Proficiency of internal medicine residents in outpatient care of patients with HIV infection

To determine internal medicine residents’ knowledge of HIV care, the authors conducted a survey of residents from four internal medicine programs in the San Francisco Bay area. On a knowledge test, the mean score was 42.4/55, 77% correct. The residents performed relatively worse on questions regarding didanosine and zalcitabine, tuberculosis prophylaxis, and risk of cervical neoplasia in HIV-infected women. Predictors of greater knowledge were specific residency program, higher postgraduate year, primary care residency track, and more extensive HIV experience. Primary care internal medicine residencies and programs with more exposure to HIV patients are most effective in producing knowledgeable residents. Supported by the AIDS Clinical Research Center, University of California San Francisco, VA Medical Center (141A), 4150 Clement Street, San Francisco, CA 94121; and National Institute of Mental Health Grant: MH44045 (Dr. Cooke). Dr. Bindman is a Robert Wood Johnson Generalist Physician Faculty Scholar. This research was conducted, in part, while Dr. Schultz was a fellow in general internal medicine and clinical epidemiology in the Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California.     

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).     

Confidence of academic general internists and family physicians to teach ambulatory procedures

OBJECTIVE: To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures. DESIGN: Mailed survey. SETTING: Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states. PARTICIPANTS: Convenience sample of full-time teaching faculty. MEASUREMENTS AND MAIN RESULTS: A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians’ confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year. CONCLUSIONS: Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills. Presented in part at the 1996 and 1998 meetings of the Society of General Internal Medicine and at the 1998 meetings of the Midwest Society of General Internal Medicine. This work was supported in part by grant 2D28PE54004 from the Bureau of Health Professions, Health Resources and Services Administration, to the Faculty, Development Program for General Internal Medicine, University of North Carolina at Chapel Hill, and by Grant 52285 from the Summa Health System, Akron, Ohio.     

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.     

Evaluation of a national curriculum reform effort for the medicine core clerkship

BACKGROUND: In 1995, the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM) developed and disseminated a new model curriculum for the medicine core clerkship that was designed to enhance learning of generalist competencies and increase interest in general internal medicine. OBJECTIVE: To evaluate the dissemination and use of the resulting SGIM/CDIM Core Medicine Clerkship Curriculum Guide. DESIGN: Survey of internal medicine clerkship directors at the 125 medical schools in the United States. MEASUREMENTS AND MAIN RESULTS: The questionnaire elicited information about the use and usefulness of the Guide and each of its components, barriers to effective use of the Guide, and outcomes associated with use of the Guide. Responses were received from 95 clerkship directors, representing 88 (70%) of the 125 medical schools. Eighty-seven (92%) of the 95 respondents were familiar with the Guide, and 80 respondents had used it. The 4 components used most frequently were the basic generalist competencies (used by 83% of those familiar with the Guide), learning objectives for these competencies (used by 83%), learning objectives for training problems (used by 70%), and specific training problems (used by 67%); 74% to 85% of those using these components found them moderately or very useful. The most frequently identified barriers to use of the Guide were insufficient faculty time, insufficient number of ambulatory care preceptors and training sites, and need for more faculty development. About 30% or more of those familiar with the Guide reported that use of the Guide was associated with improved ability to meet clerkship accreditation criteria, improved performance of students on the clerkship exam, and increased clerkship time devoted to ambulatory care. CONCLUSION: This federally supported initiative that engaged the collaborative efforts of the SGIM and the CDIM was successful in facilitating significant changes in the medicine core clerkship across the United States. Presented at the Society of General Internal Medicine annual meeting, San Francisco, Calif, April 1999. This work was supported in part by Contract No. 240-930029 from the Bureau of Health Professions, Health Resources and Services Administration.     

Does performance on the NBME part II medicine examination when used as a clerkship examination reflect knowledge acquired during the medicine clerkship?

