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BACKGROUND: Due to concerns of inadequate primary care access, national agencies like the Health Resources and Services Administration (HRSA) support primary care (PC) residencies. Recent research demonstrates that up to 35% of PC alumni lost interest in PC during residency. These alumni who lost interest noted that their continuity clinic experience influenced their career choice. The purpose of this study was to identify the specific aspects of PC residency experience that influenced career choice. METHODS: We conducted a cross-sectional electronic survey of a PC internal medicine alumni cohort (2000–2015) from a large, academic residency. Our primary predictor was PC career and our primary outcome was influential factors on career choice. We performed chi-squared or Fisher’s exact tests for categorical variables and t tests for continuous variables. RESULTS: Of the 317 PC alumni in the last 15 years, 305 were contacted. One hundred seventy-two (56%) responded with 94 (55%) reporting current careers in PC and 78 (45%) in non-PC fields. Ninety-four percent of respondents expressed interest prior to residency, while only 68% remained interested at the conclusion of residency. Sixty-one percent of PC alumni rated the overall clinic experience as the most influential factor towards their ultimate career choice. The patient-physician relationship was the most frequently endorsed positively influential factor in career choice in both groups (95% of PC alumni, 76% non-PC). There was no difference among all alumni in common frustrations of clinic including clerical duties, encounter documentation, or visit length. Similarly, resident debt did not differ between groups. CONCLUSIONS: Strong interpersonal relationships with patients and clinic mentors were associated with a PC career. These factors may compensate for the reported frustrations of clinic. Enhancing patient and mentor relationships may increase the retention of PC residents in ambulatory careers and may help address the current and projected shortage of primary care physicians. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06625-8.

BACKGROUND: Urinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported. OBJECTIVE: To describe management of UTI in a large nationwide DTC telemedicine platform. DESIGN: Cross-sectional observational study. PARTICIPANTS: Patients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018. MAIN MEASURES: Patient measures included age, sex, geographic region, satisfaction with care, and patient-reported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties. KEY RESULTS: Of the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis. CONCLUSIONS: Management of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up.

BACKGROUND: Night float rotations, where residents admit patients to the hospital, are opportunities for practice-based learning. However, night float residents receive little feedback on their diagnostic and management reasoning, which limits learning. AIM: Improve night float residents’ practice-based learning skills through feedback solicitation and chart review with guided reflection. SETTING/PARTICIPANTS: Second- and third-year internal medicine residents on a 1-month night float rotation between January and August 2017. PROGRAM DESCRIPTION: Residents performed chart review of a subset of patients they admitted during a night float rotation and completed reflection worksheets detailing patients’ clinical courses. Residents solicited feedback regarding their initial management from day team attending physicians and senior residents. PROGRAM EVALUATION: Sixty-eight of 82 (83%) eligible residents participated in this intervention. We evaluated 248 reflection worksheets using content analysis. Major themes that emerged from chart review included residents’ identification of future clinical practice changes, evolution of differential diagnoses, recognition of clinical reasoning gaps, and evaluation of resident-provider interactions. DISCUSSION: Structured reflection and feedback during night float rotations is an opportunity to improve practice-based learning through lessons on disease progression, clinical reasoning, and communication. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05913-z) contains supplementary material, which is available to authorized users.

The Association of Program Directors in Internal Medicine, the Accreditation Council for Graduate Medical Education, the Alliance for Academic Internal Medicine, and the Carnegie Foundation report on medical education recommend creating individualized learning pathways during medical training so that learners can experience broader professional roles beyond patient care. Little data exist to support the success of these specialized pathways in graduate medical education.We present the 10-year experience of the Primary Care Medicine Education (PRIME) track, a clinical-outcomes research pathway for internal medicine residents at the University of California San Francisco (UCSF). We hypothesized that participation in an individualized learning track, PRIME, would lead to a greater likelihood of publishing research from residency and accessing adequate career mentorship and would be influential on subsequent alumni careers.We performed a cross-sectional survey of internal medicine residency alumni from UCSF who graduated in 2001 through 2010. We compared responses of PRIME and non-PRIME categorical alumni. We used Pearson's chi-square and Student's t test to compare PRIME and non-PRIME alumni on categorical and continuous variables.Sixty-six percent (211/319) of alumni responded to the survey. A higher percentage of PRIME alumni published residency research projects compared to non-PRIME alumni (64% vs. 40%; p = .002). The number of PRIME alumni identifying research as their primary career role was not significantly different from non-PRIME internal medicine residency graduates (35% of PRIME vs. 29% non-PRIME). Process measures that could explain these findings include adequate access to mentors (M 4.4 for PRIME vs. 3.6 for non-PRIME alumni, p.001, on a 5-point Likert scale) and agreeing that mentoring relationships affected career choice (M 4.2 for PRIME vs. 3.7 for categorical alumni, p = .001). Finally, 63% of PRIME alumni agreed that their research experience during residency influenced their subsequent career choice versus 46% of non-PRIME alumni (p = .023).Our results support the concept that providing residents with an individualized learning pathway focusing on clinical outcomes research during residency enables them to successfully publish manuscripts and access mentorship, and may influence subsequent career choice. Implementation of individualized residency program tracks that nurture academic interests along with clinical skills can support career development within medicine residency programs.

