measures: The primary outcomes were (1) promotion to full professor and (2) productivity, as indicated by mean number of peer-reviewed publications, and federal grant support in the prior 2 years. When comparing generalists with medical specialists, surgical specialists, and basic scientists on these outcomes, we adjusted for gender, race/ethnicity, effort distribution, parental and marital status, retention in academic career, and years in academia. When modeling promotion to full professor, we also adjusted for publications.Key Results: In the intervening 17 years, generalists were least likely to have become full professors (53%) compared with medical specialists (67%), surgeons (66%), and basic scientists (78%, p < 0.0001). Generalists had a lower number of publications (mean = 44) than other faculty [medical specialists (56), surgeons (57), and basic scientists (83), p < 0.0001]. In the prior 2 years, generalists were as likely to receive federal grant funding (26%) as medical (21%) and surgical specialists (21%), but less likely than basic scientists (51%, p < 0.0001). In multivariable analyses, generalists were less likely to be promoted to full professor; however, there were no differences in promotion between groups when including publications as a covariate.Conclusions: Between 1995 and 2012, generalists were less likely to be promoted than other academic faculty; this difference in advancement appears to be related to their lower rate of publication. [ABSTRACT FROM AUTHOR]

Background: Individuals with substance use disorders (SUD) have high rates of chronic illness and readmission, yet few are engaged in addiction treatment. Hospitalization may be a reachable moment for initiating and coordinating addiction care, but little is known about motivation for change in the inpatient setting.Objective: To explore the experiences of hospitalized adults with SUD and to better understand patient and system level factors impacting readiness for change.Design: We performed a qualitative study using individual interviews. The study was nested within a larger mixed-methods needs assessment.Participants and Setting: Hospitalized adults admitted to medical or surgical units at an urban academic medical center who reported high-risk alcohol or drug use on AUDIT-C or single-item drug use screener.Approach: We conducted a thematic analysis, using an inductive approach at a semantic level.Key Results: Thirty-two patients participated. The mean age was 43 years; 75% were men, and 68% identified as white. Participants reported moderate to high-risk alcohol (39%), amphetamine (46%), and opioid (65%) use. Emergent themes highlight the influence of hospitalization at the patient, provider, and health system levels. Many patients experienced hospitalization as a wake-up call, where mortality was motivation for change and hospitalization disrupted substance use. However, many participants voiced complex narratives of social chaos, trauma, homelessness, and chronic pain. Participants valued providers who understood SUD and the importance of treatment choice. Patient experience suggests the importance of peers in the hospital setting, access to medication-assisted treatment, and coordinated care post-discharge.Conclusions: This study supports that hospitalization offers an opportunity to initiate and coordinate addiction care, and provides insights into patient, provider, and health system factors which can leverage the reachability of this moment. [ABSTRACT FROM AUTHOR]

Background: General internal medicine (GIM) careers are increasingly viewed as challenging and unsustainable.Objective: We aimed to assess academic GIM worklife and determine remediable predictors of stress and burnout.Design: We conducted an email survey.Participants: Physicians, nurse practitioners, and physician assistants in 15 GIM divisions participated.Main Measures: A ten-item survey queried stress, burnout, and work conditions such as electronic medical record (EMR) challenges. An open-ended question assessed stressors and solutions. Results were categorized into burnout, high stress, high control, chaos, good teamwork, high values alignment, documentation time pressure, and excessive home EMR use. Frequencies were determined for national data, Veterans Affairs (VA) versus civilian populations, and hospitalist versus ambulatory roles. A General Linear Mixed Model (GLMM) evaluated associations with burnout. A formal content analysis was performed for open-ended question responses.Key Results: Of 1235 clinicians sampled, 579 responded (47 %). High stress was present in 67 %, with 38 % burned out (burnout range 10-56 % by division). Half of respondents had low work control, 60 % reported high documentation time pressure, half described too much home EMR time, and most reported very busy or chaotic workplaces. Two-thirds felt aligned with departmental leaders' values, and three-quarters were satisfied with teamwork. Burnout was associated with high stress, low work control, and low values alignment with leaders (all p < 0.001). The 45 VA faculty had less burnout than civilian counterparts (17 % vs. 40 %, p < 0.05). Hospitalists described better teamwork than ambulatory clinicians and fewer hospitalists noted documentation time pressure (both p < 0.001). Key themes from the qualitative analysis were short visits, insufficient support staff, a Relative Value Unit mentality, documentation time pressure, and undervaluing education.Conclusions: While GIM divisions overall demonstrate high stress and burnout, division rates vary widely. Sustainability efforts within GIM could focus on visit length, staff support, schedule control, clinic chaos, and EMR stress. [ABSTRACT FROM AUTHOR]

