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Background: Little is known about whether assignment to simultaneous inpatient and outpatient clinical duties causes disruptions during internal medicine resident continuity clinic and impacts trainee satisfaction. Purpose: Our purpose was to determine whether dual inpatient and continuity clinic responsibilities impact resident stress and document the number, type, and immediacy of interruptions in continuity clinics. Methods: Methods included a prospective 2-residency survey of 70 internal medicine residents performing 240 half-day continuity clinic sessions. Results: More than half (52%) of trainees on inpatient rotations felt pressured to return to their ward duties. Half (50%) of residents thought clinic increased work hours, and the majority (70%) did not think continuity clinic detracted from their education on inpatient or elective rotations. Disturbances were more likely to occur on inpatient rotations (odds ratio 4.52, 95% confidence interval = 2.298.92) than on outpatient rotations. The time required to address an interruption was 3.9 +/- 4.51 min. Residents thought many (46%) problems addressed during clinic could have waited until clinic completion. Conclusions: Residents on inpatient rotations who were commonly interrupted in clinic felt pressured to return to ward duties and unable to focus on their clinic patients. Internal medicine faculty should modify curriculum to minimize the interference of other duties in resident clinics. [ABSTRACT FROM AUTHOR]

BACKGROUND: There are no objective tools to assess ambulatory teaching, an increasingly important component of medical education. PURPOSE: To develop and describe an objective ambulatory teaching tool. METHODS: Exactly 30 consecutive ambulatory teaching encounters were audio taped. Audio tapes were transcribed and teacher-learner utterances were qualitatively analyzed by 3 coders using a grounded theory approach. RESULTS: A total of 4,560 utterances were coded: 1/3 were devoted to case presentations, and the remainder to case discussion. Most learner utterances conveyed factual patient information; only 7% conveyed learner thoughts on diagnosis or management. Attending utterances were equally divided between questions, statements of fact, and management statements. Most attending questions (75%) asked patient or medical facts; few were of a higher-level asking learners to analyze, synthesize, or apply content. Feedback, although common (10%), consisted of mostly minimal statements such as 'right' or 'I agree.' At the bedside, 80% of utterances were by the teacher. CONCLUSIONS: This is a feasible tool that reliably documents ambulatory teacher and learner behaviors and may be useful for educational research and faculty development. [ABSTRACT FROM AUTHOR]

Background: Prior research on reducing variation in housestaff handoff procedures have depended on proprietary checkout software. Use of low-technology standardization techniques has not been widely studied., Purpose: We wished to determine if standardizing the process of intern sign-out using low-technology sign-out tools could reduce perception of errors and missing handoff data., Methods: We conducted a pre-post prospective study of a cohort of 34 interns on a general internal medicine ward. Night interns coming off duty and day interns reassuming care were surveyed on their perception of erroneous sign-out data, mistakes made by the night intern overnight, and occurrences unanticipated by sign-out. Trainee satisfaction with the sign-out process was assessed with a 5-point Likert survey., Results: There were 399 intern surveys performed 8 weeks before and 6 weeks after the introduction of a standardized sign-out form. The response rate was 95% for the night interns and 70% for the interns reassuming care in the morning. After the standardized form was introduced, night interns were significantly (p < .003) less likely to detect missing sign-out data including missing important diseases, contingency plans, or medications. Standardized sign-out did not significantly alter the frequency of dropped tasks or missed lab and X-ray data as perceived by the night intern. However, the day teams thought there were significantly less perceived errors on the part of the night intern (p = .001) after introduction of the standardized sign-out sheet. There was no difference in mean Likert scores of resident satisfaction with sign-out before and after the intervention., Conclusion: Standardized written sign-out sheets significantly improve the completeness and effectiveness of handoffs between night and day interns. Further research is needed to determine if these process improvements are related to better patient outcomes.