T o the EditorWe wholeheartedly agree with Stanley et. al. about how the residency experience seems to dissuade residents from pursuing primary care careers, and agree that graduate medical education reform is imperative. As the authors describe, there are many reasons why this is the case. Training programs overwhelmingly favor hospital-based rotations, with outpatient medicine typically representing not more than one-third of training time. Simply increasing ambulatory time does not address the challenges that discourage residents from pursuing primary care careers. Additionally, many residency clinics provide care to socioeconomically disadvantaged patients with complex needs. Expecting trainees to be confident and fully engaged in ambulatory care with our current training models is unrealistic. We have designed a primary care training program to address these challenges, with >50 % of the training in the ambulatory environment. To prepare primary care residents for complex disease management in an ambulatory setting, our residents participate in year-long longitudinal subspecialty ambulatory electives with subspecialty preceptors, as opposed to hospital-based subspecialty electives. These subspecialty preceptors have become resources for our residents, allowing them to experience the importance of teamwork and collaboration in primary care. We have implemented a second primary care continuity site to expose residents to diverse patient populations and ambulatory environments. To preserve the passion for advocacy that residents possess, we have integrated a community project into our program. Protected time allows residents to pursue advocacy projects of their choice. Examples of projects include a Spanish/English language and cultural exchange program, a high school nutrition curriculum, promoting health education in a homeless shelter and volunteering services to a local free clinic. Each self-selected project helps to keep our residents grounded in what initially attracted them to primary care. Mentorship is an essential feature of our program. Just as residents are encouraged to pursue subspecialty careers, it is equally important to enthusiastically encourage primary care careers. Quarterly get-togethers with the primary care codirectors are instrumental in maintaining engagement. During these dinners, we discuss medical, political and cultural issues in primary care, facilitate dialogue about career goals and promote peer group mentoring. We have graduated two classes of primary care residents to date, and 80 % of our graduates have pursued primary care careers. Additionally, several categorical residents have transferred into our program, while none of the primary care residents have left. We believe that continued innovation and mentorship will help to successfully build and maintain resident interest in primary care.

A 67-year-old man with painless jaundice for 3 weeks was brought to the emergency department by his brother. The patient noted yellow eyes and skin, white stool, fatigue, and pruritis that interfered with sleep. He denied abdominal pain, fevers, chills, diarrhea, melena, hematochezia, anorexia, dysphagia, nausea, or vomiting. He had noted a 20-lb unintentional weight loss over the last 2 months. His past medical history was notable for a stab wound in his abdomen for which he had undergone laparotomy without bowel resection many years ago. He took no medications. He was a Japanese-American Vietnam War veteran who lived with his ex-wife and owned a video store. He had previously drunk 12 beers daily, but cut back to 2 daily 1 year ago. He had a 50 pack-year smoking history and denied any illicit drug use. His family history was negative for malignancy or liver disease.

Background: Residents serve as teachers to interns and students in most internal medicine residency programs. Aim: The purpose of our study is to explore what internal medicine residents perceive as effective teaching strategies in the inpatient setting and to formulate a guideline for preparing residents to lead their ward teams. Methods: Housestaff identified as excellent teaching residents were recruited from a large internal medicine residency program. Focus groups were formed and interviews were conducted using open-ended questions. Transcripts of the interviews were reviewed, analyzed, and compared for accuracy by two investigators. The transcripts were then coded to categorize data into similar subjects from which recurrent themes in resident teaching were identified. Results: Twenty-two residents participated in four focus group interviews held in 2008. We identified five principal themes for effective teaching by residents: (T)aking advantage of teaching opportunities, (E)mpowering learners, (A)ssuming the role of leader, (C)reating a learning environment, and (H)abituating the practice of teaching. Conclusion: Strategies for effective teaching by residents exist. The TEACH mnemonic is a resident-identified method of instruction. Use of this tool could enable residency programs to create instructional curricula to prepare their residents and interns to take on the roles of team leaders and teachers.

Off-label prescribing in oncology is common and unregulated. The aim of this study was to describe the off-label use of rituximab, a novel anti-CD20 antibody, among patients from a large proprietary insurance database to understand how frequently and appropriately off-label prescribing occurs for this medication.In this descriptive study, 11,232,642 patients were enrolled in the D2 Hawkeye commercial insurance database between 2001 and 2007, and 2,782 patients received rituximab. The main outcome measures were quantity and type of off-label usage, and expenditures for off-label usage.Seven hundred five (25.3%) patients received rituximab for off-label indications, and of those, 332 (47.1%) received rituximab for uncertain or inadequate evidence-based diagnoses. Expenditures for off-label indications were 17.1% of expenditures for rituximab usage.The frequent use of rituximab for off-label indications should lead to improved postapproval surveillance of biologics by the US Food and Drug Administration, so that use can be adequately studied. This will also facilitate improved regulatory mechanisms to ensure evidence-based use.