The article discusses a project undertaken at Brigham and Womens Hospital (BWH) that focused on electronic referral order systems established in the U.S. and internationally with broad uptake by primary care physicians (PCPs) and improved physician satisfaction. It aims to add to the existing literature on eReferral systems by tracking physician satisfaction across an entire health system and using administrative claims to look at the impact of eReferral on total specialist utlization.

Background: Business literature has demonstrated the importance of networking and connections in career advancement. This is a little-studied area in academic medicine.Objective: To examine predictors of intra-organizational connections, as measured by network reach (the number of first- and second-degree coauthors), and their association with probability of promotion and attrition.Design: Prospective cohort study between 2008 and 2012.Setting: Academic medical center.Participants: A total of 5787 Harvard Medical School (HMS) faculty with a rank of assistant professor or full-time instructor as of January 1, 2008.Main Measures: Using negative binomial models, multivariable-adjusted predictors of continuous network reach were assessed according to rank. Poisson regression was used to compute relative risk (RR) and 95 % confidence intervals (CI) for the association between network reach (in four categories) and two outcomes: promotion or attrition. Models were adjusted for demographic, professional and productivity metrics.Key Results: Network reach was positively associated with number of first-, last- and middle-author publications and h-index. Among assistant professors, men and whites had greater network reach than women and underrepresented minorities (p < 0.001). Compared to those in the lowest category of network reach in 2008, instructors in the highest category were three times as likely to have been promoted to assistant professor by 2012 (RR: 3.16, 95 % CI: 2.60, 3.86; p-trend <0.001) after adjustment for covariates. Network reach was positively associated with promotion from assistant to associate professor (RR: 1.82, 95 % CI: 1.32, 2.50; p-trend <0.001). Those in the highest category of network reach in 2008 were 17 % less likely to have left HMS by 2012 (RR: 0.83, 95 % CI 0.70, 0.98) compared to those in the lowest category.Conclusions: These results demonstrate that coauthor network metrics can provide useful information for understanding faculty advancement and retention in academic medicine. They can and should be investigated at other institutions. [ABSTRACT FROM AUTHOR]

Background: Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits.Objective: To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes.Design: Observational study.Participants: Forty-seven general internists who practice in affiliated academic and community clinics.Main Measures: Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity.Key Results: The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %.Conclusions: An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population. [ABSTRACT FROM AUTHOR]

Importance: Patients are increasingly being given access to their test results, but little is known about how preferences vary with the test under consideration or the results of the test (normal or abnormal).Objective: This study was conducted to examine preferences for test result communication.Design, Setting, and Participants: We surveyed adults to explore their preferences for test result notification for three common diagnostic tests of varying "emotional impact" (dual-energy x-ray absorptiometry [DXA], genital herpes, and cancer biopsy) when test results were 1) normal and 2) abnormal. We conducted our survey between June and August 2012 on the campus of an academic medical center. For each scenario, subjects were asked to rank seven methods that might be used to communicate test results (letter, unsecured email, secured email, text message, telephone call, secure Web portal, office visit) in order of acceptability.Main Outcome Measures: The main measures were the percentage of respondents who ranked a particular test result notification method favorably and the percentage who ranked it as unacceptable.Results: When test results were normal, subjects' notification preferences were generally similar for DXA, herpes and cancer biopsy, with telephone and letter ranked most favorably for all three tests. Conversely, text message and unsecured email were viewed as unacceptable notification methods for normal results by 45.0-55.0 % of subjects across all three tests. When test results were abnormal, office visits became more popular. A higher proportion of subjects ranked office visits as their most preferred notification method for our test with high "emotional impact" (cancer biopsy) (38.4 %) as compared to DXA (28.2 %) and herpes (27.9 %) (P = 0.02). For most test scenarios, younger subjects appeared to rank electronic communication modalities (secure email or Web portal) higher than older subjects, though this difference did not reach statistical significance (P = 0.29).Conclusions: Preferences for test result notification can differ substantially depending upon the test under consideration and results of the test. Providers and health care systems should consider these factors when deciding how to communicate results to patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Remediation in the era of competency-based assessment demands a model that empowers students to improve performance. AIM: To examine a remediation model where students, rather than faculty, develop remedial plans to improve performance. SETTING/PARTICIPANTS: Private medical school, 177 medical students. PROGRAM DESCRIPTION: A promotion committee uses student-generated portfolios and faculty referrals to identify struggling students, and has them develop formal remediation plans with personal reflections, improvement strategies, and performance evidence. Students submit reports to document progress until formally released from remediation by the promotion committee. PROGRAM EVALUATION: Participants included 177 students from six classes (2009-2014). Twenty-six were placed in remediation, with more referrals occurring during Years 1 or 2 ( n = 20, 76 %). Unprofessional behavior represented the most common reason for referral in Years 3-5. Remedial students did not differ from classmates ( n = 151) on baseline characteristics (Age, Gender, US citizenship, MCAT) or willingness to recommend their medical school to future students ( p < 0.05). Two remedial students did not graduate and three did not pass USLME licensure exams on first attempt. Most remedial students (92 %) generated appropriate plans to address performance deficits. DISCUSSION: Students can successfully design remedial interventions. This learner-driven remediation model promotes greater autonomy and reinforces self-regulated learning. [ABSTRACT FROM AUTHOR]

