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Alignment between institutions and graduate medical education (GME) regarding quality and safety initiatives (QI) has not been measured. The objective was to determine US internal medicine residency program directors’ (IM PDs) perceived resourcing for QI and alignment between GME and their institutions. A national survey of IM PDs was conducted in the Fall of 2013. Multivariable linear regression was used to test association between a novel Integration Score (IS) measuring alignment between GME and the institution via PD perceptions. The response rate was 72.6% (265/365). According to PDs, residents were highly engaged in QI (82%), but adequate funding (14%) and support personnel (37% to 61%) were lower. Higher IS correlated to reports of funding for QI (76.3% vs 54.5%, P = .012), QI personnel (67.3% vs 41.1%, P < .001), research experts (70.5% vs 50.0%, P < .001), and computer experts (69.0% vs 45.8%, P < .001) for QI assistance. Apparent mismatch between GME and institutional resources exists, and the IS may be useful in measuring GME–institutional leadership alignment in QI.

Gastric cancer (GC) is the second-leading cause of cancer-related deaths worldwide, with overall 5-year survival less than 20 %. However, limited data exist investigating ethnic disparities in stage-specific GC incidence and survival in the USA. To evaluate ethnicity-specific differences in GC incidence and survival in the USA. Using data from the surveillance, epidemiology, and end results 1992–2009 population-based cancer registry, we evaluated ethnic disparities in GC incidence stratified by year of diagnosis, cancer stage at presentation, and geographical distribution of disease. Ethnic disparities in survival were evaluated using Kaplan–Meier and multivariate Cox proportional hazards models. Among men and women combined and among all cancer stages, Asians had the highest incidence of GC, more than double that among Whites (15.6 vs. 7.4 per 100,000/year, p

Physician burnout and distress has been described in national studies of practicing physicians, internal medicine (IM) residents, IM clerkship directors, and medical school deans. However, no comparable national data exist for IM residency program directors.To assess burnout and distress among IM residency program directors, and to evaluate relationships of distress with personal and program characteristics and perceptions regarding implementation and consequences of Accreditation Council for Graduate Medical Education (ACGME) regulations.The 2010 Association of Program Directors in Internal Medicine (APDIM) Annual Survey, developed by the APDIM Survey Committee, was sent in August 2010 to the 377 program directors with APDIM membership, representing 99.0 % of the 381 United States categorical IM residency programs.The 2010 APDIM Annual Survey included validated items on well-being and distress, including questions addressing quality of life, satisfaction with work-life balance, and burnout. Questions addressing personal and program characteristics and perceptions regarding implementation and consequences of ACGME regulations were also included.Of 377 eligible program directors, 282 (74.8 %) completed surveys. Among respondents, 12.4 % and 28.8 % rated their quality of life and satisfaction with work-life balance negatively, respectively. Also, 27.0 % reported emotional exhaustion, 10.4 % reported depersonalization, and 28.7 % reported overall burnout. These rates were lower than those reported previously in national studies of medical students, IM residents, practicing physicians, IM clerkship directors, and medical school deans. Aspects of distress were more common among younger program directors, women, and those reporting greater weekly work hours. Work-home conflicts were common and associated with all domains of distress, especially if not resolved in a manner effectively balancing work and home responsibilities. Associations with program characteristics such as program size and American Board of Internal Medicine (ABIM) pass rates were not found apart from higher rates of depersonalization among directors of community-based programs (23.5 % vs. 8.6 %, p = 0.01). We did not observe any consistent associations between distress and perceptions of implementation and consequences of program regulations.The well-being of IM program directors across domains, including quality of life, satisfaction with work-life balance, and burnout, appears generally superior to that of medical trainees, practicing physicians, and other medical educators nationally. Additionally, it is reassuring that program directors' perceptions of their ability to respond to current regulatory requirements are not adversely associated with distress. However, the increased distress levels among younger program directors, women, and those at community-based training programs reported in this study are important concerns worthy of further study.

Objective Medical educators and researchers recommend a patient-centered interviewing style, but little empirical data exists regarding what aspects of physician communication patients like and why. We investigated patient responses to videotaped doctor–patient vignettes to ascertain what they liked about patient-centered and biomedical communication. Methods We conducted semi-structured interviews with 230 adult medicine patients who viewed videotapes depicting both patient-centered and biomedical physician communication styles. We used a mixed methods approach to derive a “ground-up” framework of patient communication preferences. Results Respondents who preferred different communication styles articulated different sets of values, important physician behaviors, and physician–patient role expectations. Participants who preferred the patient-centered physician (69%) liked that she worked with and respected patients and explored what the patient wanted. Participants who preferred the biomedical physician (31%) liked that she prevented harm, demonstrated medical authority, and delivered information clearly. Conclusions Patients like (and dislike) patient-centered communication for thoughtful, considered reasons that appear grounded in their values and expectations about physicians, patients, and the clinical encounter. Practice implications Better understanding the diversity of patient communication preferences may lead to more effective and individualized care.

Most patients with acute hepatitis C (HCV) infections are asymptomatic, while 15% present with jaundice. Intranasal drug use can uncommonly transmit HCV via contaminated instruments and nasal epithelial breakdown. Given a 15% prevalence of HCV infection in chronic methamphetamine users, recognition of potential transmission routes is important to target prevention and screening efforts in this population.

