Internal Medicine update

Is physician engagement with Web-based CME associated with patients’ baseline hemoglobin A1c levels? The Rural Diabetes Online Care study.

UlricheDmond — Thu, 02 Sep 2010 11:17:36 +0000

Acad Med. 2010 Sep;85(9):1511-7

PURPOSE: To investigate the association between physician participants’ levels of engagement in a Web-based educational intervention and their patients’ baseline diabetes measures. METHOD: The authors conducted a randomized trial of online CME activities designed to improve diabetes care provided by family, general, and internal medicine physicians in rural areas of 11 southeastern states between September 2006 and July 2008. Using incidence rate ratios derived from negative binomial models, the relationship between physicians’ engagement with the study Web site and baseline proportion of their patients having controlled diabetes (hemoglobin A1c < or = 7%) was explored. RESULTS: One hundred thirty-three participants (intervention = 64; control = 69) provided information for 1,637 patients with diabetes. In the intervention group, physicians in practices in the worst quartiles of A1c control were least engaged with the study Web site in nearly all dimensions. Total number of pages viewed decreased as quartile of A1c control worsened (137, 73, 68, 57; P = .007); similarly, for a given 10% increase in proportion of patients with controlled A1c, participants viewed 1.13 times more pages (95% CI: 1.02-1.26, P = .02). In the control group, engagement was neither correlated with A1c control nor different across quartiles of A1c control. CONCLUSIONS: Engagement in Web-based interventions is measurable and has important implications for research and education. Because physicians of patients with the greatest need for improvement in A1c control may not use online educational resources as intensely as others, other strategies may be necessary to engage these physicians in professional development activities.

20736679

– Is physician engagement with Web-based CME associated with patients’ baseline hemoglobin A1c levels? The Rural Diabetes Online Care study.

Is physician engagement with Web-based CME associated with patients’ baseline hemoglobin A1c levels? The Rural Diabetes Online Care study.

blog1wgyxj — Thu, 02 Sep 2010 11:17:36 +0000

Acad Med. 2010 Sep;85(9):1511-7

20736679

– Is physician engagement with Web-based CME associated with patients’ baseline hemoglobin A1c levels? The Rural Diabetes Online Care study.

Communication discrepancies between physicians and hospitalized patients.

dr_vinieet — Wed, 11 Aug 2010 18:24:53 +0000

Arch Intern Med. 2010 Aug 9;170(15):1302-7

BACKGROUND: Hospital surveys indicate lack of patient awareness of diagnoses and treatments, yet physicians report they effectively communicate with patients. Gaps in understanding and communication could result in decreased quality of care. We sought to assess patient knowledge and perspectives of inpatient care and determine differences from physician assessments. METHODS: Two validated questionnaires assessed the experiences of inpatients treated by house staff from October 10, 2008, through June 23, 2009. We surveyed corresponding internal medicine resident and attending physicians, asking them to report on their care of hospitalized patients and their understanding of their patients’ perspectives on the care received. RESULTS: Eighty-nine patients and 43 physicians participated. Although 73% of patients thought there was 1 main physician, 18% correctly named that physician, compared with 67% of physicians who thought patients knew their names (P < .001). Most physicians (77%) believed patients knew their diagnosis; however, 57% of patients did (P < .001). A total of 58% of patients thought that physicians always explained things in a comprehensible way, compared with 21% of physicians who stated they always provided explanations of some kind (P < .001). Two-thirds of patients reported receiving a new medication in the hospital, yet 90% noted never being told of any adverse effects of these medications. Nearly all physicians (98%) stated that they at least sometimes discussed their patients' fears and anxieties, compared with 54% of patients who said their physicians never did this (P = .001). CONCLUSIONS: Significant differences exist between patients' and physicians' impressions about patient knowledge and inpatient care received. Steps to improve patient-physician communication should be identified and implemented.

20696951

– Communication discrepancies between physicians and hospitalized patients.

Outcomes and processes of care related to preoperative medical consultation.