The inhibition of factor VIII by autoantibody development, or acquired hemophilia, occurs in approximately one person per million each year and can cause life-threatening bleeding. Due to the disease rarity, there are no randomized studies addressing prognostic features and treatment. The goal of this study is to identify prognostic indictors in acquired hemophilia to guide treatment choices. MEDLINE and EMBASE search from 1985-2008 retrieved 32 studies with detailed clinical information on five or more patients with acquired hemophilia. Univariate and multivariate analysis of the effects of age, sex, underlying condition, inhibitor titer, and treatment regimen were evaluated with regards to complete remission and death. A total of 32 studies containing 359 patients with acquired hemophilia were included in the analysis. The all-cause mortality rate in this cohort was 21%. Multivariate analyses revealed that patients more likely to die are the elderly [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.32-4.36] and those with underlying malignancy (OR 2.76, CI 1.38-5.50). Early achievement of complete remission resulted in improved survival. Complete remission occurred in 94% of patients receiving combination chemotherapy, 82% receiving dual therapy, and 68% receiving steroids alone. Patients receiving immunosuppression had reduced odds of persistent hemophilia, with combination chemotherapy being the most efficacious (OR 0.04, CI 0.01-0.23) and steroid therapy alone being the least (OR 0.38, CI 0.14-0.94). In acquired hemophilia, increased age, underlying malignancy, and lack of complete remission are risk factors for death. Although the included studies were not randomized, patients treated with combination chemotherapy had the greatest odds of remission and the lowest odds of death.

OBJECTIVE The acquisition of data on resident duty hours has been largely dependent on self-report surveys collected in the surgical literature. We sought to implement and describe a simple method for monitoring internal medicine resident duty hours by using time-cards. DESIGN In 2002, internal medicine residents on a 3-site academic programme were asked to track their duty hours using time-cards prior to the implementation of system changes according to duty hours reform. SETTING An academic internal medicine residency programme in the USA. RESULTS Of participating residents (n = 41), 93% worked at least 1 shift longer than 30 hours, 29% worked an average of more than 80 hours per week, and 56% had less than 1 day off per week. No residents were on call more than once every third day. CONCLUSIONS This study describes the findings and challenges of using time-cards to track duty hours, and shows that many internal medicine residents on this programme were, before implementation of duty hours reforms, in violation of duty hours regulations.

A 79-year-old man reports an 18-kg weight loss over the previous six months. Seven months before admission, his house burned down and insomnia and anorexia developed. One month before admission, he began having diffuse abdominal pain that a proton-pump inhibitor did not improve.

It is rare to come across a manuscript that addresses unspoken primary care physician fears and helps support what we intuitively know is the right thing to do. This month’s JGIM features such an article. In their manuscript, Simonetti and colleagues1 demonstrate a positive correlation between patient satisfaction and the receipt of a brief alcohol screening at a primary care clinic visit. They performed a cross-sectional, secondary data analysis using the Veterans Affairs Survey of Healthcare Experiences of Patients (SHEP) data to examine if, in veterans with unhealthy alcohol use, outpatient alcohol misuse screening changed patient reported quality of care. To screen for alcohol misuse, the authors used the well-validated Alcohol Use Disorder Identification Test Consumption Questionnaire (AUDIT-C). Nearly 50 % of the veterans were screened, and reassuringly, a higher proportion of veterans who reported receipt of the brief screening intervention rated their provider more favorably than those who were not screened. While our fiduciary responsibility to our patients is to serve as a trusted professional, most of us also want our patients to like us, and we worry that if we ask about “blank” (fill in: substance abuse, alcohol misuse, sexually transmitted disease screening, seat belt use, immunizations, etc.) they may be embarrassed and not want to return. Now, with patient satisfaction surveys and 360-degree evaluations becoming more prominent feedback tools and increasingly being tied to reimbursement, these concerns with patient satisfaction are even more relevant for trainees and practicing physicians alike. However, the findings of Simonetti and colleagues seems a clear indication that our patients don’t simply want to like us, but expect us to do our job even if it means addressing difficult-to-talk-about topics such as alcohol misuse. The authors appropriately conclude that screening for alcohol misuse does not adversely affect patients’ perception of their quality of care and, in fact, increases it. This study does not address another question commonly asked in the primary care setting: What do I do now that my patient has screened positive for alcohol misuse? Although patient satisfaction increases with screening, primary care provider satisfaction likely decreases when receiving a positive screen.2 Many may feel like they have poked a skunk and don’t like the smell. Therefore, it is important to not just screen for alcohol use disorder, but to have a clear plan of action for a positive screen. Data supports that just bringing up alcohol cessation in primary care promotes abstinence from problem drinking, which is improved further with a brief intervention after a positive screen.3 But most providers remain uneasy with addressing maladaptive behaviors with a brief intervention if they don’t possess the skills to intervene. Current leaders in primary care who are involved in such efforts as the VA Centers of Excellence or Patient Centered Medical Homes emphasize a multi-provider approach to patient care where warm handoffs to behavioral health specialists can facilitate addressing substance abuse issues for willing patients.4 These excellent models have not been sufficiently adopted by most primary care systems to replace the need for front-line practioners being able to address positive screens on their own. Several models exist, however, to empower primary care practioners to help their patients change their behavior. One tool that is important for clinicians to have in their armamentarium is motivational interviewing (MI). MI utilizes a collaborative conversation style for strengthening a person’s own motivation and commitment to change. Using the OARS approach with Open-ended questions, Affirmations, Reflections and Summary statements, primary care providers can engage their patients in an open and supportive way to help move them through the stages of change.5 Simultaneously, MI can help physicians feel like they have the tools not only to screen, but to intervene. MI is one of the skills used in another very high quality resource: the Substance Use in Adults and Adolescents: Screening, Brief Intervention and Referral to Treatment (SBIRT) program. This indispensable training program is offered through the Substance Abuse and Mental Health Services Administration (SAMHSA). This free online course offers skills for primary care practioners to recognize and address substance abuse in their offices. There are also more advanced courses for practitioners who devote a significant amount of time to substance abuse screening and treatment.6 Finally, another important outcome of this study was the measurement of the overall satisfaction numbers shown by the VA study patients who had screened positive for alcohol misuse. Recently, there have been several well-publicized scandals involving the VA that have led to a dip in morale as faculty and staff feel let down by a small number of poorly performing employees. The perception portrayed in the media is that care at the VA is substandard.7 This perception is strengthened further by legislation encouraging veterans to seek care outside the VA rather than supporting our existing programs. The Simonetti study demonstrates impressive satisfaction numbers among the VA patients enrolled in the study. Amongst the patients that were screened for alcohol misuse, nearly 83 % of veterans rated their VA care as high quality. Patients screening positive for substance abuse may be more disenfranchised and more prone to lower healthcare satisfaction, making this figure all the more impressive. Similarly, the reported 87 % satisfaction score that Veterans reported with their providers is in the 75th percentile of satisfaction on the AHRQ Clinician & Group Survey (CG-CAHPS) website.8 As devoted VA clinicians, we are not surprised by these findings, although it is a welcome validation of the hard work and dedication shown by our colleagues.

