Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2021

It can be challenging to identify new evidence that may shift clinical practice within internal medicine. Synthesis of relevant articles and guideline updates can facilitate staying informed of these changes. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 8 practice-changing articles were included.     

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2022

It can be difficult for clinicians to stay updated on practice-changing articles.  Synthesis of relevant articles and guideline updates can facilitate staying informed on important new data impacting clinical practice.  The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded.  The New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association, The British Medical Journal (BMJ), the Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 5 practice-changing articles were included, along with a highlight of key guideline updates.     

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2018

The expansive scope of general internal medicine makes it difficult to identify practice-changing medical literature. Clinical updates can be facilitated by synthesizing relevant articles and implications for practice. Six internal medicine physicians reviewed the titles and abstracts in the 7 general internal medicine clinical outpatient journals with the highest impact factor and relevance to the internal medicine outpatient physician: New England Journal of Medicine (NEJM), Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA-Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus on articles based on clinical relevance to outpatient Internal Medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 7 practice-changing articles were included.     

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2017

Clinicians are challenged to identify new practice-changing articles in the medical literature. To identify the practice-changing articles published in 2017 most relevant to outpatient general internal medicine, 5 internists reviewed the following sources: 1) titles and abstracts from internal medicine journals with the 7 highest impact factors, including New England Journal of Medicine, Lancet, Journal of the American Medical Association, British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine; 2) synopses and syntheses of individual studies, including collections in the American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine; 3) databases of synthesis, including Evidence Updates and the Cochrane Library. Inclusion criteria were perceived clinical relevance to outpatient general medicine, potential for practice change, and strength of evidence. This process yielded 140 articles. Clusters of important articles around one topic were considered as a single-candidate series. A modified Delphi method was utilized by the 5 authors to reach consensus on 7 topics to highlight and appraise from the 2017 literature     

中华内科杂志近五年部分栏目引文分析

目的 分析本刊近5年部分栏目文章的引文情况及与国外同类期刊的差距。方法 选取1998-2002年本刊全部期刊和《英国医学杂志》(简称BMJ)、《美国医学会杂志》(简称JAMA)、《内科学纪事,Annals of Internal Medicine》(简称Annals)部分栏目文章的引文进行横断面统计。结果 5年论著平均引文数本刊为6．55条,《BMJ》为15．78条,《JAMA》为34．73条,《Annals》为30．37条;评论性文章的引文分别为3．82条、9．26条、18．38条和13．79条;其他栏目的文章平均引文本刊为6．03条,《BMJ》为13．58条。近5年本刊的引文中,英文文献约占总引文的86％,中文引文约占14％,日文不足1％,其他语种几乎没有。普赖斯指数分析,本刊与《BMJ》、《JAMA》、《Annals》相距不大,分别为0．50、0．58、0．57和0．42。结论 本刊引文数量与国外期刊相差较远;引文时限基本无差异;我国引文语种比较单一,有待加强。     

《中华内科杂志》2005-2011年载文被引分析

目的 应用文献计量学方法研究《中华内科杂志》2005至2011年载文的学术水平.方法 利用中国科学引文数据库(CSCD)提供的资料和数据,检索《中华内科杂志》2005至2011年载文被引用情况.结果 2005-2011年《中华内科杂志》共刊出文章2809篇,其中832篇(29.62％)被引用,共1993次.共有14位论文作者的文章总被引频次≥10次.被引文章作者来自全国25个省、市、自治区,其中北京(341篇)、上海(87篇)、广东(64篇)、江苏(45篇)、浙江(43篇)位居前列.对被引论文作者的所在机构进行统计,中国医学科学院北京协和医学院北京协和医院(205次)、北京大学人民医院(77次)、解放军总医院(76次)居前3位.结论 《中华内科杂志》近年来发表了一批高水平的学术论文,在促进医学学术交流方面起到了良好作用.     

