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Guiding while growing: The dual role of early career mentors 一边指导,一边成长:早期职业导师的双重角色。
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-26 DOI: 10.1002/jhm.13447
Samir S. Shah MD, MSCE, MHM

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引用次数: 0
To give or not give corticosteroids; that is the question 给还是不给皮质类固醇,这是一个问题。
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-26 DOI: 10.1002/jhm.13444
Claire E. Ciarkowski MD, MSc, Valerie M. Vaughn MD, MSc

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引用次数: 0
Point/counterpoint: Should we stop writing and reading letters of recommendation for residency selection? 观点/反观点:我们是否应该停止撰写和阅读住院医师遴选推荐信?
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-25 DOI: 10.1002/jhm.13440
Matthew Kelleher MD, MEd, Benjamin Kinnear MD, MEd, Danielle E. Weber MD, MEd, Michelle I. Knopp MD, Daniel Schumacher MD, MEd, PhD, Eric Warm MD
<p>As hospitalists involved in internal medicine and pediatrics residency selection, each of us have read letters of recommendation (LORs) like the one in Box 1. As part of the process of selecting candidates for residency training, LORs hold significant implications for both applicants and programs and are tainted by deep-rooted flaws. These defects continue largely because of our collective failure to confront and address the glaring issues within the process. At best, LORs offer marginal benefit in selecting residents; at worst, they become overt channels for bias, inequity, inequality, and arbitrariness, often devolving into exercises of inanity, untruthfulness, obfuscation, and even propaganda. As such, they decrease the integrity and purpose of the residency selection process.</p><p>For example, gender bias in residency application LORs has been noted for Radiology, Orthopedic Surgery, Female Pelvic Medicine and Reconstructive Surgery, Cardiovascular Surgery, Emergency Medicine, Pediatrics, Anesthesiology, Radiation Oncology, Ophthalmology, Internal Medicine, and General Surgery, among others.<span><sup>1</sup></span> Women often find themselves described in these letters with communal traits, such as <i>helpful</i> and <i>caring</i>.<span><sup>2</sup></span> In contrast, men are more likely to be portrayed with agentic traits, including <i>leader</i> and <i>taking initiative</i>. LORs for women also tend to focus more on personal appearance (such as the misogynistic but real-life example about Ms. J. Smiths' figure in the above letter) and personal life. They also contain more doubt raisers (e.g., “it appears her health and personal life are stable”<span><sup>2</sup></span>), including hesitancy from the recommender, use of faint praise, potentially negative comments, unexplained comments, and irrelevancies.<span><sup>2</sup></span></p><p>Ethnic and racial biases are also prominent in residency LORs, where differences in language can subtly influence readers' perceptions of candidates.<span><sup>3</sup></span> As with gender, agentic and communal terms are used differently based on a candidate's ethnicity or race. Even apart from bias, LORs compound inequity. The process of obtaining LORs favors already advantaged groups who are more likely to have access to the most influential letter writers. Students often spend an inordinate amount of time searching for the “right” letter writer, often choosing those with titles or positions of power over those who know them best. LORs also tend to focus only on positive aspects of applicants, neglecting the comprehensive portrayal of a candidate's journey, struggles, and growth. This one-sided representation undermines the principle of holistic review (a balanced assessment of an applicant's experiences, attributes, and academic metrics<span><sup>4</sup></span>) by not fully acknowledging the resilience and perseverance shown in overcoming challenges, especially among disadvantaged applicants. Even wo
这不正是《要点》作者所要求的有效性证据吗?事实上,在有效性证据的基础上,一项决策研究表明,通过阅读四份 SLORs,可以可靠地区分不同的申请人。30 这一点至关重要,因为住院医师培训项目需要完成对所有申请者的最终排名。目前还没有证据表明任何信息都能预测住院医师培训的成功与否,但利用 SLORs 似乎是改进住院医师培训选择、减少偏差并为项目提供其所需数据的一种方法。然而,一项又一项的研究表明,在整个住院医师遴选过程中,没有任何一项数据似乎可以预测未来的表现。14, 31 LORs 一直被认为是有价值的,具有促进公平的潜力,但同时又与住院医师遴选过程中的其他指标一样存在缺陷。取消口头推荐信破坏了整体审查的理念;我们认为,从挂毯(即住院医师遴选)中抽出一根线(即口头推荐信)有可能弊大于利。选择先删除 LOR 并不是武断的。相反,这是一个战略性举措,旨在解决住院医师遴选过程中一个典型的正常化偏差案例。正常化偏差是指偏差做法在一个组织内逐渐被接受为正常的现象,往往会导致道德和绩效标准的降低32 。就住院医师遴选而言,LORs 就是这种偏差的一个突出例子。尽管这些做法存在固有的缺陷,而且缺乏公平性,但它们已成为整个过程的常规部分。结束常态化偏差的第一步是承认并使问题显性化。取消 LOR 可以立即做到这一点。一旦迈出了这一步,重点就可以转移到住院医师申请和遴选程序的其他方面。我们的目标是建立一个公平、公正、准确、有效和有价值的系统,不仅要纠正单一方面的缺陷,还要挑战长期以来已被接受的正常化偏差模式。这种方法不仅仅是要消除单一的问题因素,而是要站在更高的诚信和有效性的立场上。CBME 的叙述性评估与广泛的利益相关者共享,包括学员、能力委员会、专业医师和院校,确保了透明度和集体监督。相比之下,LORs 的可见度仍然有限,只有作者和少数评审者可以查阅。就其目前的形式而言,它们是对 CBME 的诅咒:基于有限数据和低质量有效性证据的孤立的高风险评估。因此,所有的偏见、不准确和不公平都会加剧。医学教育者仍在学习如何利用 CBME 来明确界定并帮助医学生达到毕业的基本标准。33 一旦毕业生达到了这些标准,医学院就可以在具体的有效性证据支持下,自信地宣称他们已经做好了实习的准备。这样就不再需要LOR了。我们不需要为此等待。现在,LORs 正在造成危害,我们应该停止撰写和阅读用于住院医师遴选的 LORs。
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引用次数: 0
The next frontier of continuous pulse oximetry de-implementation: Overcoming competing priorities 连续脉搏血氧仪去实施化的下一个前沿:克服相互竞争的优先事项。
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-22 DOI: 10.1002/jhm.13441
Lauren M. McDaniel MD, Amber Kurtz MD, Mersine A. Bryan MD, MPH
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引用次数: 0
Considerations for adult transgender patients in the hospital setting 医院环境中成年变性患者的注意事项。
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-22 DOI: 10.1002/jhm.13439
Keshav Khanijow MD, Paula M. Neira JD, MSN, Carl G. Streed Jr., MD, MPH
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引用次数: 0
Where and what separates rural from urban hospital closures? 农村与城市医院关闭的区别在哪里?
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-19 DOI: 10.1002/jhm.13438
Sara D. Turbow MD, MPH, Jennifer Lom MD, Mohammed K. Ali MD, MSc, MBA