24-year-old woman with a history of intravenous drug use presented with 5 days of fevers, rightsided neck pain, and odynophagia. Physical and laboratory examination revealed tender swelling of the right neck and neutrophil-predominant leukocytosis. Computed tomography demonstrated a large right retropharyngeal fluid collection with associated stranding, right internal and external jugular vein thrombi, and multiple peripheral nodular and wedgeshaped pulmonary opacities representing septic emboli (Fig. 1) consistent with Lemierre’s syndrome. The patient underwent emergent incision and drainage of the abscess and received broad-spectrum antibiotics. Peripheral blood and abscess cultures grew methicillinresistant Staphylococcus aureus (MRSA). The patient was stable postoperatively and completed 4 weeks of intravenous antibiotics. Lemierre’s syndrome is defined by recent history of painful oropharyngeal infection (anginal illness), evidence of metastatic lesions, and either septic internal jugular thrombophlebitis or isolation of Fusobacterium sp. from blood or sterile sites. 1 While classically associated with Fusobacterium necrophorum, 14 cases associated with S. aureus are reported in the literature, with roughly half occurring in young adults under 32 years of age. 2–4 In this case, the patient’s history of intrave

To the Editors:—I read with interest the well-done meta-analysis by Powers and colleagues in the June issue of JGIM that described the limitations of the newer antihypertensive medications in examining long-term cardiovascular outcomes.1 The article was well summarized in the very clinically useful editorial written by Dr. Smetana.2 While I agree with Dr. Smetana that thiazide diuretics remain the mainstay of initial therapy as outlined in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),3 I am concerned that for most practicing physicians, thiazide-type diuretics means hydrochlorothiazide. As Dr. Smetana correctly points out, chlorthalidone (or indapamide) have the most robust cardiovascular outcomes data amongst all antihypertensive agents, but this has not penetrated widely into practice. Approximately 125 million prescriptions were written for hydrochlorothiazide alone or in combination in 2008; yet, unlike previously mentioned, longer-acting thiazide diuretics, there are no data to support hydrochlorothiazide’s ability to improve cardiovascular outcomes.4 The recent British National Institute for Clinical Excellence (NICE) guidelines published last year suggest that ACE inhibitors should be the drug of first choice for those less than fifty-five years old, and calcium channel blockers for those fifty-five years or older.5 Thiazide diuretics were relegated to third-line medications in these guidelines, but remained ahead of beta-blockers and newer agents. I think all practicing clinicians anxiously await the upcoming JNC 8 guidelines to help wade through this growing controversy.