Purpose: The study assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) preoperative cardiac assessment guidelines impact patient management and predict major cardiac events in patients undergoing orthopedic surgery., Subjects and Methods: We conducted a retrospective review of 338 consecutive orthopedic preoperative evaluations performed by internal medicine consultants. Major cardiac events were defined as myocardial infarction, congestive heart failure, and sudden cardiac death., Results: Major cardiac events occurred in 5.7% of patients. Patients with minor or absent ACC/AHA clinical risk predictors were less likely to have major cardiac events (P = .007). More than half (51%) of patients meeting ACC/AHA indications for noninvasive cardiac tests did not receive them. However, most (69%) major cardiac events occurred in patients not meeting criteria for cardiac testing. Abnormal noninvasive cardiac testing results did not alter medication recommendations and only resulted in coronary revascularization in 0.6% of patients. Only 3% of patients with abnormal noninvasive cardiac testing results had major cardiac events. Patients with abnormal cardiac test results were more likely to have recommendations for perioperative beta-blockade (P <.01). Patients aged more than 70 years (odds ratio 5.0; 95% confidence interval, 1.32-19.28) and patients undergoing hip surgery (odds ratio 7.5, 95% confidence interval, 1.02-54.55) were more likely to have major cardiac events. Major cardiac events occurred in 12% of urgent and 4% of elective procedures (P = .009)., Conclusions: The ACC/AHA guidelines accurately predict cardiac risk in orthopedic surgery. Abnormal noninvasive cardiac test results rarely affected preoperative recommendations, but improved compliance with beta-blocker therapy. Advanced age, urgent procedures, and hip surgery were associated with increased risk of major cardiac events.

Purpose: The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change., Methods: The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance., Results: Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education., Conclusion: This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.

Oral pseudoephedrine is commonly used to treat symptoms of rhinitis and rhinorrhea, but its effect on blood pressure (BP) and heart rate (HR) remains uncertain. We assessed whether pseudoephedrine causes clinically meaningful elevations in HR or BP. We searched MEDLINE, EMBASE, and the Cochrane Library for English-language, randomized placebo-controlled trials of oral pseudoephedrine treatment in adults. The primary data extracted were systolic BP (SBP), diastolic BP (DBP), and HR. Study quality was assessed using the methods of Jadad, and data were synthesized using a random-effects model and weighted mean differences. Twenty-four trials had extractable vital sign information (45 treatment arms; 1285 patients). Pseudoephedrine caused a small but significant increase in SBP (0.99, mm Hg; 95% CI, 0.08 to 1.90) and HR (2.83 beats/min; 95% CI, 2.0 to 3.6), with no effect on DBP (0.63 mm Hg, 95% CI, -0.10 to 1.35). The effect in patients with controlled hypertension demonstrated an SBP increase of similar magnitude (1.20 mm Hg; 95% CI, 0.56 to 1.84 mm Hg). Higher doses and immediate-release preparations were associated with greater BP increases. Studies with more women had less effect on BP or HR. Shorter duration of use was associated with greater increases in SBP and DBP.

Oral phenylpropanolamine is commonly used to treat congestion and obesity. Clinicians often wonder what effect it has on blood pressure and whether they are safe in hypertensive patients. The purpose of our systematic review was to assess whether these drugs cause clinically meaningful elevations in pulse or blood pressure. English-language, randomized, placebo-controlled trials of oral phenylpropanolamine in adults with extractable data on pulse or blood pressure were studied. MEDLINE (1966-2003), Embase, the Cochrane library and reviewed article references were used as sources. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate data were extracted. Additional extracted data included demographics, year, study design, study duration, drug dose and frequency, duration of washout and country. Study quality was assessed using the methods of Jadad and data were synthesized using a random effects model using weighted mean differences. In all, 33 trials reporting 48 treatment arms with 2165 patients were included. Phenylpropanolamine increased SBP 5.5 mmHg (95% CI: 3.1-8.0) and DBP 4.1 mmHg (95% CI: 2.2-6.0) with no effect on pulse. Patients with controlled hypertension were not at greater risk of blood pressure elevation. Immediate release preparations had greater effects on blood pressure than sustained release ones. Higher doses and shorter duration use also caused greater increases. Eighteen studies contained at least one treated subjects having blood pressure elevations > or =140/90 mmHg, an increase in SBP > or =15 mmHg or an increase in DBP > or =10 mmHg. In conclusion, phenylpropanolamine caused a small, but significant increase in systolic blood pressure. The effect was more pronounced with shorter-term administration, higher doses of medication and immediate release formulations.

We performed a pre-post study of the impact of three 90-minute faculty development workshops on written feedback from encounters during an ambulatory internal medicine clerkship. We coded 47 encounters before and 43 after the workshops, involving 9 preceptors and 44 third-year students, using qualitative and semiquantitative methods. Postworkshop, the mean number of feedback statements increased from 2.8 to 3.6 statements (P =.06); specific (P =.04), formative (P =.03), and student skills feedback (P =.01) increased, but attitudinal (P =.13) and corrective feedback did not (P =.41). Brief, interactive, faculty development workshops may refine written feedback, resulting in more formative specific written feedback comments.

