Brief report: Multiprogram evaluation of reading habits of primary care internal medicine residents on ambulatory rotations

OBJECTIVE: To assess the reading habits and educational resources of primary care internal medicine residents for their ambulatory medicine education. DESIGN: Cross-sectional, multiprogram survey of primary care internal medicine residents. PARTICIPANTS/SETTING: Second- and third-year residents on ambulatory care rotations at 9 primary care medicine programs (124 eligible residents; 71% response rate). MEASUREMENTS AND MAIN RESULTS: Participants were asked open-ended and 5-point Likert-scaled questions about reading habits: time spent reading, preferred resources, and motivating and inhibiting factors. Participants reported reading medical topics for a mean of 4.3+/-3.0 SD hours weekly. Online-only sources were the most frequently utilized medical resource (mean Likert response 4.16+/-0.87). Respondents most commonly cited specific patients' cases (4.38+/-0.65) and preparation for talks (4.08+/-0.89) as motivating factors, and family responsibilities (3.99+/-0.65) and lack of motivation (3.93+/-0.81) as inhibiting factors. CONCLUSIONS: To stimulate residents' reading, residency programs should encourage patient- and case-based learning; require teaching assignments; and provide easy access to online curricula.     

Measuring attending physician performance in a general medicine outpatient clinic

OBJECTIVE: To determine which aspects of outpatient attending physician performance (e.g., clinical ability, teaching ability, interpersonal conduct) were measurable and separable by resident report. DESIGN: Self-administered evaluation form. SETTING: University internal medicine resident continuity clinic. PARTICIPANTS: All residents with their continuity clinic at the university hospital evaluated the two attendings who staffed their clinic for the academic years of 1990–1991, 1991–1992, and 1992–1993 (average of 85 total residents per year). The overall response rate was 74%. ANALYSIS: Exploratory analyses were conducted on a preliminary evaluation form in the first two years of the study (236 evaluations of 20 different clinic attendings) and confirmatory analyses using factor analysis and generalizability analysis were performed on the third year’s data (142 evaluations of 15 different clinic attendings). Analysis of variance was used to evaluate factors associated with evaluation scores. RESULTS: Analyses demonstrated that the residents did not distinguish between the attendings’ clinical and teaching abilities, resulting in a single four-item scale that was named the Clinical/Teaching Excellence Scale, measured on a five-point scale from poor to outstanding (Cronbach’s alpha=0.92). A large amount of the variance for this scale score was associated with attending identity (adjusted R²=46%). However, two alternative approaches to evaluating the performance of the attending (preference for him or her to the “average” attending and perceived impact of the attending on residents’ clinical skills) did not provide useful information independent of the Clinical/Teaching Excellence Scale. The ratings of three separate conduct scales [availability in clinic (Availability Scale), treating residents and patients with respect (Respect Scale), and time efficiency in staffing cases (Slow Staffing Scale)] were separable from each other and from the rating of clinical/teaching excellence. For the Clinical/Teaching Excellent Scale, as few as four evaluations produced good interrater reliability and eight evaluations produced excellent reliability (reliability coefficients were 0.70 and 0.84, respectively). CONCLUSIONS: Although this evaluation instrument for measuring clinic attending performance must be considered preliminary, this study suggests that relatively few attending evaluations are required to reliably profile an individual attending’s performance, that attending identity is associated with a large amount of the scale score variation, and that special issues of attending performance more relevant to the outpatient setting than the inpatient setting (availability in clinic and sensitivity to time efficiency) should be considered when evaluating clinic attending performance. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 29, 1994.     

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.     

Data and the internal medicine houseofficer

The authors surveyed 112 recent alumni and 92 current residents (70% responded) at a residency program that requires original research. Most alumni felt that the research project was a valuable learning experience, particularly in improving their abilities to critically review the medical literature. Almost a third felt that it had influenced their career choices (academic medicine vs private practice). The overall learning value of no other residency program component was rated significantly higher than that of the research project. While 65% of current residents supported making the senior resident research project optional, 64% of alumni opposed this change (p<0.0001). These results support requiring formal oral presentations and encouraging original research projects as a part of residency training. Presented in part at the annual meeting of the Association of Program Directors in Internal Medicine, San Diego, Ca, March 23, 1992.     