Background Entrustable professional activities (EPAs) can form the foundation of competency-based assessment in medical training, focused on performance of discipline-specific core clinical activities. Objective To identify EPAs for the Internal Medicine (IM) Educational Milestones to operationalize competency-based assessment of residents using EPAs. Methods We used a modified Delphi approach to conduct a 2-step cross-sectional survey of IM educators at a 3-hospital IM residency program; residents also completed a survey. Participants rated the importance and appropriate year of training to reach competence for 30 proposed IM EPAs. Content validity indices identified essential EPAs. We conducted independent sample t tests to determine IM educator-resident agreement and calculated effect sizes. Finally, we determined the effect of different physician roles on ratings. Results Thirty-six IM educators participated; 22 completed both surveys. Twelve residents participated. Seventeen EPAs had a content validity index of 100%; 10 additional EPAs exceeded 80%. Educators and residents rated the importance of 27 of 30 EPAs similarly. Residents felt that 10 EPAs could be met at least 1 year earlier than educators had specified. Conclusions Internal medicine educators had a stable opinion of EPAs developed through this study, and residents generally agreed. Using this approach, programs could identify EPAs for resident evaluation, building on the initial list created via our study.

Background Professional organizations have called for individualized training approaches, as well as for opportunities for resident scholarship, to ensure that internal medicine residents have sufficient knowledge and experience to make informed career choices. Context and Purpose To address these training issues within the University of California, San Francisco, internal medicine program, we created the Areas of Distinction (AoD) program to supplement regular clinical duties with specialized curricula designed to engage residents in clinical research, global health, health equities, medical education, molecular medicine, or physician leadership. We describe our AoD program and present this initiative's evaluation data. Methods and Program Evaluation We evaluated features of our AoD program, including program enrollment, resident satisfaction, recruitment surveys, quantity of scholarly products, and the results of our resident's certifying examination scores. Finally, we described the costs of implementing and maintaining the AoDs. Results AoD enrollment increased from 81% to 98% during the past 5 years. Both quantitative and qualitative data demonstrated a positive effect on recruitment and improved resident satisfaction with the program, and the number and breadth of scholarly presentations have increased without an adverse effect on our board certification pass rate. Conclusions The AoD system led to favorable outcomes in the domains of resident recruitment, satisfaction, scholarship, and board performance. Our intervention showed that residents can successfully obtain clinical training while engaging in specialized education beyond the bounds of core medicine training. Nurturing these interests may empower residents to better shape their careers by providing earlier insight into internist roles that transcend classic internal medicine training.

Background Malignant pleural effusions (MPE) are a frequent cause of dyspnea and discomfort at the end of cancer patients' lives. The tunneled indwelling pleural catheter (TIPC) was approved by the FDA in 1997 and has been investigated as a treatment for MPE. Objective To systematically review published data on the efficacy and safety of the TIPC for treatment of MPE. Design We searched the MEDLINE, EMBASE, and ISI Web of Science databases to identify studies published through October 2009 that reported outcomes in adult patients with MPE treated with a TIPC. Data were aggregated using summary statistics when outcomes were described in the same way among multiple primary studies. Main Measures Symptomatic improvement and complications associated with use of the TIPC. Key Results Nineteen studies with a total of 1,370 patients met criteria for inclusion in the review. Only one randomized study directly compared the TIPC with the current gold standard treatment, pleurodesis. All other studies were case series. Symptomatic improvement was reported in 628/657 patients (95.6%). Quality of life measurements were infrequently reported. Spontaneous pleurodesis occurred in 430/943 patients (45.6%). Serious complications were rare and included empyema in 33/1168 patients (2.8%), pneumothorax requiring a chest tube in 3/51 (5.9%), and unspecified pneumothorax in 17/439 (3.9%). Minor complications included cellulitis in 32/935 (3.4%), obstruction/clogging in 33/895 (3.7%) and unspecified malfunction of the catheter in 11/121 (9.1%). The use of the TIPC was without complication in 517/591 patients (87.5%). Conclusions Based on low-quality evidence in the form of case series, the TIPC may improve symptoms for patients with MPE and does not appear to be associated with major complications. Prospective randomized studies comparing the TIPC to pleurodesis are needed before the TIPC can be definitively recommended as a first-line treatment of MPE.

Objective: To determine whether a low-intensity versus high-intensity medical intensive care unit (MICU) format in a Veterans Affairs (VA) hospital setting improves patient outcomes, as measured by duration of mechanical ventilation (MV), ventilator-free days (VFDs), and hospital mortality. Design: Retrospective cohort study. Setting: Medical intensive care unit at the San Francisco Veterans Affairs Medical Center (SFVAMC). Patients: On July 1, 2004, the SFVAMC transitioned from a low-intensity MICU to a high-intensity MICU. All patients admitted to the MICU who required MV for 18 months before (n = 96) and 18 months after (n = 131) the transition were included in the analysis. Measurements: We prospectively defined the primary outcome measure as the difference in the median duration of MV between groups. Secondary outcomes included VFDs and hospital mortality. Continuous variables were compared using the Wilcoxon rank sum test; dichotomous variables were compared using Fisher exact test. Main results: The low-intensity and high-intensity MICU groups were similar in age, gender, weight, and admitting diagnosis (P > .27 in all cases). Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were 22.0 in the low-intensity era and 20.0 in the high-intensity era (P = .048). Median duration of MV was significantly lower in the high-intensity MICU format compared to the low-intensity MICU format (102 vs 61 hours, P for log-rank test = .0052). After controlling for covariates, there were 4.2 more VFDs in the high-intensity era (95% CI 1.9 to 6.6 days). The high-intensity era was associated with a reduced hospital mortality rate (27% vs 40%) and an adjusted odds ratio of 0.34 (95% CI 0.15 to 0.74). Conclusions: For critically ill veterans admitted to an MICU requiring MV, a high-intensity ICU structure is associated with more favorable mechanical ventilatory outcomes and lower mortality.