This paper is part 1 of a 2-part series on interpretation of 12-lead resting electrocardiograms (ECGs). Part 1 is a position paper that presents recommendations for initial competency, competency assessment, and maintenance of competency on ECG interpretation, as well as recommendations for the role of computer-assisted ECG interpretation. Part 2 is a systematic review of detailed supporting evidence for the recommendations. Despite several earlier consensus-based recommendations on ECG interpretation, substantive evidence on the training needed to obtain and maintain ECG interpretation skills is not available. Some studies show that noncardiologist physicians have more ECG interpretation errors than do cardiologists, but the rate of adverse patient outcomes from ECG interpretation errors is low. Computers may decrease the time needed to interpret ECGs and can reduce ECG interpretation errors. However, they have shown less accuracy than physician interpreters and must be relied on only as an adjunct interpretation tool for a trained provider. Interpretation of ECGs varies greatly, even among expert electrocardiographers. Noncardiologists seem to be more influenced by patient history in interpreting ECGs than are cardiologists. Cardiologists also perform better than other specialists on standardized ECG examinations when minimal patient history is provided. Pending more definitive research, residency training in internal medicine with Advanced Cardiac Life Support instruction should continue to be sufficient for bedside interpretation of resting 12-lead ECGs in routine and emergency situations. Additional experience or training in ECG interpretation when the patient's clinical condition is unknown may be useful but requires further study.

Background: There have been many proposals for objective standards designed to optimize training, testing, and maintaining competency in interpretation of electrocardiograms (ECGs). However, most of these recommendations are consensus based and are not derived from clinical trials that include patient outcomes., Purpose: To critically review the available data on training, accuracy, and outcomes of computer and physician interpretation of 12-lead resting ECGs., Data Sources: English-language articles were retrieved by searching MEDLINE (1966 to 2002), EMBASE (1974 to 2002), and the Cochrane Controlled Trials Register (1975-2002). The references in articles selected for analysis were also reviewed for relevance., Study Selection: All articles on training, accuracy, and outcomes of ECG interpretations were analyzed., Data Extraction: Study design and results were summarized in evidence tables. Information on physician interpretation compared to a "gold standard," typically a consensus panel of expert electrocardiographers, was extracted. The clinical context of and outcomes related to the ECG interpretation were obtained whenever possible., Data Synthesis: Physicians of all specialties and levels of training, as well as computer software for interpreting ECGs, frequently made errors in interpreting ECGs when compared to expert electrocardiographers. There was also substantial disagreement on interpretations among cardiologists. Adverse patient outcomes occurred infrequently when ECGs were incorrectly interpreted., Conclusions: There is no evidence-based minimum number of ECG interpretations that is ideal for attaining or maintaining competency in ECG interpretation skills. Further research is needed to clarify the optimal way to build and maintain ECG interpretation skills based on patient outcomes.

Objective: While several models of medical student instruction in the ambulatory setting exist, few have been formally studied. We wished to assess the impact of a faculty development workshop based on the One-Minute Preceptor model on the amount and quality of feedback in the outpatient setting., Design: Ambulatory teaching behaviors were studied during consecutive outpatient precepting sessions before and after 3 faculty development workshops. Student-teacher interactions were assessed using audiotapes of teaching encounters coded through qualitative techniques, and surveys of teacher, learner, and patient satisfaction., Setting: Ambulatory internal medicine clinic in a tertiary care medical center., Patients/participants: Nine board-certified internist faculty preceptors and 44 third-year medical students., Interventions: Three 90-minute faculty development seminars based on the One-Minute Preceptor teaching model., Measurements and Main Results: Ninety-four encounters with 18577 utterances were recorded, half before and half after the seminars. After the workshops, the proportion of utterances that contained feedback increased from 17% to 22% (P =.09) and was more likely to be specific (9% vs 15%; P =.02). After the workshops, teachers reported that the learning encounters were more successful (P =.03) and that they were better at letting the students reach their own Conclusions (P =.001), at evaluating the learners (P =.03), and at creating plans for post-encounter learning (P =.02). The workshops had no effect on the duration of the student-teacher encounter or on student or patient satisfaction with the encounters., Conclusions: Brief, interactive, faculty development workshops based on the One-Minute Preceptor model of clinical teaching resulted in modest improvements in the quality of feedback delivered in the ambulatory setting.

