Journal of General Internal Medicine最新文献

Background: The internal medicine acting internship (AI rotation) is a capstone rotation for demonstrating residency readiness, yet grading inflation and rotation variability limit transparent assessment and communication of student skills to residency programs. The Association of American Medical Colleges' Core Entrustable Professional Activities for Entering Residency (EPAs) offer a shared assessment framework, but their implementation in the AI rotation is incompletely characterized nationally.

Objective: To describe national usage of EPAs in the AI rotation, identify which EPAs are emphasized, and examine associations between EPA use and assessment/grading practices.

Design: Cross-sectional electronic survey of AI rotation course directors (January 2023) with selected comparison to prior medicine core clerkship benchmarks.

Participants: Course directors at LCME-accredited US schools (71/140; response rate 50.7%).

Main measures: We evaluated the presence of EPA-focused teaching and assessment in the AI rotation, as well as the correlation of EPA incorporation with institutional practices surrounding student assessment and evaluation.

Key results: Most institutions (57%) reported EPA incorporation into the AI rotation. Higher complexity EPAs such as EPA 4 (entering/discussing orders), EPA 8 (patient handover), and EPA 10 (urgent/emergent care) were more frequently assessed in the AI rotation than in the core clerkship, although assessment rates for these EPAs remained below 50%. EPA incorporation was correlated with the use of required workplace-based assessments and competency-based rubrics but showed no association with the use of narrative comments in evaluation (p = 0.76), institutional grading structure (p = 0.57), use of grading committees (p = 0.41), perceived grade inflation (p = 0.47), or inclusion of grade distributions in the MSPE (p = 0.23). Reported gaps included limited instruction and formative assessment for EPA 8 and EPA 10.

Conclusion: Despite growing adoption, EPA incorporation during the AI rotation remains heterogeneous. Greater intentional incorporation of EPAs to align with acting intern responsibilities represents an opportunity to improve the UME-GME transition.

Background: Telehealth use has expanded in the primary care safety net, but disparities in telehealth persist, known as the "digital divide." Digital navigation, where patients receive support to enable telehealth access, is a promising strategy, but little is known about its prevalence or implementation.

Objective: To characterize the current digital navigation landscape of California safety-net primary care clinics and provide recommendations for digital navigation implementation strategies.

Design: Mixed-methods study, including survey and interview components.

Participants: Participants working in California primary care safety-net settings, including individuals with roles in clinical care, administration, information technology, and patient support services.

Approach: We developed a survey and interview guide using the Consolidated Framework for Implementation Research (CFIR). We calculated summary statistics for survey results. We conducted in-depth semi-structured interviews with a subsample of survey participants via video and analyzed transcripts using a mixed inductive-deductive approach to identify features of digital navigation implementation and themes relevant to CFIR.

Key results: Of 50 survey participants representing 35 practices, 80% reported their health system had implemented or attempted to implement digital navigation in some form. Qualitative analysis of 16 interviews identified five distinct digital navigation models: (1) integrated staff role, (2) information technology support, (3) dedicated digital navigator, (4) volunteer/external partners, and (5) rural access hub. Challenges to digital navigation implementation included unmet need for access to digital devices and broadband, lack of staff buy-in and digital literacy, and the lack of data-driven screening and referral programs.

Conclusions: The majority of primary care safety-net sites had some form of digital navigation, ranging from a dedicated navigator to community partnerships. Equitable digital access, a key health-related social need, can be provided through diverse digital navigation models. Ongoing advocacy for device and broadband access and reimbursement mechanisms will be critical for digital navigation implementation and sustainability.

Introduction: Self-reported healthcare quality often reflects older adults' health experiences and has been linked to improved clinical outcomes. However, limited evidence exists on the relationship between an area's social vulnerability level and patient-reported healthcare quality scores and access to care and prescribed medicine. This study examined the relationship between social vulnerability and patient-reported healthcare quality measures among Medicare beneficiaries, focusing on overall healthcare quality, ease of accessing needed care and medications, and the physician-patient relationship.

Methods: The study conducted a cross-sectional analysis using pooled data from the 2018, 2019, 2021, and 2022 Consumer Assessment of Healthcare Providers and Systems surveys, linked with the Social Vulnerability Index (SVI) using beneficiaries' county of residence.

