Journal of General Internal Medicine最新文献

Background: Nearly 39% of Internal Medicine (IM) residents in American training programs are international medical graduates (IMGs), whose prior training in women's health is variable. There is a paucity of data about women's health training programs that train IMG IM residents in pelvic examinations/Pap smears.

Aim: To train IMG IM residents to competently perform pelvic examinations/Pap smears.

Setting: Montefiore Wakefield IM residency clinic, Bronx NY.

Participants: IMG categorical IM residents.

Program description: In 2015, we established the Women's Health Clinic (WHC) to train residents in pelvic examinations/Pap smears. The educational model includes one hour of didactics followed by trainees seeing up to four patients, supervised by WHC faculty in 1:2 preceptor to resident ratio.

Program evaluation: We evaluated the impact of WHC on IMG residents' self-reported competence in performing pelvic examinations/Pap smears by using McNemar's test to compare self-reported competence in pelvic examinations and Pap smears before and after WHC participation.

Discussion: WHC improved self-reported competence among IMG residents by utilizing standardized didactics reinforced through immediate and repeated patient interactions. It is an educational model that could be reproduced by other IM programs to improve training for IMG residents.

Background: Outpatient procedure training in internal medicine residency has not been shown to produce high-level outcomes such as improved volume and quality of procedures performed on real patients.

Objective: The objective of this study was to improve the volume and quality of outpatient procedures performed by internal medicine residents by administering a simulation-based curricular intervention.

Design: Validated teaching materials and local faculty input were used to design a simulation curriculum for teaching the knee joint injection/aspiration and skin abscess incision and drainage. A prospective curricular intervention was implemented for a single cohort of internal medicine interns.

Participants: All internal medicine interns at Beth Israel Deaconess Medical Center during the 2021-2022 academic year were allowed to participate in this educational intervention with no exclusion criteria.

Interventions: Forty-seven interns received 30 min of simulation education for each procedure.

Main measures: Primary outcomes included total number of procedures performed in clinic, volume of procedures performed by residents, percentage of total procedures performed by residents, and procedural success and complication rates before and after the curricular intervention.

Key results: At 1-year post-curriculum, the total number of procedures in clinic increased by 25%. Procedures by residents increased by 110%, with joint injections/aspirations increasing by 317% and skin abscess incision and drainage increasing by 200%. Complication rates reduced from 25 to 0%, and 100% of resident-performed procedures post-curriculum were completed successfully.

Conclusion: These findings demonstrate that a novel outpatient procedures simulation curriculum can positively impact higher-level clinical practice outcomes for internal medicine residents.

Background: Emerging evidence shows the lasting impact of SARS-CoV-2 infection on health care use and needs. Policy-makers require data on population-level service use to understand patient needs and health system impacts following hospitalization for COVID-19.

Objective: To compare health service use within 12 months following hospitalization for COVID-19 among people with and without pre-existing disabilities, and to determine the extent to which such use is related to disability and other risk factors.

Design: Population-based cohort study, Ontario, Canada.

Participants: Adults with and without disabilities hospitalized for COVID-19, 01/25/2020-02/28/2022.

Main measures: We used Poisson regression to model adjusted rate ratios (aRR) of ambulatory care visits, diagnostic testing, emergency department (ED) visits, hospital admissions, and palliative care visits within 1-year post-discharge, comparing patients with and without disabilities. Models were adjusted sequentially for sociodemographic factors, comorbidities, and prior health service use. The importance of each set of covariates in its ability to explain observed associations was determined by calculating relative changes in disability parameter coefficients after each sequential risk-adjustment.

Key results: The cohort included 25,320 patients with disabilities and 15,953 without. In the year after hospitalization for COVID-19, people with disabilities had higher rates of ambulatory care visits, diagnostic tests, ED visits, hospital admissions, and palliative care visits. A significant proportion of these associations was explained by sociodemographic factors, comorbidities, and prior health service use. However, adjusted relative rates associated with disability remained elevated, even after adjustment, for ambulatory care visits (aRR 1.09, 95% CI 1.08, 1.10), diagnostic tests (aRR 1.14, 95% CI 1.12, 1.16), ED visits (aRR 1.25, 95% CI 1.21, 1.29), and hospital admissions (aRR 1.21, 95% CI 1.16, 1.29).

Conclusions: These findings support the need to develop and evaluate models of care for the post-COVID-19 condition that address the needs of people with disabilities.

Background: The surge in drug overdose fatalities in the USA, particularly from synthetic opioids, highlights the need for effective interventions. Medication for opioid use disorder (MOUD) shows promise in treatment, but disparities in access persist.

Objective: This study was designed to investigate disparities in MOUD receipt in the outpatient settings for patients diagnosed with opioid use disorder (OUD).

Design: Observational cohort study.

Participants: The nationwide electronic medical record (EMR) from the IQVIA Ambulatory EMR-US database was utilized, comprising 32,929 patients diagnosed with OUD between January 2014 and September 2022. The analysis focused on Black and White populations, the majority of whom have commercial insurance.