Background: Back pain is one of the most common problems in primary care. Antidepressant medication is often prescribed, especially for chronic back discomfort, to alleviate pain and restore the patient's ability to conduct activities of daily living., Objective: To assess the efficacy of antidepressants in treating back pain in adults., Methods: We searched the MEDLINE (1966-2000), PsycLit, Cinhal, EMBASE, AIDSLINE, HealthSTAR, CANCERLIT, the Cochrane Library (clinical trials registry and the Database of Systematic Reviews), Micromedex, and Federal Research in Progress databases and references of reviewed articles. Included articles were written in English and dealt with randomized placebo-controlled trials of antidepressant medication use among adults with chronic back pain. Two reviewers abstracted data independently. Two continuous outcomes, change in back pain severity and ability to perform activities of daily living, were measured. Study quality was assessed with the methods used by Jadad and colleagues, and data were synthesized using a random-effects model., Results: Nine randomized controlled trials with 10 treatment arms and 504 patients were included. Seven treatment arms included patients with major depression. Patients had chronic back pain, averaging 10.4 years. Patients treated with antidepressants were more likely to improve in pain severity than those taking placebo (standardized mean difference, 0.41; 95% confidence interval, 0.22-0.61) but not in activities of daily living (standardized mean difference, 0.24; 95% confidence interval, -0.21-0.69). Patients treated with antidepressants experienced more adverse effects (22% vs 14%, P =.01) than those receiving placebo., Conclusion: Antidepressants are more effective than placebo in reducing pain severity but not functional status in chronic back pain.

Purpose: Surveys conducted by the American College of Physicians-American Society of Internal Medicine have shown that the public has varying opinions about the capabilities of internists. However, the perceptions of patients seeking care from internists remain uncertain. We wished to determine how patients visiting general internists perceived them and discover whether patients understood the differences between internists and other primary care physicians., Subjects and Methods: We surveyed established adult patients visiting three general internal medicine clinics in Georgia, Iowa, and Vermont. Patients answered 11 questions about their perceptions of an internist's scope of care and selected which of 24 diseases, symptoms, or examination skills they thought an internist could manage., Results: Patients completed 601 (66%) of the 911 surveys distributed. Nearly half of patients (45%) confused internists with family physicians and 39% thought internists could treat children. Patients with college education were more than twice as likely to know that internists were not interns (Odds ratio = 2.6, 95% confidence interval 1.8 to 3.8, P < 0.001) compared with patients having less education. Only 50% of patients thought an internist was trained in women's health. Significantly more (P < 0.001) patients demonstrated confidence in an internist's ability to treat symptoms (76%) than treat specific diseases (59%) or perform clinical examinations (54%)., Conclusions: Established patients seeking care in internal medicine clinics lack consensus on the capabilities of internists, especially on how they differ from other specialties. Continued public education efforts should be considered to promote better understanding of the role of the internist as a specialist in adult medicine.

Objective: To determine the opinion of current residents and recent graduates of internal medicine training programs regarding an additional mandatory year of residency training., Methods: A survey was made of 2,000 associate members of the American College of Physicians from five geographic regions., Results: Of 917 respondents, 70.3% thought a fourth year of training would impact negatively on their choice of a career in internal medicine, and 82.9% believed a mandatory fourth year should not be required of residents choosing a subspecialty career. Furthermore, 58.1% of physicians surveyed thought a mandatory fourth year would discourage individuals from pursuing subspecialty careers. If a mandatory fourth year of training were required, 50.7% respondents indicated that it should consist of ambulatory training in a number of general fields, while 49.6% physicians believed the training should focus on one or two subspecialty fields., Conclusions: A mandatory fourth year of training is not supported by residents and recent graduates of the programs surveyed.

The centrally accentuated antineutrophil cytoplasmic antibody test (c-ANCA) is widely regarded as a sensitive and specific marker for Wegener's granulomatosis (WG). There are increasing reports, however, of false-positive c-ANCAs, usually in the setting of other vasculidities. We report a case of a 27-year-old man with ulcerative colitis who developed pulmonary symptoms, peripheral nodular lung infiltrates, and an elevated c-ANCA suggesting WG. Chest CT and open lung biopsy specimens were consistent with WG. The symptoms and pulmonary infiltrates resolved after discontinuation of sulfasalazine therapy. The c-ANCA remained elevated due to the occurrence of false-positive values in ulcerative colitis. We conclude sulfasalazine toxicity can mimic clinical aspects of WG and that c-ANCA testing should be interpreted with caution in patients with ulcerative colitis.