nightwal7 — Wed, 11 Aug 2010 13:44:00 +0000

Arch Intern Med. 2010 Aug 9;170(15):1365-74

BACKGROUND: Preoperative consultations by internal medicine physicians facilitate documentation of comorbid disease, optimization of medical conditions, risk stratification, and initiation of interventions intended to reduce risk. Nonetheless, the impact of these consultations, which may be performed by general internists or specialists, on outcomes is unclear. METHODS: We used population-based administrative databases to conduct a cohort study of patients 40 years or older who underwent major elective noncardiac surgery in Ontario, Canada, between 1994 and 2004. Propensity scores were used to assemble a matched-pairs cohort that reduced differences between patients who did and did not undergo preoperative consultation by general internists or specialists. The association of consultation with mortality and hospital stay was determined within this matched cohort. As a sensitivity analysis, we evaluated the association of consultation with an outcome for which no difference would be expected: postoperative wound infection. RESULTS: Of 269 866 patients in the cohort, 38.8% (n = 104 695) underwent consultation. Within the matched cohort (n = 191 852), consultation was associated with increased 30-day mortality (relative risk [RR], 1.16; 95% confidence interval [CI], 1.07-1.25; number needed to harm, 516), 1-year mortality (1.08; 1.04-1.12; number needed to harm, 227), mean hospital stay (difference, 0.67 days; 0.59-0.76), preoperative testing, and preoperative pharmacologic interventions. Notably, consultation was not associated with any difference in postoperative wound infections (RR, 0.98; 95% CI, 0.95-1.02). These findings were stable across subgroups as well as sensitivity analyses that tested for unmeasured confounding. CONCLUSIONS: Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing. These findings highlight the need to better understand mechanisms by which consultation influences outcomes and to identify efficacious interventions to decrease perioperative risk.

20696963

– Outcomes and processes of care related to preoperative medical consultation.

The patient panel conference experience: what patients can teach our residents about competency issues.

drkhanktk — Wed, 11 Aug 2010 08:54:00 +0000

Acad Med. 2009 Dec;84(12):1833-9

PURPOSE: In 2007, the Scott & White/Texas A&M HSC College of Medicine began requiring all internal medicine residents to attend quarterly patient panel conferences, during which former Scott & White patients speak frankly about their inpatient and outpatient experiences. The main purpose of this mixed-methods pilot study was to determine whether residents’ competency education could be enhanced via the conferences. METHOD: Of the 54 internal medicine residents in the residency program, 31, 39, and 41 participated in three patient panel conferences, respectively, between December 2007 and August 2008. Each resident completed an assessment that included a reflection on his or her own practice and the identification of competency issues highlighted by patients’ oral narratives. Content analyses of responses to open-ended questions were performed. Consensus on themes was reached. Descriptive statistics were run on quantitative data. RESULTS: Six themes were identified: improve communication with patients/families, improve patient care, improve professional behaviors, empathize with patients/families, display sensitivity to patients’/families’ needs/concerns, and recognize system issues. When asked if the conference highlighted competency problems, residents answered “agree” or “strongly agree” as follows: 82% for professionalism, 82.9% for systems-based practice, 85.2% for interpersonal and communication skills, and 84.4% for patient care. The majority were able to provide examples of competency issues. CONCLUSIONS: The patient panel conference experience was a powerful mechanism for enhancing competency education. The conferences were an effective means of presenting real-life examples of systems issues in the context of a hospital system.

19940596

– The patient panel conference experience: what patients can teach our residents about competency issues.

In the clinic. Hypothyroidism.

drkhanktk — Wed, 11 Aug 2010 06:00:53 +0000

Ann Intern Med. 2009 Dec 1;151(11):ITC61

The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians’ Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP’s Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic.

19949140

– In the clinic. Hypothyroidism.

Sins of our fathers: two of The Four Doctors and their roles in the development of techniques to permit covert autopsies.

nightwal7 — Wed, 11 Aug 2010 01:02:04 +0000

Arch Pathol Lab Med. 2009 Dec;133(12):1969-74

CONTEXT: -Sir William Osler, MD, and Howard Kelly, MD, were probably the preeminent practitioners of their respective specialties, internal medicine and gynecology, during the late 19th and early 20th centuries. Both were passionately interested in pathology. Although not widely known, during the 1880s, both allegedly pioneered “arm’s length” methods to perform covert autopsies that involved removing abdominal and even thoracic organs via the anus, vagina, or a small perineal incision hidden behind the scrotum. These techniques were allegedly used, at least occasionally, to circumvent autopsy-consent regulations and to procure teaching specimens for medical museums. OBJECTIVE: -To examine the historical evidence for these alleged events and to examine these behaviors within the context of (1) the need to obtain pathologic specimens for teaching gross pathology and clinical pathologic correlation to medical trainees, (2) the loose interpretation of autopsy-consent regulations at “charity hospitals” during the late 19th century, (3) the medical museum movement, and (4) the paternalistic approach to the practice of medicine typical of the times. DESIGN: -To address these issues, standard historiographic methods were used to examine available primary and secondary historical sources. RESULTS: -The evidence suggests that Kelly developed and published 3 arm’s length methods for covert autopsies while a resident in Philadelphia, Pennsylvania, and that both Kelly and Osler pioneered the use of these methods in the 1880s. The brief history of these “minimally invasive” autopsy techniques is also examined by reviewing 19th and 20th century textbooks of autopsy technique. CONCLUSIONS: -Howard Kelly, MD, and William Osler, MD, pioneered arm’s length methods for covert autopsies. In fact, this activity appears to have initiated the 2 doctors’ long professional relationship.

19961254

– Sins of our fathers: two of The Four Doctors and their roles in the development of techniques to permit covert autopsies.

Prognostic significance of serum uric acid in patients admitted to the Department of Medicine.