Results: We found that healthcare quality scores were consistently lower in areas with higher social vulnerability. Among Medicare Fee-for-Service beneficiaries, individuals living in higher SVI areas, i.e., areas with more vulnerability, had significantly lower odds of reporting favorable healthcare ratings, ease of accessing care and treatments, and consistent positive experiences with their healthcare providers. They were also less likely to report ease of obtaining prescribed medications. Similar patterns were observed among Medicare Advantage beneficiaries, with those in more vulnerable areas reporting lower odds of high healthcare ratings, timely access to care, and prescription fulfillment.

Conclusions: These findings underscore disparities in self-reported healthcare quality among Medicare beneficiaries living in socially vulnerable areas.

Background: Outpatient faculty face persistent workplace teaching challenges such as high patient volume and limited visit time. Traditional faculty development rarely provides individualized strategies for improving teaching in the clinical workplace.

Aim: To implement an individualized faculty development program that uses coaching to help faculty identify an outpatient teaching challenge and develop a feasible solution.

Setting: A large academic medical center in Boston, Massachusetts.

Participants: Twenty-four outpatient teaching faculty from six departments completed the program between September 2021 and May 2022.

Program description: Faculty participated in a 60-min individualized coaching session. Participants reflected on their outpatient teaching and clinic workflow, identified a priority teaching challenge, and designed a small, feasible solution (a "micro-innovation"). The program emphasized faculty-created workplace-specific solutions.

Program evaluation: Evaluation included a 6-month survey (75% response, 18/24), a 9-month focus group, and a 3-year follow-up survey (75% response, 15/20). At 6 months, all respondents (18/18) reported implementing their micro-innovation and perceived a positive impact on student clinics. At 3 years, 53% of respondents (8/15) continued using their micro-innovation. Faculty valued the individualized format for its relevance to their clinic context.

Discussion: An individualized coaching program can support outpatient educators in addressing teaching challenges through small, sustainable changes.

Background: SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1RA) reduce cardiovascular and metabolic risks in type-2 diabetes, cardiovascular disease, and obesity, yet social determinants of health (SDOH) may influence access to these therapies. We conducted a systematic review and meta-analysis to assess whether SDOH-socioeconomic status (SES), insurance status, education, geography, neighborhood deprivation-and demographic characteristics-race and sex-are associated with differential utilization of SGLT2i or GLP-1RA.

Methods: Six databases (Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar) were searched through February 2025. Retrospective and cross-sectional studies reporting association between at least one SDOH and prescription of SGLT2i and/or GLP-1RA were included. The primary outcome was the adjusted odds of utilization of SGLT2i, GLP-1RA, or both drugs by SDOH categories. Meta-analyses were conducted separately for SGLT2i and GLP-1RA using random-effects models. Risk of bias was assessed using ROBINS-I.

Results: Twenty-six studies (> 14.6 million patients) were included. Low-SES patients had reduced odds of utilization (aOR 0.73; 95% CI 0.61-0.76). Medicaid (aOR 0.70; 95% CI 0.55-0.89), Medicare (0.68; 0.60-0.78), and Medicare Advantage (aOR 0.41; 95% CI 0.30-0.57) patients had lower odds than privately insured patients. Lower educational attainment (aOR 0.70; 95% CI 0.53-0.93) and rurality (aOR 0.91; 95% CI 0.87-0.95) were associated with reduced utilization. Patients in high-deprivation neighborhoods (aOR 0.80; 95% CI 0.69-0.93) had lower odds of GLP-1RA utilization. Women had lower odds of SGLT2i utilization (aOR 0.89; 95% CI 0.82-0.95), but greater odds of GLP-1RA (aOR 1.33, 1.23-1.43). Black (aOR 0.80; 95% CI 0.79-0.82) patients had reduced utilization of both drugs, while Hispanic (aOR 0.81; 95% CI 0.69-0.96), and Asian (aOR 0.49; 95% CI 0.41-0.58) patients had reduced odds of GLP-1RA.

Discussion: Disparities in SGLT2i and GLP-1RA utilization span SES, insurance, education, geography, neighborhood deprivation, race, and sex, potentially limiting population-level benefits and warranting interventions to improve access.