BACKGROUND At teaching hospitals, bedside procedures (paracentesis, thoracentesis, lumbar puncture, arthrocentesis and central venous catheter insertion) are performed by junior residents and supervised by senior peers. Residents’ perceptions about supervision or how often peer supervision produces unsafe clinical situations are unknown. OBJECTIVE To examine the experience and practice patterns of residents performing bedside procedures. DESIGN AND PARTICIPANTS Cross-sectional e-mail survey of 653 internal medicine (IM) residents at seven California teaching hospitals. MEASUREMENTS Surveys asked questions in three areas: (1) resident experience performing procedures: numbers of procedures performed and whether they received other (e.g., simulator) training; (2) resident comfort performing and supervising procedures; (3) resident reports of their current level of supervision doing procedures, experience with complications as well as perceptions of factors that may have contributed to complications. RESULTS Three hundred sixty-seven (56%) of the residents responded. Most PGY1 residents had performed fewer than five of any of the procedures, but most PGY-3 residents had performed at least ten by the end of their training. Resident comfort for each procedure increased with the number of procedures performed (p

Background Although residency programs must prepare physicians who can analyze and improve their practice, practice improvement (PI) is new for many faculty preceptors. We describe the pilot of a PI curriculum incorporating a practice improvement module (PIM) from the American Board of Internal Medicine for residents and their faculty preceptors. Methods Residents attended PI didactics and completed a PIM during continuity clinic and outpatient months working in groups under committed faculty. Results All residents participated in PI group projects. Residents agreed or strongly agreed that the projects and the curriculum benefited their learning and patient care. A self-assessment revealed significant improvement in PI competencies, but residents were just reaching a “somewhat confident” level. Conclusion A PI curriculum incorporating PIMs is an effective way to teach PI to both residents and faculty preceptors. We recommend the team approach and use of the PIM tutorial approach especially for faculty.

purpose: The purpose of this study was to investigate the prescribing practices for the use of psychoactive medication in treating hospitalized patients with the acquired immunodeficiency syndrome (AIDS). patients and methods: The medical charts were studied for all patients admitted to a 20bed AIDS inpatient ward from July through December 1986. One hundred and fifty-one patientadmissions comprised the sample. The average age of the patients was 37 years, and the average length of the hospital stay was 13 days. Retrospective chart review collected demographic data, length of stay, medical diagnosis, psychiatric history, and mental status on admission. Data on psychoactive drugs included the reasons for use, maximum daily dose and duration, and side effects ascribed to the drugs. results: Psychoactive drugs were used in 89% of the cases. Anxiolytics accounted for 49% of the psychoactive prescriptions, and hypnotics made up 43% of these prescriptions. The five most frequently used psychoactive drugs were benzodiazepines. The most frequent reasons for psychotropic prescriptions were insomnia (39%), psychologic distress (20%), and nausea (16%). The most frequently used anxiolytic and antipsychotic medications were used in moderate dosage, while the most frequently used antidepressant was prescribed in low dosage. conclusions: Hospitalized AIDS patients are highly likely to be prescribed a psychotropic medication, especially an anxiolytic or hypnotic. Anxiolytics are used for several purposes, including reduction of nausea associated with the use of antibiotics. Antidepressants and antipsychotics are rarely used. Practitioners must be sensitive to the presence of psychiatric conditions presenting as insomnia or disturbed mood so that the most specific and appropriate treatments can be used.

In patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality.To review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis.Structured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity.Studies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis.Three authors independently abstracted data from the included studies.Fourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts25,000/microL: LR, 0.32; 95% CI, 0.23-0.43; for countsor =25,000/microL: LR, 2.9; 95% CI, 2.5-3.4; for counts50,000/microL: LR, 7.7; 95% CI, 5.7-11.0; and for counts100,000/microL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47).Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.

The acquisition of data on resident duty hours has been largely dependent on self-report surveys collected in the surgical literature. We sought to implement and describe a simple method for monitoring internal medicine resident duty hours by using time-cards.In 2002, internal medicine residents on a 3-site academic programme were asked to track their duty hours using time-cards prior to the implementation of system changes according to duty hours reform.An academic internal medicine residency programme in the USA.Of participating residents (n = 41), 93% worked at least 1 shift longer than 30 hours, 29% worked an average of more than 80 hours per week, and 56% had less than 1 day off per week. No residents were on call more than once every third day.This study describes the findings and challenges of using time-cards to track duty hours, and shows that many internal medicine residents on this programme were, before implementation of duty hours reforms, in violation of duty hours regulations.