UlricheDmond — Tue, 10 Aug 2010 20:36:25 +0000

Am J Med Sci. 2010 Jan;339(1):15-21

BACKGROUND: Hyperuricemia has been linked to proatherogenic processes, including increased oxidative stress and leukocyte activation, and was shown to predict adverse prognosis in heart failure, renal failure, and hypertension. Recently, serum uric acid (SUA) was shown to be an independent predictor of long-term mortality in patients with cardiovascular diseases. However, the prognostic significance of SUA for the short-term outcome of admitted medical patients is unknown. METHODS: Initial SUA, together with epidemiological, clinical, and laboratory data, was analyzed for a prospective cohort of 650 consecutive adult patients admitted to the department of internal medicine during a 3-month period. RESULTS: The mean, median, and range of SUA at admission were 6.1 +/- 2.7, 5.6, and 1.2 to 24 mg/dL, respectively. Increased SUA was significantly correlated with age, gender, comorbidities (coronary heart disease, heart failure, hypertension, diabetes, renal failure, and gout), use of diuretics, and current admission for cardiovascular diseases but not with current diagnosis of infection, malignancy, or inflammatory diseases, nor with C-reactive protein. However, SUA significantly correlated with mortality (7.7 versus 6 mg/L, P < 0.025) and was an independent predictor of mortality in a multivariate regression analysis (odds ratio: 1.11; confidence interval: 1.003-1.218; P = 0.04), with a significant difference in mortality between normal SUA (<6 mg/dL) with 5% mortality and high SUA (>12 mg/dL) with 27% mortality. CONCLUSIONS: Initial SUA is an independent predictor of mortality in admitted medical patients. Whether significant asymptomatic hyperuricemia should be treated remains to be determined in further studies.

19996731

– Prognostic significance of serum uric acid in patients admitted to the Department of Medicine.

Low influenza vaccination rate among patients with systemic sclerosis.

drkhanktk — Tue, 10 Aug 2010 17:25:59 +0000

Rheumatology (Oxford). 2010 Mar;49(3):600-6

OBJECTIVE: To evaluate the influenza vaccination rate and factors influencing it in patients with SSc. METHODS: A total of 177 SSc patients fulfilling the ACR and/or LeRoy and Medsger criteria were evaluated during annual meetings of the French patient association in 2006 (n = 71) and 2007 (n = 70) or during hospitalization in the Internal Medicine Department of Cochin Hospital in 2007 (n = 36). Information on influenza vaccination was collected by a standardized form. RESULTS: Mean (s.d.) age and disease duration were 58.7 (12.6) and 10.5 (9.5) years, respectively. Overall, 69 (39%) patients received an influenza vaccination during the previous year. Among the 108 patients who were not vaccinated, 78 (72.2%) presented at least one indication for vaccination. The most frequent reasons for non-vaccination were absence of physician recommendation and fear of side effects. Patients who were and were not vaccinated did not differ in anxiety, depression, global disability or quality of life. Vaccination rate was significantly higher (59%) for patients who remembered receiving a letter from the French National Health Insurance Agency encouraging vaccination than among those who did not (26%, P = 0.0001). Multivariate analysis revealed the year of the last vaccination and age as two independent parameters associated with vaccination. CONCLUSIONS: Influenza vaccination coverage is low in SSc patients. Lack of information and fear of adverse effects are the most common reasons for non-vaccination. Efforts are needed to increase the influenza vaccination coverage in this population.

20040532

– Low influenza vaccination rate among patients with systemic sclerosis.

Medical students’ professionalism narratives: a window on the informal and hidden curriculum.

DRAMAL — Tue, 10 Aug 2010 13:19:00 +0000

Acad Med. 2010 Jan;85(1):124-33

PURPOSE: The aim of this study was to use medical students’ critical incident narratives to deepen understanding of the informal and hidden curricula. METHOD: The authors conducted a thematic analysis of 272 stories of events recorded by 135 third-year medical students that “taught them something about professionalism and professional values.” Students wrote these narratives in a “professionalism journal” during their internal medicine clerkships at Indiana University School of Medicine, June through November 2007. RESULTS: The majority of students’ recorded experiences involved witnessing positive embodiment of professional values, rather than breaches. Attending physicians and residents were the central figures in the incidents. Analyses revealed two main thematic categories. The first focused on medical-clinical interactions, especially on persons who were role models interacting with patients, families, coworkers, and colleagues. The second focused on events in the teaching-and-learning environment, particularly on students’ experiences as learners in the clinical setting. CONCLUSIONS: The findings strongly suggest that students’ reflective narratives are a rich source of information about the elements of both the informal and hidden curricula, in which medical students learn to become physicians. Experiences with both positive and negative behaviors shaped the students’ perceptions of the profession and its values. In particular, interactions that manifest respect and other qualities of good communication with patients, families, and colleagues taught powerfully.

20042838

– Medical students’ professionalism narratives: a window on the informal and hidden curriculum.