《中华内科杂志》被引频次的影响因素分析

目的 分析发表于《中华内科杂志》2008-2010年所有学术性文章的属性和被引情况,以探讨影响《中华内科杂志》影响因子(IF)的因素.方法 检索并套录中国生物医学期刊引文数据库(CMCI)中收录的《中华内科杂志》 2008-2010年的所有文献,手工统计文献各相关因素并进行分层比较.结果 《中华内科杂志》3年共发表1164篇学术性文献,篇均参考文献9.95条,总被引频次为1029次,其中篇均被引0.93次/篇,面均被引0.31次/面,零被引文献736篇,占发文总数的63.2％.论著类、纯临床类的文献有较好的引文产出.在基金资助方面,无基金资助的研究比有基金支持者有更好的产出.血液病学、心血管病学、胃肠病学是统计年中发文量最多的3个专业,而内科领域亚专业中的重症医学、急诊医学和肾脏病学发文量最少;虽然各学科间引文情况存在固有差异,但仅就引用绝对值看,引文产出较好的是神经/精神病学(篇均被引0.73次)、心血管病学(0.65次)和胃肠病学(0.54次),而血液病学、基础医学和风湿病学对IF的贡献相对不足.结论 加强优秀论文的组稿和宣传力度,减少零被引文献的数量,扩大显示度,提供更快捷和便利的文献阅读方式是编辑部下一步工作的重点.     

Chancen und Risiken der chirurgischen Adipositastherapie

News headlines around the world read “Obesity Surgery Can Cure Diabetes” following the first randomized controlled study of the effect of laparoscopic adjustable gastric banding (LAGB) on type 2 diabetes was published today in the Journal of the American Medical Association (JAMA). As bariatric and metabolic surgeons we have known this for years, but today’s study, along with the two landmark studies published in The New England Journal of Medicine in August 2007 that showed a significant increase in survival among people who have bariatric surgery, provide new and important evidence that this type of surgery saves lives and can eliminate, or dramatically improve, disease. The risks of the surgery are less than the existing combination of obesity with metabolic syndrome. Surgery in overweight and obese patients is the most effective treatment for diabetes.     

Changes in study design,gender issues,and other characteristics of clinical research published in three major medical journals from 1971 to 1991

OBJECTIVE: To examine trends in study design and other characteristics of original research published inJAMA, Lancet, and theNew England Journal of Medicine (NEJM) between 1971 and 1991. DESIGN: A retrospective cross-sectional study of original clinical research published inJAMA, Lancet, andNEJM during 1971, 1981, and 1991. MEASUREMENTS: Four hundred forty-four articles were independently reviewed by at least two investigators and classified according to study design and other preselected study characteristics. Changes over time were analyzed by chi-square tests for categorical variables and analysis of variance for continuous variables. MAIN RESULTS: Clinical results doubled, from 17% of all articles in 1971 to 35% in 1991 (p<0.004), while case series decreased from 30% to 4% (p<0.0001). Of 118 clinical trials, randomized controlled trials increased from 31% to 76% (p<0.003) and nonrandomized controlled trials decreased from 42% to 8% (p<0.002). Multicenter studies increased from 10% to 39% (p<0.0001) and the prevalence of health services research increased from none in 1971 to 12% in 1991 (p<0.001). The proportion of the studies explicitly excluding women from the subject population decreased from 11% in 1971 to 3% in 1991 (p<0.03). In 1991 7% of the studies were composed entirely of men subjects, while only 0.7% of the studies were specific to men’s health. Twelve percent of the studies in 1991 were specific to women’s health. Between 1971 and 1991 there was no change in the prevalence of women first authors or studies addressing women’s or minorities’ health issues. CONCLUSIONS: Several important changes in clinical research studies published inJAMA, Lancet, andNEJM have taken place between 1971 and 1991. Clinical trials have increased in frequency, largely replacing studies containing ten or fewer subjects. Health services research has increased in prevalence, reflecting growing interest in studies addressing the delivery of health care. Our data support the hypothesis that exclusion of women from clinical research studies is an important contributor to the paucity of data concerning women’s health. Presented at the annual meeting of the Midwest Regional Society of General Internal Medicine, September 11, 1993, Chicago, Illinois, and at the annual national meeting of the Society of General Internal Medicine, April 27–29, 1994, Washington, DC.     