Although clinicians commonly use computed tomography or ultrasonography to diagnose acute appendicitis, the accuracy of these imaging tests remains unclear.To review the diagnostic accuracy of computed tomography and ultrasonography in adults and adolescents with suspected acute appendicitis.The authors used MEDLINE, EMBASE, bibliographies, review articles, textbooks, and expert opinion to retrieve English- and non-English-language articles published from 1966 to December 2003.The authors included prospective studies evaluating computed tomography or ultrasonography followed by surgical confirmation or clinical follow-up in patients at least 14 years of age with suspected appendicitis.One assessor (for non-English-language studies) or 2 assessors (for English-language studies) independently reviewed each article to abstract relevant study characteristics and results.Twelve computed tomography studies and 14 ultrasonography studies met inclusion criteria. Computed tomography had an overall sensitivity of 0.94 (95% CI, 0.91 to 0.95), a specificity of 0.95 (CI, 0.93 to 0.96), a positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 0.86 (CI, 0.83 to 0.88), a specificity of 0.81 (CI, 0.78 to 0.84), a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27). Verification bias and inappropriate blinding of reference standards were noted in all of the included studies.The summary assessment of the diagnostic accuracy for both tests was limited by the small number of studies, heterogeneity among study samples, and poor methodologic quality in the original studies.Computed tomography is probably more accurate than ultrasonography for diagnosing appendicitis in adults and adolescents. Prospective studies that apply gold standard diagnostic testing to all study participants would more reliably estimate the true diagnostic accuracy of these tests.

Advance directive education is an important social work role in many medical settings. Despite its obvious benefit in terms of time-effectiveness, group education around advance directives has received little previous attention in the social work research literature. In a retrospective cohort (n = 13,913), we compared three education strategies in an attempt to evaluate their effectiveness on advance directive completion: (1) participation in a group session, (2) one or more individual sessions with a social worker, and (3) no advance directive education. Social work education of any kind resulted in an overall completion rate of 20% versus 2.1% in the non-intervention group. Group education was twice as effective as an individual social work session, and as effective as multiple sessions, but less time consuming. Our study confirmed previous findings that older patients are more likely to complete advance directives independent of education strategy. Participants in the group sessions were also older than the rest of the cohort, leading us to hypothesize about the particular appeal of group education to older patients. We conclude that group education is an effective as well as time- and cost-efficient social work tool for facilitating completion of advance medical directives, particularly among older patients.

A 67-year-old woman presented with four weeks of gradually worsening exertional dyspnea, post-tussive right-sided chest pressure, intermittent foot swelling and drenching night sweats. She had a history of sarcoidosis, aspergilloma and recently completed several courses of antibiotics for repeated pneumonia. A chest x-ray (Fig. 1) demonstrated a pre-existing left apical bleb (1), stable fungal infection (2) and new moderate right-sided pneumothorax (3). Her prior coronal computerized tomography (CT) (Fig. 2) is included for comparison. She was treated with a temporary chest tube and did well with symptomatic improvement. Figure 1 Chest x-ray revealing a large left apical bleb (1), stable fungal infection (2) and new pneumothorax (3). Figure 2 Baseline computerized tomography displays a large left apical bleb (1) and fungal infection (2). Secondary spontaneous pneumothorax (SSP) occurs in the context of underlying lung disease and frequently requires urgent management due to limited cardiopulmonary reserve.1 Compared to primary spontaneous pneumothorax, secondary cases occur later in life1 and portend poor outcomes with up to a fourfold increase in mortality for patients with chronic obstructive pulmonary disease.2 Recurrence is seen in up to 50% of patients with SSP2 and should prompt pulmonary consultation for consideration of a preventive intervention such as pleurodesis after the first presentation.2,3 This patient was discharged with outpatient evaluation for lung transplant. She was subsequently re-admitted with recurrent pneumothorax and is undergoing expedited inpatient evaluation for transplantation (pleurodesis would preclude transplant).

A 71-year-old woman with multiple sclerosis and hypertension lost consciousness in bed. Paramedics noted she was breathing spontaneously but had a Glasgow coma scale score of 3. An electrocardiogram (ECG) revealed new ST segment elevations in V2-V6 (Fig. 1). Her lab tests were significant for a troponin of 0.09 micrograms/liter (normal laboratory value is less than 0.05). The patient’s pupils were anisocoric, fixed and non-reactive. Computerized tomography of the brain revealed a large left-sided fronto-temporal subarachnoid and intraventricular hemorrhage with right sub-falcine shift and early hydrocephalus (Fig. 2). After emergent consultation, neurosurgical and cardiac interventions were deferred, and she died six hours later.

A 74-year-old man with a history of upper gastrointestinal bleeding and iron deficiency anemia presented to clinic with three weeks of worsening fatigue, weakness, and dyspnea on exertion. He did not have melena, hematochezia, or hematemesis. He had stopped all medications including iron supplementation six months prior. Examination was notable for pallor of the conjunctivae, face, palms, and palmar creases (Fig. ​(Fig.1).1). The patient’s hemoglobin tested result was 4.7 g/dl and subsequent esophagogastroduodenoscopy demonstrated erosive gastritis. Palmar crease pallor has a positive likelihood ratio of 7.9 for the diagnosis of anemia,1 which increases the post-test probability of anemia by approximately 40 %.2 The physical exam cannot rule out anemia,3 but the presence of pallor in the hands, eyes, or mucosa should prompt the physician to send for a complete blood count and consider the diagnosis of anemia. Figure 1. Pallor of the palmar creases in the patient’s hand (red arrow) compared to the examiner’s hand (blue arrow).

