Journal of General Internal Medicine最新文献

Background: The number of graduates from accelerated 3-year MD (A3YP) programs has increased over the past decade. Previous work showed that A3YP graduates perform comparably to non-accelerated (4-year) graduates from the same medical schools on mid-year and end-year Accreditation Council of Graduate Medical Education (ACGME) harmonized milestones. In shifting to the residency program perspective, it remains unclear how the performance of A3YP graduates compares to non-accelerated graduates including traditional 4-year, international, and osteopathic medical school graduates.

Objective: To compare the intern performance of A3YP graduates compared with non-accelerated graduates using mid-year and end-year ACGME milestones in Internal Medicine (IM) residency programs.

Design: The study employed a retrospective cohort design, hypothesizing that graduates from A3YPs were comparable to non-accelerated graduates in the same program.

Participants: 108 interns who graduated from A3YP were compared to 3,542 interns from non-accelerated programs at the same 34 IM residency programs.

Main measures: Descriptive statistics were provided for ACGME milestone performance. Cross-classified random-effects regression was used to account for residency program effects and estimate group differences.

Key results: After controlling for residency programs, the milestone ratings of A3YP graduates were higher in all competency domains at mid-year except practice-based learning and improvement (PBLI) at .04 (P = .089) (coefficients ranged from 0.08 for medical knowledge (MK) (P < .001) to 0.23 in professionalism (PROF) (P < .001)). These differences persisted at the end-year period (coefficients ranged from 0.05 in PBLI (P = .039) to 0.17 in PROF (P < .001)) except MK at .02 (P = .656). Patient care differences were 0.15 (P < .001) at mid- and 0.14 (P = .005) at end-year.

Conclusions: This study contributes to the literature demonstrating that interns graduating from A3YP are at least equivalent in terms of milestone assessment and possibly better in the competencies of PC and PROF than their non-accelerated counterparts.

Background: Chronic benzodiazepine use remains common among older adults, despite limited evidence of benefit and substantial risks. Evidence-based approaches that are feasible in primary care settings are needed to support benzodiazepine deprescribing for older adults.

Objectives: To determine the feasibility, acceptability, and exploratory patient-centered outcomes of a team-based approach to benzodiazepine deprescribing in primary care.

Design: Single-arm prospective clinical trial.

Participants: Adults age 65 and older prescribed long-term benzodiazepines recruited from four primary care clinics in an academic health system.

Interventions: Ten-week virtual primary care embedded program consisting of pharmacist-guided tapering and three psychologist-led mindfulness-informed cognitive behavioral therapy (CBT) sessions.

Main measures: Feasibility outcomes included enrollment, retention, and intervention adherence. Acceptability outcomes were collected through qualitative interviews. Exploratory efficacy outcomes included change in mean daily benzodiazepine dose, change in PROMIS anxiety score, and change in PROMIS sleep disturbance score.

Key results: Seventeen participants (mean age 72, 29% female, mean 17 years of benzodiazepine use) enrolled and completed all six study visits (100% fidelity). Participants' mean (SD) baseline daily benzodiazepine dose was 9.0 (8.6) diazepam milligram equivalents. At completion, participants had a mean 60.5 percentage point reduction in benzodiazepine use (95% CI -69.9% to -51.3%; p < .001), with all participants reducing their dose and 3 stopping completely. Mean PROMIS anxiety scores decreased from 55.2 to 51.8 (-3.5 point change, 95% CI -6.5 to -0.7; p = 0.02) and mean PROMIS sleep disturbance scores were unchanged at week 10 (-1.7 point change, 95% CI -4.9 to 1.5; p = 0.30). Qualitative interviews indicated the program may target increased self-efficacy to reduce benzodiazepines and endorsed utility from both pharmacist- and psychologist-led components.

Conclusions: A primary care embedded virtual intervention involving pharmacist-led tapering and mindfulness-informed CBT sessions to support benzodiazepine deprescribing is feasible, acceptable, may reduce older adults' benzodiazepine use, and warrants multi-site testing.

Clinicaltrials:

Gov trial number: NCT06119308.

Clinicaltrials:

Gov registration date: 10/27/2023.

Background: Point-of-care ultrasound (POCUS) is an important clinical skill in internal medicine (IM) and requires robust methods to assess competency.

Objective: The objectives of this research were to develop an entrustable professional activity (EPA) framework and instrument for POCUS competency assessment.

Design: An expert panel of seven IM POCUS educators guided the development of the EPA framework and assessment instrument. We evaluated the EPA framework and assessment instrument for validity, reliability, and feasibility of use for IM learners.

Participants: Trained raters assessed POCUS competency in IM learners at the bedside. We performed a total of 604 assessments on 48 unique learners across three US academic sites.

Main measures: Authors analyzed the data using correlation, generalizability (G-) study, and decision (D-) study statistics to generate evidence for the validity, reliability, and feasibility of the instrument.

Key results: The authors developed the EPA, "Assessing the acutely ill patient using POCUS," using a structured process. The study team performed assessments on the ten clinical syndromes identified by the expert panel and single organ practice studies. The variance component attributed to learners ranged from 27.7 to 31.4%. The estimated number of observations needed to obtain a reliability index of 0.8 ranged from 11 for clinical syndromes to nine for single organ practice studies. The time to complete the supervisory scale and provide feedback to learners was 4.65 min.

Conclusions: The authors developed an EPA and EPA-based assessment instrument for workplace-based assessments of IM POCUS learners. The analysis generated validity, reliability, and feasibility evidence that supports competency assessment of IM learners using POCUS at the bedside. Authors anticipate that this will have high utility for IM programs seeking to assess POCUS learner competence.

Background: Trauma-informed care (TIC) acknowledges the events, experiences, and effects of trauma. Research shows that TIC may improve patient trust in providers, yet remains poorly integrated into graduate medical education.

Objective: We conducted a needs assessment of internal medicine (IM) residents to (1) quantify knowledge, attitudes, perceived competence, practices, and barriers; (2) explore experiences with TIC; (3) identify factors shaping TIC implementation; and (4) determine unmet needs.

Design: We conducted a multi-phase study involving a survey and a focus group. Survey data analysis included descriptive statistics, composite scores, Spearman's correlations, and ANOVAs. Qualitative data analysis used an inductive and deductive thematic approach.

Participants: We surveyed 69 IM residents at a large urban academic medical center (56% response rate). Ten residents participated in a focus group.

Main measures: The Trauma-Informed Care Provider Survey assessed TIC knowledge, opinions, perceived competence, barriers, and practices. The focus group explored experiences with trauma disclosures, barriers, facilitators, and training needs.

Key results: Residents demonstrated moderate knowledge (74%) and favorable opinions (80%) of TIC, but low self-rated competence (42%). Time constraints and lack of training were the most common barriers. Residents performed fewer than half of TIC practices on average; self-rated competence (ρ = 0.42, p = 0.0003) and attitudes (ρ = 0.33, p = 0.005) were positively associated, while lack of training predicted lower practice (F = 5.81, p = 0.005). Focus group themes include (1) residents understand TIC's impact; (2) barriers hinder trauma screening; (3) residents feel unprepared to address trauma disclosures; (4) continuity of care is crucial for TIC; and (5) residents desire improved training.

Conclusions: IM residents recognize TIC's role in strengthening therapeutic relationships, yet multiple factors constrain consistent implementation. Addressing these barriers through improved training, clinical frameworks, and organizational support is essential to improving residents' capacity to deliver patient-centered, trust-building care.