For the General Internist: A Review of Relevant 2013 Innovations in Medical Education

We conducted a review of articles published in 2013 to identify high-quality research in medical education that was relevant to general medicine education practice. Our review team consisted of six general internists with expertise in medical education of varying ranks, as well as a professional medical librarian. We manually searched 15 journals in pairs, and performed an online search using the PubMed search engine for all original research articles in medical education published in 2013. From the total 4,181 citations identified, we selected 65 articles considered most relevant to general medicine educational practice. Each team member then independently reviewed and rated the quality of each selected article using the modified Medical Education Research Study Quality Instrument. We then reviewed the quality and relevance of each selected study and grouped them into categories of propensity for inclusion. Nineteen studies were felt to be of adequate quality and were of moderate to high propensity for inclusion. Team members then independently voted for studies they felt to be of the highest relevance and quality within the 19 selected studies. The ten articles with the greatest number of votes were included in the review. We categorized the studies into five general themes: Improving Clinical Skills in UME, Inpatient Clinical Teaching Methods, Advancements in Continuity Clinic, Handoffs/Transitions in Care, and Trainee Assessment. Most studies in our review of the 2013 literature in general medical education were limited to single institutions and non-randomized study designs; we identified significant limitations of each study. Selected articles may inform future research and practice of medical educators.     

Bedside Ultrasonography (US), Echoscopy and US Point of Care as a new kind of stethoscope for Internal Medicine Departments: the training program of the Italian Internal Medicine Society (SIMI)

In recent years, thanks to the development of miniaturized ultrasound devices, comparable to personal computers, tablets and even to smart phones, we have seen an increasing use of bedside ultrasound in internal medicine departments as a novel kind of ultrasound stethoscope. The clinical ultrasound-assisted approach has proved to be particularly useful in assessing patients with nodules of the neck, dyspnoea, abdominal pain, and with limb edema. In several cases, it has allowed a simple, rapid and precise diagnosis. Since 2005, the Italian Society of Internal Medicine and its Ultrasound Study Group has been holding a Summer School and training courses in ultrasound for residents in internal medicine. A national network of schools in bedside ultrasound was then organized for internal medicine specialists who want to learn this technique. Because bedside ultrasound is a user-dependent diagnostic method, it is important to define the limits and advantages of different new ultrasound devices, to classify them (i.e. Echoscopy and Point of Care Ultrasound), to establish appropriate different levels of competence and to ensure their specific training. In this review, we describe the point of view of the Italian Internal Medicine Society on these topics.     

Graphical literacy: the quality of graphs in a large-circulation journal

STUDY OBJECTIVES: We sought to characterize the quantity and quality of graphs in the Journal of American Medicine (JAMA), contrasting articles published in 1999 with those published in 2000 after the addition of a dedicated tables and figures editor. We also sought to compare the quality of graphs in JAMA with the quality of graphs in Annals of Emergency Medicine. METHODS: Two reviewers independently assessed all graphs in original research articles from 12 randomly chosen issues of JAMA, 6 each from 1999 and 2000, using a standardized abstraction form. We noted graph type, clarity, and completeness and identified internal discrepancies. We examined the graphs and articles to observe discrepancies with text, to observe efficiency of graph presentation, and to determine whether the graph portrayed unaggregated data. Results were compared with results from a previously published study of graphs from 18 consecutive issues of Annals of Emergency Medicine beginning in January 1998. RESULTS: The 12 JAMA issues contained 56 research articles, with 64 graphs in the 37 articles that had graphs (28 in 27 1999 articles, 36 in 29 2000 articles). Simple bar or point charts (63%) predominated. We rarely encountered internal errors (8%), contradictions with text (3%), numeric distortion (6%), lack of visual clarity (5%), nonstandard graphing conventions (11%), or extraneous decoration (0%). Graphs generally defined all symbols (98%), but 31% were not self-explanatory; that is, despite knowing the study's design and reading the figure's legend, we could not unambiguously interpret the graph. Fourteen percent contained redundancies. Graphs infrequently portrayed by-subject data (9%) or advanced features (15%) such as pairing, symbolic dimensionality, or small multiples. Forty-eight percent (21/44) of graphs did not illustrate the underlying distribution, 48% (26/54) did not depict important covariates, and 67% (14/21) did not portray pairing inherent in the data. There were no differences between 1999 and 2000 graphs, although we noted more graphs in the 2000 issues. Graph quality was similar in Annals of Emergency Medicine and JAMA, but graphs were more common in the original research articles in JAMA. Although univariate displays predominated in both publications, there were more bivariate displays in Annals of Emergency Medicine but fewer advanced graphic features. CONCLUSION: The graphs in JAMA were similar to those in Annals of Emergency Medicine and, although generally clear and without errors, often failed to depict detailed data. Authors and editors could improve data presentations by incorporating graphic formats that depict stratified, detailed data.     