BACKGROUND: Elimination of wasteful diagnostic testing will improve value for the United States health care system. OBJECTIVE: Design and implement a multimodal intervention to improve evidence-based ordering of cardiac biomarkers for the diagnosis of acute coronary syndrome (ACS). DESIGN: Interrupted times series. SUBJECTS: A total of 60,494 adult inpatient admissions from January 2009 through July 2011 (pre-intervention) and 24,341 admissions from November 2011 through October 2012 (post-intervention) at an academic medical center in Baltimore, Maryland. INTERVENTION: Multimodal intervention introduced August through October 2011 that included dissemination of an institutional guideline and changes to the computerized provider order entry system. MAIN MEASURES: The primary outcome was percentage of patients with guideline-concordant ordering of cardiac biomarkers, defined as three or fewer troponin tests and zero CK-MB tests in patients without a diagnosis of ACS. Secondary outcomes included counts of tests ordered per patient, incidence of diagnosis of ACS, and estimated change in charges for cardiac biomarker tests in the post-intervention period. KEY RESULTS: Twelve months following the intervention, we estimated that guideline-concordant ordering of cardiac biomarkers increased from 57.1 % to 95.5 %, an absolute increase of 38.4 % (95 % CI, 36.4 % to 40.4 %). We estimated that the intervention led to a 66 % reduction in the number of tests ordered, and a $1.25 million decrease in charges over the first year. At 12 months, there was an estimated absolute increase in incidence of primary diagnosis of ACS of 0.3 % (95 % CI, 0.0 % to 0.5 %) compared with the expected baseline rate. CONCLUSIONS: We implemented a multimodal intervention that significantly increased guideline-concordant ordering of cardiac biomarker testing, leading to substantial reductions in tests ordered without impacting diagnostic yield. A trial of this approach at other institutions and for other diagnostic tests is warranted and if successful, would represent a framework for eliminating wasteful diagnostic testing. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patient care and medical knowledge are Accreditation Council for Graduate Medical Education (ACGME) core competencies. The correlation between amount of patient contact and knowledge acquisition is not known. OBJECTIVE: To determine if a correlation exists between the number of patient encounters and in-training exam (ITE) scores in internal medicine (IM) and pediatric residents at a large academic medical center. DESIGN: Retrospective cohort study PARTICIPANTS: Resident physicians at Mayo Clinic from July 2006 to June 2010 in IM (318 resident-years) and pediatrics (66 resident-years). METHODS: We tabulated patient encounters through review of clinical notes in an electronic medical record during post graduate year (PGY)-1 and PGY-2. Using linear regression models, we investigated associations between ITE score and number of notes during the previous PGY, adjusted for previous ITE score, gender, medical school origin, and conference attendance. KEY RESULTS: For IM, PGY-2 admission and consult encounters in the hospital and specialty clinics had a positive linear association with ITE-3 % score ( β = 0.02; p = 0.004). For IM, PGY-1 conference attendance is positively associated with PGY-2 ITE performance. We did not detect a correlation between PGY-1 patient encounters and subsequent ITE scores for IM or pediatric residents. No association was found between IM PGY-2 ITE score and inpatient, outpatient, or total encounters in the first year of training. Resident continuity clinic and total encounters were not associated with change in PGY-3 ITE score. CONCLUSIONS: We identified a positive association between hospital and subspecialty encounters during the second year of IM training and subsequent ITE score, such that each additional 50 encounters were associated with an increase of 1 % correct in PGY-3 ITE score after controlling for previous ITE performance and continuity clinic encounters. We did not find a correlation for volume of encounters and medical knowledge for IM PGY-1 residents or the pediatric cohort. [ABSTRACT FROM AUTHOR]