HIV and HCV health beliefs in an inner-city community

Summary. Chronic infection with the hepatitis C virus (HCV) is more prevalent than human immunodeficiency virus (HIV) infection, but more public health resources are allocated to HIV than to HCV. Given shared risk factors and epidemiology, we compared accuracy of health beliefs about HIV and HCV in an at‐risk community. Between 2002 and 2003, we surveyed a random patient sample at a primary care clinic in New York. The survey was organized as domains of Common Sense Model of Self‐Regulation: causes (‘sharing needles’), timeline/consequences (‘remains in body for life’, ‘causes cancer’) and controllability (‘I can avoid this illness’, ‘medications may cure this illness’). We compared differences in accuracy of beliefs about HIV and HCV and used multivariable linear regression to identify factors associated with relative accuracy of beliefs. One hundred and twenty‐two subjects completed the survey (response rate 42%). Mean overall health belief accuracy was 12/15 questions (80%) for HIV vs 9/15 (60%) for HCV (P < 0.001). Belief accuracy was significantly different across all domains. Within the causes domain, 60% accurately believed sharing needles a risk factor for HCV compared to 92% for HIV (P < 0.001). Within the timeline/consequences domain, 42% accurately believed HCV results in lifelong infection compared to 89% for HIV (P < 0.001). Within the controllability domain, 25% accurately believed that there is a potential cure for HCV. Multivariable linear regression revealed female gender as significantly associated with greater health belief accuracy for HIV. Thus, study participants had significantly less accurate health beliefs about HCV than about HIV. Targeting inaccuracies might improve public health interventions to foster healthier behaviours and better hepatitis C outcomes.     

General internal medicine practice trends in large multispecialty clinics

Objective:To assess practice trends in the general internal medicine departments of large multispecialty clinics. Design:A survey questionnaire addressing the following issues: 1) department size and rate of growth, 2) services provided, 3) patient population, 4) individual clinical workload, 5) call arrangements, 6) time away from practice, and 7) benefits and salary. Participants:22 multispecialty clinics, with a mean of 279 physicians. Measurements and results:Mean general internal medicine department physician expansion was 28% over the preceding three years. Primary care, clinic system access, care of patients laterally shifted from subspecialty internists, and preoperative evaluations were the four major services provided. The mix of fee-for-service, Medicare/Medicaid, and prepaid-plan patients was diverse. Mean outpatient clinical scheduling was 35 hours per week exclusive of hospital practice, administrative time, and paperwork. Study of call arrangements revealed a definite trend toward a group practice model of shared responsibility during the day as well as nights and weekends. Mean meeting and vacation time was 35 days per year. Salary was set by committee, formula, or both. Department stresses and dissatisfactions were also reported. Conclusions:Rapid expansion of general internal medicine departments and services will continue as subspecialists back away from providing primary care. The evolution of general internal medicine practice must be anticipated and managed for optimal patient and departmental outcomes.     

Faculty perceptions of effective ambulatory care teaching

The authors interviewed faculty members to determine their perceptions of what constitutes effective teaching in the ambulatory setting. They conducted semistructured interviews with experienced clinician-tutors who supervise residents in two internal medicine clinics. Tutors identified similarities as well as important differences between inpatient teaching and outpatient teaching. Questioning, role modeling, and emphasizing general principles and concept comprehension can be used effectively in both settings. On the other hand, the two settings differ strikingly in teaching of problem solving, bedside teaching, and provision of feedback. Many characteristics of the setting influence outpatient teaching, but the tutors offered differing viewpoints about whether these characteristics are beneficial or detrimental. Received from the Division of General Internal Medicine, McGill University, Montreal, Quebec, Canada. Presented at the Innovations in Medical Education Exhibits, annual meeting of the Association of American Medical Colleges, October 19–25, 1990, San Francisco, California. Supported in part by the Association of Canadian Medical Colleges, the Royal College of Physicians and Surgeons of Canada, the Departments of Medicine at Royal Victoria and Montreal General Hospitals, and Merck Frosst Canada Inc.     