Expert ratings of primary care goals and objectives

OBJECTIVE: To develop consensus on proficiencies internal medicine residents should master in the area of primary and managed care. DESIGN: A draft compendium of primary care educational objectives including important clinical topics was developed at the Sepulveda Veterans Health Administration Medical Center Pilot Ambulatory Care and Education (PACE) Program as part of a local and regional primary care curricular review. Fifty-one experts, including leaders in the Society of General Internal Medicine, the Association of Program Directors in Internal Medicine, the American College of Physicians, general internal medicine division chiefs, and Veterans Affairs (VA) associate chiefs of staff for ambulatory care rated the compendium. MEASUREMENTS AND MAIN RESULTS: Eleven objectives and nine clinical topics were rated “critically important” (4.7 or above on a five-point scale). General internal medicine chiefs and associate chiefs of staff for ambulatory care judged them to be covered adequately in fewer than half of the 17 VA Western Region-affiliated internal medicine programs. Forty-five objectives and 77 clinical topics were considered at least somewhat important to the education of general internal medicine residents in primary care. The VA raters reported that in the prior academic year, their housestaffs had spent between 21% (postgraduate year I) and 33% (postgraduate year III) of their time in ambulatory care settings. CONCLUSION: With the emphasis on primary and managed care, there is a need for national consensus on educational objectives in primary care general internal medicine. This review provides educators with a benchmark to test the adequacy of their institutions’ curricula in primary care internal medicine. Presented in abstract Jorm at the annual meeting of the Society of General Internal Medicine, April 28, 1994, Washington, DC.     

Dietary counseling of hypercholesterolemic patients by internal medicine residents

Objective:To assess the knowledge, attitudes, and practices of internal medicine residents concerning dietary counseling for hypercholesterolemic patients. Design:Cross-sectional, self-administered questionnaire survey. Setting:Survey conducted August 1989 in seven internal medicine residency programs in four southeastern and middle Atlantic states. Participants:All 130 internal medicine residents who were actively participating in outpatient continuity clinic. Interventions:None. Measurements and main results:Only 32% of the residents felt prepared to provide effective dietary counseling, and only 25% felt successful in helping patients change their diets. Residents had good scientific knowledge, but the degree of practical knowledge about dietary facts varied. Residents reported giving dietary counseling to 58% of their hypercholesterolemic patients and educational materials to only 35%. Residents who felt more self-confident and prepared to counsel reported more frequent use of effective behavior modification techniques in counseling. Forty-three percent of residents had received no training in dietary counseling skills during medical school or residency. Conclusion:Internal medicine residents know much more about the rationale for treatment for hypercholesterolemia than about the practical aspects of dietary therapy, and they feel ineffective and ill-prepared to provide dietary counseling to patients. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, May 2–4, 1990. Supported by the University of North Carolina Faculty Development Fellowship Program in General Medicine and General Pediatrics (54004-05, Bureau of Health Professions, Washington, DC) and by grants from the Medical Foundation of North Carolina, the Georgia Affiliate of the American Heart Association, and the Geisinger Foundation.     