Despite the recent closure of several high-profile metropolitan hospitals, investigations into risk factors for metropolitan hospital closures have been limited. The goal of this study was to describe metropolitan hospitals that closed and compare them to metropolitan hospitals that remain open and micropolitan and rural hospitals that closed using American Hospital Association Annual Survey Data from 2010 to 2021. We independently verified hospitals reported as closed in the Annual Survey and examined the hospital characteristics associated with closure using bivariate statistics and logistic regression. We found that metropolitan hospitals that closed (n = 142) were more likely to be for-profit (66.9% vs. 29.7%, p < .0001; adjusted odds ratio [AOR]: 3.05, 95% confidence interval [CI]: 1.93, 4.81) and to come from a state that did not expand Medicaid (45.1% vs. 29.4%, p < .0001; AOR: 1.66, 95% CI: 1.16, 2.38). Policies tailored to metropolitan hospitals should be developed to identify at-risk hospitals and mitigate the effect of closures on patients, clinicians, and other stakeholders.

尽管最近有几家备受瞩目的大都市医院关闭,但对大都市医院关闭风险因素的调查却很有限。本研究的目的是利用美国医院协会 2010 年至 2021 年的年度调查数据,对关闭的大都市医院进行描述,并将其与仍在营业的大都市医院以及关闭的微型和乡村医院进行比较。我们对年度调查中报告为关闭的医院进行了独立核实,并使用二元统计和逻辑回归检验了与关闭相关的医院特征。我们发现,关闭的大都市医院(n = 142)更有可能是营利性医院(66.9% vs. 29.7%,p<0.05)。
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引用次数: 0
Clinical progress note: Anti-amyloid monoclonal antibodies 临床进展记录:抗淀粉样蛋白单克隆抗体。
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-18 DOI: 10.1002/jhm.13434
Molly J. Horstman MD, MS, Shaun A. Howell ALM, Sharyl R. Martini MD, PhD
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引用次数: 0
Medicaid expansion and 30-day hospital readmissions: A nationwide study 医疗补助扩展与 30 天再入院:一项全国性研究。
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-18 DOI: 10.1002/jhm.13427
Sami Tahhan MD, Cynthia Avila MBS, Chloe Carr MD, Rehan Qayyum MD, MHS

In 2010, Congress enacted the Patient Protection and Affordable Care Act (ACA) to enhance health insurance affordability via subsidies and Medicaid expansion (ME). However, not all states adopted ME. We examined national hospital readmissions from 2005 to 2019 to investigate readmission reduction trends based on state ME status. The states were divided into those that expanded Medicaid in 2014 (ME-States) and those that did not until 2019 (non-ME States). Using a difference-in-difference framework and adjusting for hospital and population characteristics, we assessed the relationship between ME and 30-day readmissions following pneumonia, heart failure (HF), and acute myocardial infarction (AMI) hospitalizations. Both before and after the expansion, ME-States had higher mean readmission rates than non-ME-States. After ME, hospitals in ME-States exhibited larger reductions in readmission rates compared to non-ACA States: pneumonia (−0.12%; 95% confidence interval [CI] = −0.19%, −0.04%; p = .002), HF (−0.18%; 95% CI = −0.28%, −0.08%; p = .001), and AMI (−0.23%; 95% CI = −0.32%, −0.13%; p < .001).