Background: Each July thousands begin medical residencies and acquire increased responsibility for patient care. Many have suggested that these new medical residents may produce errors and worsen patient outcomes-the so-called "July Effect;" however, we have found no U.S. evidence documenting this effect.Objective: Determine whether fatal medication errors spike in July.Design: We examined all U.S. death certificates, 1979-2006 (n = 62,338,584), focusing on medication errors (n = 244,388). We compared the observed number of deaths in July with the number expected, determined by least-squares regression techniques. We compared the July Effect inside versus outside medical institutions. We also compared the July Effect in counties with versus without teaching hospitals.Outcome Measure: JR = Observed number of July deaths / Expected number of July deaths.Results: Inside medical institutions, in counties containing teaching hospitals, fatal medication errors spiked by 10% in July and in no other month [JR = 1.10 (1.06-1.14)]. In contrast, there was no July spike in counties without teaching hospitals. The greater the concentration of teaching hospitals in a region, the greater the July spike (r = .80; P = .005). These findings held only for medication errors, not for other causes of death.Conclusions: We found a significant July spike in fatal medication errors inside medical institutions. After assessing competing explanations, we concluded that the July mortality spike results at least partly from changes associated with the arrival of new medical residents. [ABSTRACT FROM AUTHOR]

Background: Previous studies of hospital readmission have focused on specific conditions or populations and generated complex prediction models.Objective: To identify predictors of early hospital readmission in a diverse patient population and derive and validate a simple model for identifying patients at high readmission risk.Design: Prospective observational cohort study.Patients: Participants encompassed 10,946 patients discharged home from general medicine services at six academic medical centers and were randomly divided into derivation (n = 7,287) and validation (n = 3,659) cohorts.Measurements: We identified readmissions from administrative data and 30-day post-discharge telephone follow-up. Patient-level factors were grouped into four categories: sociodemographic factors, social support, health condition, and healthcare utilization. We performed logistic regression analysis to identify significant predictors of unplanned readmission within 30 days of discharge and developed a scoring system for estimating readmission risk.Results: Approximately 17.5% of patients were readmitted in each cohort. Among patients in the derivation cohort, seven factors emerged as significant predictors of early readmission: insurance status, marital status, having a regular physician, Charlson comorbidity index, SF12 physical component score, >or=1 admission(s) within the last year, and current length of stay >2 days. A cumulative risk score of >or=25 points identified 5% of patients with a readmission risk of approximately 30% in each cohort. Model discrimination was fair with a c-statistic of 0.65 and 0.61 for the derivation and validation cohorts, respectively.Conclusions: Select patient characteristics easily available shortly after admission can be used to identify a subset of patients at elevated risk of early readmission. This information may guide the efficient use of interventions to prevent readmission. [ABSTRACT FROM AUTHOR]