Clinical reasoning is a quintessential skill of the internist, the cornerstone of safe, effective medical care. While new technologies and accumulating evidence continue to change practice, they supplement rather than supplant clinical judgment in the care of the individual patient. Multiple studies show that transparency and instruction in clinical reasoning are what trainees seek most from their attending physicians. And while we know good reasoning when we see it, we often have difficulty describing it in specific terms. With this issue, JGIM introduces readers to the lexicon of clinical reasoning with a new feature called Exercises in Clinical Reasoning. These exercises build on the successful format of other series that intersperse iterative case presentations with extemporaneous expert clinician commentary. We allow the reader to follow along as an experienced clinician approaches an unknown, challenging patient care dilemma. But we add another layer of commentary that peers into the clinician’s mind (as much as we can) to highlight the normal, insightful, and sometimes errant judgment displayed in attempting to solve each case. We hope that this running diagnostic reasoning commentary and concluding discussion will help our readers become more facile with the science of clinical reasoning, enabling them to become more cognizant of their own judgments and more effectively teach reasoning skills to others. In this issue, “Doing What Comes Naturally” begins the Exercises with a relatively straightforward case involving a common clinical problem (hypertension) to introduce basic clinical reasoning concepts. In upcoming issues we hope to present cases with more twists, turns, blind alleys, or errors that highlight the more nuanced aspects of clinical reasoning. We invite clinicians to submit their interesting cases and to provide any suggestions or critiques on this new series.

The purpose of this study was to investigate the prescribing practices for the use of psychoactive medication in treating hospitalized patients with the acquired immunodeficiency syndrome (AIDS).The medical charts were studied for all patients admitted to a 20-bed AIDS inpatient ward from July through December 1986. One hundred and fifty-one patient-admissions comprised the sample. The average age of the patients was 37 years, and the average length of the hospital stay was 13 days. Retrospective chart review collected demographic data, length of stay, medical diagnosis, psychiatric history, and mental status on admission. Data on psychoactive drugs included the reasons for use, maximum daily dose and duration, and side effects ascribed to the drugs.Psychoactive drugs were used in 89% of the cases. Anxiolytics accounted for 49% of the psychoactive prescriptions, and hypnotics made up 43% of these prescriptions. The five most frequently used psychoactive drugs were benzodiazepines. The most frequent reasons for psychotropic prescriptions were insomnia (39%), psychologic distress (20%), and nausea (16%). The most frequently used anxiolytic and anti-psychotic medications were used in moderate dosage, while the most frequently used antidepressant was prescribed in low dosage.Hospitalized AIDS patients are highly likely to be prescribed a psychotropic medication, especially an anxiolytic or hypnotic. Anxiolytics are used for several purposes, including reduction of nausea associated with the use of antibiotics. Antidepressants and antipsychotics are rarely used. Practitioners must be sensitive to the presence of psychiatric conditions presenting as insomnia or disturbed mood so that the most specific and appropriate treatments can be used.

Background Patients with hepatitis C virus (HCV) are at increased risk for hepatocellular carcinoma. Although serum alpha-fetoprotein (AFP) is often used to detect hepatocellular carcinoma in HCV-infected individuals, its utility is unclear. Purpose To define the test characteristics of AFP for the diagnosis of hepatocellular carcinoma in patients with HCV. Data sources MEDLINE search from 1966 to December 2002 for English- and non-English-language articles examining the test characteristics of AFP for identifying hepatocellular carcinoma. Study selection Articles were included if they reported the sensitivity and specificity of AFP for detecting hepatocellular carcinoma in patients with HCV. Articles were excluded if the cause of hepatitis was ambiguous or if 50% or more of the study patients did not have HCV. Data extraction Relevant articles were evaluated for quality of evidence; test characteristics were abstracted and calculated. Data synthesis Five studies met all inclusion criteria and were analyzed. The overall quality of evidence was limited; only one study universally applied an acceptable gold standard test, and three of five studies used a case-control design that potentially overestimates diagnostic accuracy. By using the most commonly reported cutoff value of a positive test result for hepatocellular carcinoma (AFP level > 20 microg/L), the ranges of test characteristics were as follows: sensitivity, 41% to 65%; specificity, 80% to 94%; positive likelihood ratios, 3.1 to 6.8; and negative likelihood ratios, 0.4 to 0.6. Conclusions The paucity of high-quality data calls for more rigorous study of AFP and other diagnostic tests for detecting hepatocellular carcinoma in HCV-infected patients with an accepted gold standard applied to the entire cohort. Even if the "best-case" estimates of AFP sensitivity and specificity are accurate, AFP has limited utility for detecting hepatocellular carcinoma.