Main measures: Access to FDA-approved medications for OUD treatment within 180 days after index OUD diagnosis across the USA were measured by medication receipt rate, average days of medication supply, and retention rate.

Key result: Notable racial disparities were identified in MOUD receipt, with Black population having significantly lower rates than White. State-level disparities were also evident, with 25 out of 41 states showing lower MOUD receipt rates among Black than in White population. Quarterly trends in receipt rates showed lower rates among Black population in most years. Additionally, the average days of supply for MOUD prescriptions were lower for Black population across most states.

Conclusions: Significant racial and state-level disparities exist in MOUD receipt among patients in outpatient settings. The study underscores the need for targeted interventions to address these inequities in MOUD access.

Background: Educational opportunities in federally qualified health centers (FQHCs) are important to develop our physician workforce at FQHCs but are rare in internal medicine (IM) training programs.

Aim: To describe the process, feasibility, and early outcomes of an IM resident continuity clinic at a FQHC.

Setting and participants: The IM residency is a large academic program. The FQHC serves over 40,000 patients per year, of which the vast majority are Hispanic/Latino(a) (88%), speak Spanish (69%), live below 100% of the federal poverty level (80%), and rely on Medicaid (60%) or lack insurance (22%).

Program description: The continuity clinic was launched in July 2022 with six residents.

Program evaluation: After 18 months, patient panel grew to 680 patients. Patients are young (age 18-39 = 55%), uninsured (54%), below 100% federal poverty line (82%), and Spanish speaking (84%). Residents' continuity was 53.3% with a no-show and same day cancel rate of 26.6%. Residents saw an average of 15.76 patients per day while the attending's non-resident clinic saw 15.44 per day (P = 0.31). Average resident satisfaction was 96%.

Discussion: A collaborative IM resident continuity clinic at a FQHC is feasible, highly satisfying for residents, and cost-neutral for the FQHC.

Long COVID continues to impose a significant burden on COVID-19 survivors, presenting with diverse symptoms and clinical uncertainty. This review synthesized evidence from 97 studies, including 26 randomized controlled trials and 15 non-randomized comparative studies, which explored the effectiveness, comparative effectiveness, and potential risks of proposed interventions for managing common long COVID symptoms: fatigue, neurocognitive symptoms, anxiety, depression, and sleep issues. Our comprehensive analysis, encompassing English-language articles, gray literature, and feedback from 14 Key Informants (i.e., patients, caregivers, clinicians, payors, and researchers), reveals a persistently weak body of evidence, characterized by high imprecision and considerable uncertainty regarding the benefits and harms of the interventions. The studies examined a wide array of treatment categories, including multi-component rehabilitation, supplements, complementary treatments, prescription medications, and the COVID-19 vaccine. Key informants emphasized the critical need for establishing robust diagnostic criteria and utilizing functional outcomes while also highlighting significant barriers to care, including dismissive attitudes from healthcare providers, inadequate insurance coverage, and restricted access to specialty care. Given the evolving definitions of long COVID and the variable mechanisms of its management, our findings underscore the pressing need for further rigorous research to refine and validate effective treatment protocols. Until more definitive evidence is available, both clinicians and patients face substantial uncertainty in treatment decisions, with many resorting to self-treatment using costly and potentially ineffective options.

Background: Discussion of patients' treatment preferences for cardiopulmonary resuscitation is routine practice for adults admitted to hospital. Ideally, these "code status discussions" provide an opportunity to ensure patients receive care that is concordant with their values and priorities. The degree of physician recommendations that occur during these discussions is unknown.

Objective: This study sought to characterize physician treatment recommendations during code status discussions in older hospitalized medical patients.

Design, participants, and approach: We conducted a retrospective cohort study of 200 patients, 75 years or older, admitted to the general medical service in one of four hospitals in Toronto, Canada. Medical records were reviewed to abstract documentation by physicians that referenced a code status discussion. We used qualitative discourse analysis to characterize the nature of these documented code status discussions, with a focus on physician treatment recommendations.

Key results: The majority of recommendations involved de-escalation or avoidance of invasive treatments. The strength of recommendations ranged from a passive physician role of providing advice, where the ultimate decision was deferred to the patient/surrogate, to an active role of explicitly not offering interventions, which involved informed non-dissent. Physicians often documented a brief rationale for specific recommendations, either focused on their estimation that the patient had a poor prognosis or their interpretation of the patient's goals and priorities. However, there was a paucity of documentation supporting how physicians determined these interpretations. Some physicians used the term "quality of life" to imply that invasive life-sustaining treatments were unlikely to benefit the patient.

Conclusions: We uncovered a range of physician practices in providing recommendations during code status discussions. While the strength and rationale varied, physicians often failed to document patients' goals and priorities when making treatment recommendations. These findings highlight an opportunity to improve how physicians formulate, communicate, and document their recommendations around code status.