Efforts to improve primary care treatment of depression incorporate elements of the chronic illness care model, including patient self-management strategies. Case studies, focus groups and the literature suggest six key components of depression self-management programs: (1) implement behavioral change interventions, (2) plan for crisis and relapse prevention, (3) re-establish personal meaning, (4) attend to patients' experience, context and community, (5) build a patient-clinician partnership and (6) create an integrated, self-management support structure. Successful implementation of these components is facilitated by (1) the care system's collective and empathic understanding of the disease itself; (2) sufficient time; (3) adequate funding and (4) robust clinical information systems.

OBJECTIVE: To investigate patient preferences for a patient-centered or a biomedical communication style. DESIGN: Randomized study. SETTING: Urgent care and ambulatory medicine clinics in an academic medical center. PARTICIPANTS: We recruited 250 English-speaking adult patients, excluding patients whose medical illnesses prevented evaluation of the study intervention. INTERVENTION: Participants watched one of three videotaped scenarios of simulated patient-physician discussions of complementary and alternative medicine (CAM). Each participant watched two versions of the scenario (biomedical vs. patient-centered communication style) and completed written and oral questionnaires to assess outcome measurements. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were 1) preferences for a patient-centered versus a biomedical communication style; and 2) predictors of communication style preference. Participants who preferred the patient-centered style (69%; 95% confidence interval [CI], 63 to 75) tended to be younger (82% [51/62] for age 59; P

A 72-year-old woman presented to the hospital with 3 days of emesis, anorexia and generalised fatigue without any report of chest pain. Her physical examination was significant for mild confusion and bright red blood per rectum. On presentation she had bilateral lower extremity weakness, but was able to move both lower extremities; dorsalis pedis pulses were present bilaterally. Initial laboratory examinations demonstrated a white cell count of 16.7 K/μL, creatinine of 3.0 mg/dL, aspartate aminotransferase/alanine aminotransferase of 1189/382 U/L, lactate of 4.5 mmol/L and a troponin of 0.52 ng/mL. ECG was unremarkable. An initial chest X-ray showed a dilated aortic arch and a modestly widened mediastinum. A CT scan of the chest was not done. Several hours after presentation, the patient was noted to have …

A 31-year-old woman presented with left eye pain and vision loss after being hit in the eye by a cigarette lighter. Exam revealed a globe protrusion encased by conjunctiva at the inferior limbus (Fig. 1), elevated intraocular pressures (IOP) (> 50 mmHg), and grade IV hyphema. Computed tomography (CT) scan confirmed anterior globe rupture (Fig. 2). She received an alpha agonist, a beta blocker, steroids, cycloplegics, and a carbonic anhydrase inhibitor before undergoing open globe repair.1,2 Figure 1 External eye examination. The cornea appeared completely black (blue arrow) after the initial injury. The anterior rupture (red arrow) appeared two weeks later and prompted the patient to come to the emergency room. The protrusion occurred inferior ... Figure 2 Sagittal view of CT scan showing area of anterior rupture encased by a thin layer of overlying conjunctiva (red arrow). This area corresponds to the protrusion seen at the inferior limbus of the left eye in Figure ​Figure1.1. The lighter layer ... Post-traumatic hyphema is an ophthalmologic emergency that can result in permanent vision loss. Accumulation of blood in the anterior chamber causes trabecular meshwork obstruction, thereby elevating IOP. Hyphema with increased IOP can result in corneal blood staining, reduced corneal transparency, and vision loss.1 Other complications of traumatic hyphema include endophthalmitis from penetrating trauma and optic nerve damage via elevated IOPs. Hyphemas are graded by the percentage of the anterior chamber (AC) filled with blood, and range from Grade I (blood occupying

Depression is associated with poor chronic illness outcomes, but it is unknown whether depression influences the quality of communication during the clinical encounter. We investigated whether diabetes patients with depressive symptoms, compared with those without depressive symptoms, report worse clinician-patient communication, and which domains of communication are most affected.We surveyed 231 ethnically diverse, English-speaking patients with diabetes to ascertain their experiences of communication with their primary care clinician. We selected measures from the interpersonal processes of care (IPC) instrument to assess communication and dichotomized the 7 subscales into "optimal" or "suboptimal" communication. We used the Clinical Epidemiologic Services for Depression (CES-D 10) to categorize patients as having no (CES-D 10 score10), mild (CES-D 10 score 10-14), or severe (CES-D 10 score14) depressive symptoms. We used multivariable logistic regression to evaluate the relationship between depressive symptoms and communication subscales.Thirty-five percent of subjects reported severe depressive symptoms. Compared with those with no depressive symptoms, the presence of severe depressive symptoms was independently associated with suboptimal communication in 4 of 7 subscales: elicitation of patient problems, concerns, and expectations (adjusted odds ratio [AOR], 2.94; 95% confidence interval [CI], 1.14-7.61); explanations of condition (AOR, 3.79; 95% CI, 1.41-10.21); empowerment (AOR, 2.98; 95% CI, 1.35-6.58); and decision-making (AOR, 2.56; 95% CI, 1.14-5.78).Diabetes patients with severe depressive symptoms are more likely than those without depressive symptoms to report suboptimal clinician-patient communication across multiple domains of communication, especially those that involve more interactive and "patient-centered" communication. Further investigation of this relationship may uncover explanatory mechanisms and help guide interventions for improving care for both conditions.