Objective:The purpose of this study was to examine whether the National Board of Medical Examiners (NBME) Medicine Examination provides a reasonable assessment tool for testing students’ knowledge acquired during a medicine clerkship. Design:Comparison of the performances of two classes of medical students on the NBME Part II Medicine Examination on the first and last days of 12-week medicine clerkships in a two-year period (1985–87). Participants:176 medical students in two consecutive classes at the Oregon Health Sciences University. Measurements and results:There was no significant difference in students’ performances on the NBME Part II Medicine Examination on the first day of the medicine clerkship, regardless of the quarter in which they took the clerkship. Prior clerkship experiences did not appear to influence the baseline pre-clerkship internal medicine knowledge base as defined by NBME Part II Medicine Examination performances. Students in the second half of the year, however, demonstrated greater gains in post-clerkship NBME Part II Medicine Examination performances than did their counterparts from the first half of the year, despite similar pre-clerkship testing performances. Received from the Division of General Internal Medicine, Oregon Health Sciences University, Portland VA Medical Center, Portland, Oregon. Presented in part at the January 1990 Northwest Regional Meeting of the Society of General Internal Medicine, Seattle, Washington.     

Treatment of patients with acute myocardial infarction at a veterans affairs (VA) hospital and a non-VA hospital

Comparisons of care in Veterans Affairs (VA) hospitals with care in non-VA hospitals are needed to define the future role of the VA health care system. Therefore, the authors conducted a retrospective cohort study of 385 patients who had acute myocardial infarctions and were admitted to a private nonprofit teaching hospital and to a university-affiliated VA hospital, which were staffed by attending and resident physicians from a single medicine department. Data were obtained from hospital databases and from patient records. The authors found that the 206 VA patients, compared with the 179 non-VA patients, were younger and more likely to be men. The VA patients also had higher comorbidity but lower admission severity of illness, according to previously validated measures. Although the VA patients were less likely than the non-VA patients to receive thrombolytic therapy (6% vs 20%, respectively; p<0.05), they were more likely to undergo coronary angiography (67% vs 57%; p<0.05) and echocardiography or gated blood pool scanning (54% vs 44%; p<0.05) during hospitalization. Finally, the VA and the non-VA patients had similar rates of in-hospital mortality in univariate analysis (9% vs 11%, respectively; p=0.4) and in multivariate analysis, adjusting for covariates. These results suggest that the VA and the non-VA patients who had acute myocardial infarction had similar outcomes and generally received care of similar qualities. Future studies are needed to explore the generalizability of these findings and to provide the data needed to adequately define the VA’s future role in American health care. Received from the Section of Clinical Epidemiology, Division of General Internal Medicine, Department of Medicine, Cleveland Veterans Affairs Medical Center and University Hospitals of Cleveland; and Case Western Reserve University School of Medicine, Cleveland, Ohio. Presented in part at the Department of Veterans Affairs 11th Annual HSR&D Service Meeting, Washington, DC, April 27, 1993. Supported by a grant (LIP 41-063) from the Department of Veterans Affairs Great Lakes Regional HSR&D Field Program.     

A comparison of the methods and criteria used by traditional and primary care internal medicine programs to select residents

OBJECTIVE: To determine whether there are differences in the methods and criteria used by primary care and traditional internal medicine programs to select first-year residents. DESIGN: A questionnaire was sent to primary care and traditional internal medicine program directors, who were asked to rank in importance ten documents of an applicant’s file and to score the relative importance, on a scale of −5 to +5, of 21 candidate traits of four types: academic, demographic, personal, and career goal. SETTING: Programs at institutions (n=54) that have categorical residency programs in both traditional and primary care internal medicine. PARTICIPANTS: Of 108 questionnaires, the overall response rate was 81%, with 40 pairs (74%) of matched respondents. Seventy-two percent of the responding institutions were university- administered. RESULTS: Primary care and traditional programs use similar methods to process applicants, rank similarly ten documents in an applicant’s file, and value academic success during the clinical years as the most important candidate trait. Compared with traditional tracks, primary care tracks place greater emphasis on a candidate’s career goals and select for candidates planning to pursue primary care careers (3.9±1.4 vs 0.9±1.5, p<0.001), enter practice (1.4±1.5 vs 0.1±1.2, p<0.001), or serve medically indigent populations (2.7±1.5 vs 1.2±1.2, p<0.001). Primary care programs rate negatively candidates who intend to subspecialize, whereas traditional programs view them almost neutrally (−1.8±2.2 vs 0.5±1.5, p<0.001). CONCLUSION: Primary care and traditional track internal medicine programs use similar methods to select residents and both rank academic achievement during the clinical years as a candidate’s most important attribute. However, only primary care programs strongly select for candidates on the basis of their career plans and in particular prefer candidates who are committed to pursuing primary care careers and serving the medically indigent. Received from the Division of General Internal Medicine and Primary Care, Department of Medicine, University of California, Irvine, California. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 29-May 1, 1992. Supported in part by a grant from the U.S. Public Health Service (2 D28 PE19154).     