Alumni perspectives comparing a general internal medicine program and a traditional medicine program

Objective:To evaluate a primary care internal medicine curriculum, the authors surveyed four years (1983–1986) of graduates of the primary care and traditional internal medicine residency programs at their institution concerning the graduates’ preparation. Design:Mailed survey of alumni of a residency training program. Setting:Teaching hospital alumni. Subjects/methods:Of 91 alumni of an internal medicine training program for whom addresses had been found, 82 (90%) of the residents (20 primary care and 62 traditional) rated on a five-point Likert scale 82 items for both adequacy of preparation for practice and importance of training. These items were divided into five groups: traditional medical disciplines (e.g., cardiology), allied disciplines (e.g., orthopedics), areas related to medical practice (e.g., patient education), basic skills and knowledge (e.g., history and physical), and technical procedures. Main results:Primary care residents were more likely to see themselves as primary care physicians versus subspecialists (84% versus 45%). The primary care graduates felt significantly better prepared in the allied disciplines and in areas related to medical practice (p<0.01). There was no significant difference overall in perceptions of preparation in the traditional medical disciplines, basic skills and knowledge, and procedures. The same results were obtained when the authors looked only at graduates from the two programs who spent more than 50% of their time as primary care physicians versus subspecialists. There was no significant difference between the two groups in the perceived importances of these areas to current practice. Conclusions:These results suggest that the primary care curriculum has prepared residents in areas particularly relevant to primary care practice. Additionally, these individuals feel as well prepared as do their colleagues in the traditional medical disciplines, basic skills and knowledge, and procedural skills. Received from the Division of General Internal Medicine, Brown University Program in Medicine, and the Rhode Island Hospital, Providence, Rhode Island. Dr. Kiel is a Henry J. Kaiser Family Foundation Faculty Scholar in general internal medicine. Address correspondence and reprint requests to General Internal Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.     

Structure and quality of outpatient care for people living with an HIV infection

Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.     

Practice satisfaction and dissatisfaction in general internal medicine departments of large multispecialty clinics

General internal medicine (GIM) physician practice satisfaction and dissatisfaction in large multispecialty clinics were assessed utilizing a survey designed to elicit physician perceptions of practice. 420 GIM physicians in 22 multispecialty clinics were contacted, and 168 participated in the survey. The most significant positive components of practice satisfaction were patient interactions and favorable physician colleague interactions. The prominent negative components were paperwork hassles and perceived “second-class” physician status. Coping strategies were varied and included increased political involvement, career change, and withdrawal via depression.     

Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics

Objective:To determine the prevalence of domestic violence among patients seen in three university-affiliated ambulatory care internal medicine clinics and to assess the personal characteristics of those patients affected by domestic violence. Design:Survey using a self-administered, anonymous questionnaire. Setting:Three university-affiliated internal medicine clinics at the University of California Irvine Medical Center. Participants:We asked all patients on randomly selected days during the three-month study to participate. 453 (72%) of the 629 eligible English- and Spanish-speaking patients completed the questionnaire. Measurements and main results:28% of participants had experienced domestic violence at some time in their lives, and 14% were currently experiencing domestic violence. Logistic regression analysis showed that female gender, unmarried status, and poverty were important predictors of domestic violence. However, domestic violence occurred in all groups regardless of sex, ethnicity, age, or socioeconomic status. Conclusions:The study found an unexpectedly high prevalence of domestic violence in the three internal medicine clinics. Physicians should ask their patients routinely about domestic violence and, when domestic violence is present, should offer emotional support, information about social service agencies, and psychological care. Received from the Division of General Internal Medicine and Primary Care, Department of Medicine, University of California, Irvine, Irvine, California. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, VA, May 2 – 4, 1990. Supported in part by a grant from the United States Public Health Service (2-D28PE-19154).     