2010 年,美国国会颁布了《患者保护与可负担医疗法案》(ACA),通过补贴和扩大医疗补助(Medicaid)来提高医疗保险的可负担性。然而,并非所有州都采用了 ME。我们研究了 2005 年至 2019 年的全国医院再入院率,根据各州的 ME 状态调查再入院率降低趋势。我们将各州分为在 2014 年扩大医疗补助计划的州(ME 州)和在 2019 年之前没有扩大医疗补助计划的州(非 ME 州)。我们采用差分法框架并对医院和人口特征进行调整,评估了 ME 与肺炎、心力衰竭 (HF) 和急性心肌梗死 (AMI) 住院后 30 天再入院率之间的关系。无论在扩大之前还是之后,ME 州的平均再入院率都高于非 ME 州。ME 扩容后,与非 ACA 州相比,ME 州的医院在肺炎(-0.12%;95% 置信区间 [CI] = -0.19%,-0.04%;P = .002)、心力衰竭(-0.18%;95% 置信区间 = -0.28%,-0.08%;P = .001)和急性心肌梗死(-0.23%;95% 置信区间 = -0.32%,-0.13%;P = .001)方面的再入院率下降幅度更大。
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引用次数: 0
Implementation and qualitative evaluation of an innovative social work-led intervention for patients experiencing homelessness 以社会工作为主导,对无家可归患者进行创新干预的实施和定性评估。
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-18 DOI: 10.1002/jhm.13429
Erin Bredenberg MD, MPH, Michael Castellarin MD, Amanda V. Johnson MD, Sarah Mann MA, Lauren McBeth BA, Amanda Van Andel LCSW, Gregory Misky MD
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引用次数: 0
Do acting interns need residents? A comparison of acting intern experience on hospital medicine resident versus nonresident teams 代理实习生需要住院医生吗?医院内科住院医师与非住院医师团队中代理实习生的经验比较。
IF 2.4 4区 医学 Q1 MEDICINE, GENERAL & INTERNAL Pub Date : 2024-06-16 DOI: 10.1002/jhm.13417
Adam Gray MD, Alan M. Hall MD, Jagriti Chadha MD, Stephanie Leung MD, Kelsey Karnik PhD, Anthony A. Mangino PhD, John W. Ragsdale MD

Background

The clinical demands for hospitalist groups have grown at academic medical centers, without similar growth of teaching opportunities for faculty. Traditional resident teaching teams are often crowded with learners which can limit acting intern (or subintern) patient encounters. Medical students are often placed on nonresident teaching teams, although there are few studies on learner experience on a nonresident teaching team model.

Methods

To address these concerns, we created two nonresident teaching teams composed of one attending and two acting interns. We compared acting intern experience on the nonresident teaching teams to the traditional resident teams to determine if there were significant differences in student experience by reviewing course evaluation data on the two team models.

Results

Of the 276 students who completed the Internal Medicine Acting Internship from 2019 to 2023, 224 students (81%) completed the course evaluation. The course was highly rated, and the ratings were similar in both models demonstrating that the nonresident teaching team model is an effective option for acting interns.

Conclusion

The nonresident teaching team model can offload crowded teaching teams, add additional acting intern experiences, and add teaching opportunities for hospital medicine attendings.

背景:学术医疗中心对住院医师团队的临床需求不断增长,但教师的教学机会却没有相应增加。传统的住院医师教学团队往往挤满了学习者,这可能会限制实习医生(或副实习医生)与病人的接触。医学生通常被安排在非住院医师教学团队中,但有关非住院医师教学团队模式下学习者体验的研究却很少:为了解决这些问题,我们创建了两个由一名主治医生和两名实习医生组成的非住院教学团队。我们通过审查两种教学团队模式的课程评估数据,比较了非常驻教学团队和传统常驻团队中的代理实习生体验,以确定学生体验是否存在显著差异:在 2019 年至 2023 年期间完成内科代理实习的 276 名学生中,有 224 名学生(81%)完成了课程评估。课程评价很高,两种模式的评价相似,这表明非驻地教学团队模式是表演实习生的有效选择:结论:非驻地教学团队模式可以减轻拥挤的教学团队的负担,增加额外的表演实习生经验,并为医院内科主治医师增加教学机会。
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引用次数: 0
期刊
Journal of hospital medicine
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