Background/objective: With the growth of hospitalist services and the reduction in residency work hours, medical education has changed dramatically. The objective of this study was to examine changes in junior medical student-patient encounters after initiation of residency work hours and implementation of a large hospitalist practice at our academic medical center.Design: Medicine clerkship students from 2002-2007 recorded the number of hospital patients and their principal diagnoses cared for during a 6-week block rotation. Comparisons were made between clerkship experiences among students in 2002-2004 and 2005-2007 for number of patients and diversity of patient diagnoses seen. Data from the 2004-2005 transition period, when teams fluctuated during implementation of the hospitalist service, were excluded.Measurements and Main Results: A total of 4,697 patients were seen by students during the two periods, and patient logs for 154 students (3,253 patients in 2002-2004) and 120 students (1,444 patients in 2005-2007) were compared. The mean number of patients directly cared for by students on their junior medicine clerkship dropped from 21 patients (2002-2004) to 12 patients (2005-2007) per student (p < 0.001). Compared to 2002-2004, fewer students from 2005-2007 helped manage patients with chest pain (85.7% vs. 74.2%, p = 0.016), pancreatitis (66.9% vs. 23.3%, p < 0.001), pneumonia (69.5% vs. 54.2%, p = 0.009), gastroenteritis (45.5% vs. 20.8%, p < 0.001), or cellulitis (46.8% vs. 19.2%, p < 0.001). Alternatively, students from 2005-2007 saw more patients with abdominal pain (64.9% vs. 79.2%, p = 0.010), anemia (44.8% vs. 70.8%, p < 0.001), mental status changes (32.5% vs. 51.7%, p = 0.001), failure to thrive (16.2% vs. 53.3%, p < 0.001), and endocrine disorders (including diabetes, thyroid disorders, Addison's, 51.3% vs. 74.2%, p < 0.001).Conclusions: With institutional and residency changes, junior medicine clerkship students had fewer opportunities for direct care of patients and encountered a different mix of patient diagnoses. Increasingly during their junior medicine clerkship, students may not have exposure to basic medical conditions, which may affect their ability to care for future patients. [ABSTRACT FROM AUTHOR]

The article discusses the resident-led implementation of National Diabetes Prevention Program (NDPP) of Centers for Disease Control and Prevention (CDC) at a resident community clinic in the Fall of 2013. Topics discussed include pilot grant received through "Fostering Innovation Grant" program, and work to expand NDPP to other primary care sites of University Michigan Health System (UMHS) with Adult Diabetes Education team under Division of Metabolism, Endocrinology and Diabetes (MEND).

Background: Energized, talented faculty are essential to achieving the missions of academic medical centers (AMCs) in education, research and health care. The alignment of individuals' values with workplace experiences are linked to meaningfulness of work and productivity.Objective: To determine faculty values and their alignment with institutional values.Design: A qualitative hypothesis-generating interview study to understand the professional experiences of faculty and organizational approach in five AMCs that were nationally representative in regional and organizational characteristics. Analysis was inductive and data driven.Participants: Using stratified, purposeful sampling, we interviewed 96 male and female faculty at different career stages (early career, plateaued, senior faculty and those who had left academic medicine) and diverse specialties (generalists, medical and surgical subspecialists, and research scientists).Approach: Dominant themes that emerged from the data.Results: Faculty described values relating to excellence in clinical care, community service (including care for the underserved and disadvantaged), teaching, intellectual rigor/freedom and discovery, all values that mirror the stated missions of AMCs. However, many faculty also described behaviors that led them to conclude that their AMCs, in practice, undervalued excellence in clinical care, and their social and educational missions. Themes were seen across gender, career stage, race and discipline, except that female leaders appeared more likely than male leaders to identify incongruence of individual values and organizational practices.Conclusions: In this study of five diverse medical schools, faculty values were well aligned with stated institutional missions; however, many perceived that institutional behaviors were not always aligned with individual faculty values. [ABSTRACT FROM AUTHOR]

Background: Although others have reported national disparities in the quality of diabetes care between the Veterans Affairs (VA) and private health care delivery systems, it is not known whether these differences persist among internal medicine resident providers in academic settings.Objective: We compared the quality of diabetes primary care delivered by resident physicians in either a private academic health care system (AHS) or its affiliated VA health care system.Design: Cross-sectional observational studyParticipants: We included patients who: had a diagnosis of diabetes, had >2 primary care visits with the same resident provider during 2005, and were not separately managed by an attending physician or endocrinologist. A total of 640 patients met our criteria and were included in the analysis.Measurements and Results: Compared to the VA, patients in the AHS were more likely to be younger, female, have fewer medications, and be treated with insulin, but had less comorbidity. Patients in the VA were more likely to be referred for an annual eye exam (94% vs. 78%), receive lipid screening (88% vs. 74%), receive proteinuria screening (63% vs. 34%), and receive a complete foot exam (85% vs. 32%) in analyses adjusted for patient demographics and comorbidities (p-value <0.001 for all comparisons). In adjusted analyses, there were no significant differences in HbA1(c), blood pressure, or LDL cholesterol control.Conclusions: In spite of similar resident providers and practice models, there were substantial differences in the diabetes quality of care delivered in the VA and AHS. Understanding how these factors influence subsequent practice patterns is an important area for study. [ABSTRACT FROM AUTHOR]