Trends in market demand for internal medicine 1999 to 2004

BACKGROUND: The health care marketplace has changed substantially since the last assessment of demand for internal medicine physicians in 1996. METHODS: We reviewed internal medicine employment advertisements published in 4 major medical journals between 1996 and 2004. The number of positions, specialty, and other practice characteristics (e.g., location) were collected from each advertisement. RESULTS: Four thousand two hundred twenty-four advertisements posted 4,992 positions. Of these positions, jobs in the Northeast (31% of positions) or single specialty groups (36.8% of positions) were most common. The relative proportion of advertisements for nephrologists declined (P < .001), while the relative proportions of advertisements for critical care specialists (0.5% in 1996 to 1.7% in 2004, P = .004) and hospitalists (1.0% in 1996 to 12.1% in 2004, P < .001) increased. Advertisements for outpatient-based generalist positions (i.e., Primary Care and Internal Medicine) declined (-2.7% relative annual change, 95% confidence interval [95% CI] -4.1%, -1.2%) between 1996 and 2004, a decrease largely due to a substantial decline in advertisements noted between 1996 and 1998. However, over the entire time period, the combined proportion of advertisements for all generalists (hospitalists and outpatient-based generalists) did not change (0.5% relative annual change, 95% CI -0.8% to 2.0%). CONCLUSIONS: Since 1996, demand for the majority of medical subspecialties has remained constant while relative demand has decreased for primary care and increased for hospitalists and critical care. Increase in demand for generalist-trained hospitalists appears to have offset falling demand for outpatient generalists.     

Treating depression in staff-model versus network-model managed care organizations

OBJECTIVE: To compare primary care providers’ depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN: Survey of primary care providers’ depression-related practices in 1996. SETTING AND PARTICIPANTS: We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS: We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS: Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs. Earlier versions of this paper were presented at the Eleventh International Conference on Mental Health Problems in the General Health Care Sector, Washington D.C., September 1997, and the Sixteenth Annual VA Health Services Research and Development Meetings, Washington, D.C., February 1998. This research was supported by grants from the National Institute of Mental Health (U01-MH54443, U01-MH54444, U01-MH50732, and P01-MH54623) and the Agency for Health Care Policy and Research (R01-HS08349).     

American internal medicine in the 21<Superscript>st</Superscript> century

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.     

Do ratings on the american board of internal medicine resident evaluation form detect differences in clinical competence?

Objective: To determine whether raters using the American Board of Internal Medicine (ABIM) Resident Evaluation Form can detect differences among residents in clinical competence. Design: Cross-sectional study. Setting: Inpatient general medicine service in a university-affiliated public hospital. Participants: University-based internal medicine (UCIM) residents (ABIM certifying examination pass rate, 91%; mean score, 95th percentile), community hospital-based internal medicine (CHIM) residents (ABIM examination pass rate, 68%; mean score, 42nd percentile), and residents from three university-based non-internal medicine (UC non-IM) programs all assigned to the same inpatient general medicine service over a three-year period. Four hundred eighty-nine evaluations of 110 postgraduate-year-one residents were analyzed. Measurements and main results: Mean ratings for the UCIM residents were significantly higher than those for the CHIM or UC non-IM residents (analysis of variance [ANOVA], p<0.05). Variance was smallest for the UCIM residents (F test, p<0.01), and only the UCIM residents’ mean scores were in the “superior” range (7–9) in all evaluated categories. The mean ratings for the CHIM residents while at the university-affiliated hospital were not significantly different from the ratings of the same residents at their home hospital. The ratings for the CHIM residents at either site were significantly lower than those for the UCIM residents in all categories (ANOVA, p<0.05). Factor analysis revealed a single factor accounting for 76% of the variance among the ratings with all dimensions loading high on that factor (0.75–0.95), providing evidence for a “halo” effect. Mean interrater agreement over all variables was 0.87, indicating good consistency among raters. Conclusions: Ratings on the ABIM Resident Evaluation Form detect global differences among residents in clinical competence in the expected direction based on type of training program and performance on the ABIM certification examination, but fail to differentiate among the nine evaluated dimensions of clinical care. This rating method may be valid for assessing overall clinical performance, but is less useful for providing feedback in specific areas to individual residents. Presented in part at the annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1, 1991. Supported in part by grant PE 19179 for residency training in general internal medicine and general pediatrics from the Bureau of Health Professions, Health Resources and Services Administration of the Public Health Service.     