Certification in internal medicine: 1989–1992

Objective: To determine whether changes in the demographic/educational mix of those entering internal medicine from 1986 to 1989 were associated with differences among them at the time of certification. Participants: Included in the study were all candidates for the 1989 to 1992 American Board of Internal Medicine certifying examinations in internal medicine. Measurements: Demographic information and medical school, residency training, and examination experience were available for each candidate. Data defining quality, size, and number of subspecialties were available for internal medicine training programs. Results: From 1990 to 1992, the total number of men and women candidates increased as did the numbers of foreign-citizen non-U.S. medical school graduates and osteopathic medical school graduates; the number of U.S. medical school graduates remained nearly constant and the number of U.S.-citizen graduates of non-U.S. medical schools declined. The pass rates for all groups of first-time examination takers decreased, while the ratings of program directors remained relatively constant. Program quality, size, and number of subspecialty programs had modest positive relationships with examination performance. Conclusions: Changes in the characteristics of those entering internal medicine from 1986 to 1989 were associated with declines in performance at the time of certification. These declines occurred in all content areas of the test and were apparent regardless of program quality. These data identify some of the challenges internal medicine faces in the years ahead. Received from the American Board of Internal Medicine, Philadelphia, Pennsylvania. This research was supported by the American Board of Internal Medicine but does not necessarily reflect its opinions or policies.     

Practice patterns and the adequacy of residency training in consultation medicine

Objective: To describe consultation practice patterns of graduates of an internal medicine residency program and to determine whether they consider themselves to be adequately trained to practice in the area of internal medicine consultations. Design: The authors surveyed graduates of the internal medicine residency program at the University of California, San Diego, School of Medicine from 1980 to 1989. Respondents described their practice types and the mechanics of consultations they currently perform, as well as the adequacy of their training in and frequency of encountering 74 clinical problems in the area of internal medicine consultation. Topics were categorized as Group I: excessive training; Group II: adequate training, frequently encountered; Group III: adequate training, infrequently encountered; Group IV: inadequate training, frequently encountered; and Group V: inadequate training, infrequently encountered. Setting: University teaching hospital. Participants: Of 214 graduates, 91 returned surveys adequate for analysis. Results: Internists prefer verbal communication with their colleagues and seeing surgical patients in the office prior to admission. Residents perceive that they have been excessively trained in preoperative evaluations of the asymptomatic and chronically ill adult and in several postoperative complications. Topics seen frequently in clinical practice but inadequately taught include: issues in convalescence and rehabilitation from surgical procedures, use of psychotropic medications, and management of eating disorders. Conclusions: To prepare residents for practice, program directors in consultation medicine might consider incorporating outpatient preoperative evaluation assessments, encouraging a liaison between surgeons and internists, and modeling verbal communication among colleagues. Consideration should be given for more didactic training for Group IV topics. Received from the Department of Medicine, Division of General Internal Medicine/Geriatrics, University of California, San Diego School of Medicine, Lajolla, California.     

The relevance to clinical practice of the certifying examination in internal medicine

Objective: To determine the relevance of the initial certifying examination to the practice of internal medicine and the suitability of items used in initial certification for recertification. Design: Using a matrix-sampling approach, items from the 1991 Certifying Examination were assigned to two sets of judges: directors of the American Board of Internal Medicine (ABIM) and practicing general internists. Each judge rated the relevance of items on a five-point scale. Participants: 54 current or former directors of the ABIM and 72 practicing general internists; practitioners were nominated by directors and their ratings were included if they spent > 80% of their time in direct patient care. Results: The directors’ mean rating of all 576 items was 3.98 (SD=0.62); the practitioners’ mean rating was 4.11 (SD=0.82). The directors assigned to 27 items ratings of less than 3 and the practitioners assigned to 42 items ratings of less than 3; seven of these items received low ratings from both groups. There were differences in the two groups’ ratings of the relevance of various medical content categories, but the mean rating of core items was higher than that of noncore items and the mean rating of items testing clinical judgment was higher than that of items testing knowledge or synthesis. Conclusions: These findings suggest that the initial certifying examination is relevant to clinical practice and that many of the examination items are suitable for use in recertification. Differences in perception appear to exist between practitioners and directors, and the use of practitioner ratings is likely to be a routine part of judging the suitability of items for Board examinations in the future.