Mount Sinai Journal of Medicine最新文献

With growing numbers of patient-centered medical homes and accountable care organizations, and the potential implementation of the Patient Protection and Affordable Care Act, the provision of primary care in the United States is expanding and changing. Therefore, there is an urgent need to create more primary-care physicians and to train physicians to practice in this environment. In this article, we review the impact that the changing US healthcare system has on trainees, strategies to recruit and retain medical students and residents into primary-care internal medicine, and the preparation of trainees to work in the changing healthcare system. Recruitment methods for medical students include early preclinical exposure to patients in the primary-care setting, enhanced longitudinal patient experiences in clinical clerkships, and primary-care tracks. Recruitment methods for residents include enhanced ambulatory-care training and primary-care programs. Financial-incentive programs such as loan forgiveness may encourage trainees to enter primary care. Retaining residents in primary-care careers may be encouraged via focused postgraduate fellowships or continuing medical education to prepare primary-care physicians as both teachers and practitioners in the changing environment. Finally, to prepare primary-care trainees to effectively and efficiently practice within the changing system, educators should consider shifting ambulatory training to community-based practices, encouraging resident participation in team-based care, providing interprofessional educational experiences, and involving trainees in quality-improvement initiatives. Medical educators in primary care must think innovatively and collaboratively to effectively recruit and train the future generation of primary-care physicians.

The US healthcare system is plagued by unsustainable costs and yields suboptimal outcomes, indicating that new models of healthcare delivery are needed. The patient-centered medical home is one model that is increasingly regarded as a promising strategy for improving healthcare quality, decreasing cost, and enhancing the experience of both patients and providers. Conceptually, the patient-centered medical home may be described as combination of the core attributes of primary care-access, continuity, comprehensiveness, and coordination of care-with new approaches to healthcare delivery, including office practice innovations and reimbursement reform. Implementation efforts are gaining momentum across the country, fueled by both private-payer initiatives as well as supportive public policy. High-quality evidence on the effectiveness of the patient-centered medical home is limited, but the data suggest that, under some circumstances, patient-centered medical home interventions may lead to improved outcomes and generate moderate cost savings. Although the patient-centered medical home enjoys broad support by multiple stakeholders, significant challenges to widespread adoption of the model remain.

This article reviews the barriers to diversity in biomedical research and describes the evolution of efforts to address climate issues to enhance the ability to attract, retain, and develop underrepresented minorities, whose underrepresentation is found both in science and medicine, in the graduate-school biomedical research doctoral programs (PhD and MD/PhD) at Mount Sinai School of Medicine. We also describe the potential beneficial impact of having a climate that supports diversity and inclusion in the biomedical research workforce. The Mount Sinai School of Medicine diversity-climate efforts are discussed as part of a comprehensive plan to increase diversity in all institutional programs: PhD, MD/PhD, and MD, and at the residency, postdoctoral fellow, and faculty levels. Lessons learned from 4 decades of targeted programs and activities at the Mount Sinai School of Medicine may be of value to other institutions interested in improving diversity in the biomedical science and academic medicine workforce.

Primary care in the United States has been in the midst of a transformation from a system based solely on individual office interactions to one that includes managing health at a population level. The chronic care model provides a robust framework for health systems to transform and restructure their delivery of care to one that is committed to delivering multidisciplinary quality care with a proactive approach. Patient and disease registries are the essential tools necessary to inform all elements of the chronic care model and guide practices though this transformation. Nationally as well as internationally, when used as part of a robust continuous quality-improvement program, registries have demonstrated to improve patient outcomes and reduce healthcare costs. Despite challenges practices may confront when initially developing a patient registry, it is evident that population management is now an important and integral component of a successful primary-care practice whose aim is to improve quality of patient care.

Noncommunicable diseases, including cardiovascular disease, chronic respiratory disease, diabetes, cancer, and mental illness, are the leading causes of death and disability worldwide. These diseases are chronic and often mediated predominantly by social determinants of health. Currently there exists a global-health workforce crisis and a subsequent disparity in the distribution of providers able to manage chronic noncommunicable diseases. Clinical competency in global health and primary care could provide practitioners with the knowledge and skills needed to address the global rise of noncommunicable diseases through an emphasis on these social determinants. The past decade has seen substantial growth in the number and quality of US global-health and primary-care training programs, in both undergraduate and graduate medical education. Despite their overlapping competencies, these 2 complementary fields are most often presented as distinct disciplines. Furthermore, many global-health training programs suffer from a lack of a formalized curriculum. At present, there are only a few examples of well-integrated US global-health and primary-care training programs. We call for universal acceptance of global health as a core component of medical education and greater integration of global-health and primary-care training programs in order to improve the quality of each and increase a global workforce prepared to manage noncommunicable diseases and their social mediators.

Home-based primary care has a long history in American medicine, and its prevalence is again increasing slowly in the United States in response to a changing demographic, societal, and health-policy climate. There are many models of home-based primary care, including private practice, academic, Veterans Affairs-associated, and concierge practices. There is a growing body of literature supporting the effectiveness of the medical house-call model. New healthcare reform initiatives could further impact the number and size of home-based primary-care practices, including the Independence at Home and the Accountable Care Organization demonstration projects.

Although both heart transplantation and left ventricular assist device therapy have enjoyed clinical success in the treatment of patients with end-stage heart disease, newer left ventricular assist devices currently undergoing testing are likely to have a tremendous impact on the management of these patients. Smaller, more durable devices with improved safety profiles will allow for longer duration of therapy and make biventricular support more feasible, obviating the need for the total artificial heart. In this article we review the historical aspects of both forms of therapy and highlight the current use of left ventricular assist device therapy on patients awaiting heart transplantation.