Principles to consider in defining new directions in internal medicine training and certification

SGIM endorses seven principles related to current thinking about internal medicine training: 1) internal medicine requires a full three years of residency training before subspecialization; 2) internal medicine residency programs must dramatically increase support for training in the ambulatory setting and offer equivalent opportunities for training in both inpatient and outpatient medicine; 3) in settings where adequate support and time are devoted to ambulatory training, the third year of residency could offer an opportunity to develop further expertise or mastery in a specific type or setting of care; 4) further certification in specific specialties within internal medicine requires the completion of an approved fellowship program; 5) areas of mastery in internal medicine can be demonstrated through modified board certification and recertification examinations; 6) certification processes throughout internal medicine should focus increasingly on demonstration of clinical competence through adherence to validated standards of care within and across practice settings; and 7) regardless of the setting in which General Internists practice, we should unite to promote the critical role that this specialty serves in patient care.     

Managed care, attitudes, and career choices of internal medicine residents

The influence of managed care on internal medicine residents' attitudes and career choices has not yet been determined and could be substantial. In a survey of 1,390 third-year internal medicine residents, 21% believed that managed care was the best model of health care for the United States, and 31% stated they would be satisfied working in a managed care system. Those from high managed care communities (>30% penetration) were only slightly more accepting of managed care, but were more likely to choose general internal medicine as a career (54%, p = .0009) than those from communities with lower managed care penetration.     

Myelodysplastic features in patients with long-term HIV infection and haemophilia

HIV-related bone marrow changes are consistent with myelodysplastic features (MDF). Their pathogenesis may differ from primary myelodysplastic syndromes (MDS) and is associated with various factors including the virus itself or the antiretroviral therapy. In order to evaluate the differences between HIV-related MDF and MDS, the morphological changes in peripheral blood and bone marrow, cytogenetic analysis and the response to anaemia treatment were studied in 158 HIV+ patients with haemophilia and the results were compared with those of 61 patients with primary MDS (31 with RA, 10 with RARS, 11 with RAEB, three with RAEB-t and six with CMML). The eligibility criteria for patients with MDS were primary MDS, Hb levels < 10 g dL(-1), and no significant organ disease. The peripheral blood and bone marrow examination revealed MDF in 44 HIV-infected haemophilic patients (27.8%). The median time from seroconversion was 12.5 years and the mean time under AZT therapy was 44.1 months. Nineteen of these patients (43.1%) had Hb levels < 10 g dL(-1), while neutropenia and thrombocytopenia were observed in 29.5% and 25%, respectively. Every patient of this study with Hb < 10 g dL(-1) received erythropoietin (Epo). There were statistically significant morphological alterations between HIV-related MDF and MDS: hypocellularity, plasmatocytosis and eosinophilia were more pronounced in HIV haemophiliacs with MDF, while dysplasia of erythroblasts, megakaryocytes and granulocytes was more frequent in MDS patients. No HIV haemophilic patient with MDF had more than 5% blasts in the bone marrow nor did any develop RAEB or acute leukaemia during the period of this study. The cytogenetic analysis was normal in HIV-infected patients with haemophilia whereas 42.6% of patients with MDS had an abnormal karyotype. Complete erythroid response was achieved with Epo administration in 84.2% of HIV+ haemophilic patients with anaemia compared to 19.7% of patients with MDS. These data suggest that bone marrow changes in long-term HIV patients have different characteristics from primary MDS and constitute the entity for which the name HIV-myelopathy has been proposed in the literature.