Background: The field of hospital medicine is growing rapidly in academic medical centers. However, few organizations have explicitly considered the opportunities and barriers posed to hospital medicine's development as an academic field in internal medicine.Objective: To develop consensus around key areas limiting or facilitating hospital medicine's development as an academic discipline.Design: Consensus format conference of key stakeholders in academic hospital medicine.Results: The Consensus Group identified several issues impeding the development of academic hospital medicine as a recognized entity in academic settings, including extraordinarily rapid growth, increasingly preponderate non-teaching roles, and demands to perform non-clinical duties (such as quality improvement) not generally viewed as academic pursuits. The Consensus Group developed recommendations for addressing these concerns, specifically 1) characterizing the 'optimal' job description for an academic hospitalist, 2) developing better local and at-a-distance opportunities for training academic hospitalists in key aspects of early career success, 3) advocacy for development of fellows and junior faculty researchers in hospital medicine. Fostering academic hospital medicine will help address these issues more effectively and will help the field while also attracting the next generation of generalists needed to care for an increasingly complex inpatient population. [ABSTRACT FROM AUTHOR]

Background: Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes.Methods: We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient's PCP was associated with the 30-day composite outcome.Results: A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 - 1.34), the presence of a discharge summary (0.84, 95% CI 0.57-1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73-1.59).Conclusion: Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample. [ABSTRACT FROM AUTHOR]

Background: Family members of patients in intensive care units (ICUs) are at risk for mental health morbidity both during and after a patient's ICU stay.Objectives: To determine prevalences of and factors associated with anxiety, depression, posttraumatic stress and complicated grief in family members of ICU patients.Design: Prospective, longitudinal cohort study.Participants: Fifty family members of patients in ICUs at a large university hospital participated.Measurements: We used the Control Preferences Scale to determine participants' role preferences for surrogate decision-making. We used the Hospital Anxiety and Depression Scale, Impact of Event Scale, and Inventory of Complicated Grief to measure anxiety and depression (at enrollment, 1 month, 6 months), posttraumatic stress (6 months), and complicated grief (6 months).Results: We interviewed all 50 participants at enrollment, 39 (78%) at 1 month, and 34 (68%) at 6 months. At the three time points, anxiety was present in 42% (95% CI, 29-56%), 21% (95% CI, 10-35%), and 15% (95% CI, 6-29%) of participants. Depression was present in 16% (95% CI, 8-28%), 8% (95% CI, 2-19%), and 6% (95% CI, 1-18%). At 6 months, 35% (95% CI, 21-52%) of participants had posttraumatic stress. Of the 38% who were bereaved, 46% (95% CI, 22-71%) had complicated grief. Posttraumatic stress was not more common in bereaved than nonbereaved participants, and neither posttraumatic stress nor complicated grief was associated with decision-making role preference or with anxiety or depression during the patient's ICU stay.Conclusions: Symptoms of anxiety and depression diminished over time, but both bereaved and nonbereaved participants had high rates of posttraumatic stress and complicated grief. Family members should be assessed for posttraumatic stress and complicated grief. [ABSTRACT FROM AUTHOR]

One of the most significant changes in US hospitals over the past decade has been the emergence of hospitalists as key providers of inpatient care. The number of hospitalists in both community and teaching hospitals is growing rapidly, and as the field burgeons, many are questioning where hospitalists should reside within the academic medical center (AMC). Should they be a distinct division or department, or should they be incorporated into existing divisions? We describe hospital medicine's current trajectory and provide recommendations for hospital medicine's place in the AMC. Local social and economic factors are most likely to determine whether hospital medicine programs will become independent divisions at most AMCs. We believe that in many large AMCs, separate divisions of hospital medicine are less likely to form soon, and in our opinion should not form until they are able to fulfill the tripartite mission traditionally carried out by independent specialist divisions. At community hospitals and less research-oriented AMCs, hospital medicine programs may soon be ready to become separate divisions. [ABSTRACT FROM AUTHOR]