Objective: To examine the effect of serial neuroimaging studies on the diagnosis, therapy, and outcome of patients with acute stroke., Design: Retrospective case series., Setting: Tertiary care teaching hospital., Patients: 206 adult patients (mean age +/- SD, 66.0 +/- 10.8 years) hospitalized with a diagnosis of acute stroke between 1990 and 1993., Measurements: Strokes were retrospectively assigned to five categories (large-vessel, small-vessel, cardioembolic, other, or unknown) using standardized criteria based on the history, physical examination, ancillary test results, and first computed tomographic (CT) or magnetic resonance imaging (MRI) study of the head. Strokes were reclassified after the results of further neuroimaging studies, if any, were reviewed. The type and timing of therapy and the patient outcome at hospital discharge were documented., Results: The additional studies changed stroke classification in only 20.0% of the 140 patients who had two or more neuroimaging studies. All classification changes were from the unknown cause category to a category with a specific cause. In most patients receiving treatment (93.2%), therapy began before an additional CT or MRI study was obtained. In patients who had one neuroimaging study, 70.1% went home, 24.0% went to a skilled nursing facility, and 5.9% died; the corresponding percentages in persons who had multiple studies were 73.3%, 24.4%, and 2.2% (P > 0.1)., Conclusions: Serial neuroimaging studies did not alter the classification of strokes for which an initial diagnosis had already been made. However, they were useful in determining the cause of strokes initially classified as having an unknown cause. Therapy was almost always begun immediately after the first CT or MRI study was obtained. Outcome at hospital discharge was not significantly related to the number of neuroimaging studies obtained.

Drug-induced eosinophilic lung disease commonly presents as a simple pulmonary eosinophilia-like syndrome consisting of transient pulmonary infiltrates, peripheral eosinophilia, and mild pulmonary symptoms that disappear promptly upon withdrawal of the offending medication. However, a more fulminant presentation most resembling acute eosinophilic pneumonia has been recently described. We present a patient with BAL-confirmed eosinophilic pneumonia (EP) and respiratory failure after a trazodone overdose. This is the first case of EP associated with trazodone and only the third drug-mediated EP reported to precipitate respiratory failure.

Calcium channel antagonists have gained widespread acceptance for treatment of a variety of cardiovascular disorders. Newer drugs of the dihydropyridine class are especially attractive for treating hypertension and angina because of their increased vascular selectivity, favorable side-effect profile, and pharmacokinetics that allow once-daily dosing. In the future, calcium channel antagonists may also play a role in antiatherogenic therapy and in treatment of congestive heart failure and cerebrovascular disease as results of prospective studies become available and new agents are developed.

Preview The success of calcium channel antagonists in controlling hypertension, angina pectoris, and arrhythmias is well known. In recent years, second-generation agents have been introduced that are also effective against migraine headaches and Raynaud's phenomenon and appear to improve atherosclerosis and congestive heart failure. The authors summarize the characteristics that calcium channel antagonists have in common and describe the specific niche filled by the newer agents, particularly those of the dihydropyridine class.

A 44-year-old female is described who developed persistent upper extremity and orolingual dystonia several weeks after suspected onset of central pontine myelinolysis (CPM), later confirmed by characteristic pontine lesions on MRI. No foci of the extrapontine myelinolysis were evident. This case confirms that dystonia may be a late and persistent sequela of CPM and may occur in the absence of visible lesions outside the brainstem.

Study Objective: To determine the incidence, type, and outcome of protocol deviations in an emergency medical services (EMS) system., Design: Retrospective consecutive case series., Setting: Seven advanced life support ambulance services servicing five area hospital emergency departments., Patients: 1,246 patients requiring advanced life support care., Interventions: None., Measurements and Main Results: Advanced life support ambulance runs during a two-month period were examined for protocol deviations. Of 1,246 runs examined, 16% had deviations. Approximately 55% of these deviations were minor, 38% were serious, and 7% were very serious in nature. The effects of the errors were evaluated using hospital records. Results showed that 89.5% of patients were unaffected, 5.0% improved, and 5.5% suffered complications from deviations. Emergency medical technicians committed 69% of the deviations without the consent of medical control, medical control committed an additional 18%, and both were responsible in 13% of cases. Incomplete histories were found in 8% of cases., Conclusion: Protocol deviations committed in prehospital care do not usually cause direct harm to patients. On review of these deviations, however, several disturbing trends were uncovered, including misconceptions in the use of IV therapy, a number of serious deviations in advanced cardiac life support protocols, and lack of communication with medical control. This type of quality assurance study has the ability to identify areas of strength and weakness in an EMS system, allowing planning of ongoing educational efforts in the system.

The work of physicians at Turner's Lane Military Hospital, Philadelphia, stimulated interest in neurology in the United States, leading to the post-Civil War emergence of neurology as a distinct medical specialty. These physicians advanced their profession and benefitted their patients.