Faculty ratings of resident humanism predict patient satisfaction ratings in ambulatory medical clinics

Objective: To determine whether patient satisfaction ratings can be predicted by faculty ratings or self-ratings of resident humanism. Design: A prospective three-month collection of patient satisfaction ratings in two ambulatory care clinics and simultaneous acquisition of faculty ratings and self-ratings of resident humanism using ABIM questionnaires. Setting: Two teaching hospital ambulatory care internal medicine clinics. Participants: Forty-seven internal medicine residents and 17 faculty internists were sent questionnaires for evaluation of humanism of individual residents. One thousand one hundred ninety-four consecutive outpatients cared for by the residents were eligible for patient satisfaction questionnaires. Measurements and main results: Thirty-three residents and 13 faculty completed evaluations of resident humanism while 792 patients completed satisfaction questionnaires, which were used for analysis. The faculty ratings of resident humanism correlated strongly with patient satisfaction ratings, while the resident self-ratings did not. Conclusions: Faculty ratings of resident humanism were highly predictive of patient satisfaction with the care rendered by internal medicine residents in two ambulatory care clinics. This suggests that ambulatory care settings are useful for evaluation of noncognitive behavioral features of resident performance. Received from McGill University, Departments of Medicine and Epidemiology and Biostatistics, Montreal General and Royal Victoria Hospitals, Montreal, Quebec, Canada. Supported by the Fonds de la recherche en santé du Quebec and the Royal Victoria Hospital Department of Medicine research and education fund.     

Ambulatory morning report

We assessed the ability of a novel ambulatory morning report format to expose internal medicine residents to the breadth of topics covered by the American Board of Internal Medicine (ABIM) exam. Cases were selected by the Ambulatory Assistant Chief Residents and recorded in a logbook to limit duplication. We conducted a retrospective review of 406 cases discussed from July 1998 to July 2000 and cataloged each according to the primary content area. The percentage of cases in each area accurately reflected that covered by the ABIM exam, with little redundancy or over-selection of esoteric diseases. Our data suggest that a general medicine clinic is capable of exposing house staff to the wide breadth of internal medicine topics previously thought to be unique to subspecialty clinics.     

Underdetection of clinical benign prostatic hyperplasia in a general medical practice

OBJECTIVE: To measure detection of clinical benign prostatic hyperplasia (BPH) in a general medicine practice. DESIGN: Self-administered questionnaire and retrospective ambulatory medical record review. SETTING: Hospital-based general medicine practice. PATIENTS: Two hundred and four men aged 50 years and older. MEASUREMENTS AND M AIN RESULTS: Clinical information was obtained from a self-administered questionnaire containing the American Urological Association symptom index and the BPH Impact Index bother scale, and from retrospective review of ambulatory medical records for the previous 24 months. Thirty percent of patients had moderate to severe urinary tract symptoms, and 67% of these individuals were bothered by the symptoms. Only 52% with moderate to severe symptoms recalled any discussion with their primary care physician about their symptoms. There was medical record documentation of a review of urinary tract symptoms in only 18% and a prostate examination in only 64%. Patients with more symptoms and bother tended to recall a discussion of urinary tract symptoms with their physician. However, moderate to severe symptoms and bother were not associated with increased documentation of a history of urinary tract symptoms or prostate examination. CONCLUSIONS: Clinical BPH was underdetected in a general medicine practice. Because many men do not complain to their physicians about urinary tract symptoms and reduced quality of life, perhaps primary care physicians should pay more attention to recognizing this common condition of older men. Received from the Section of General Internal Medicine, Evans Memorial Department of Medicine, Boston Medical Center, Mass. Presented in part at the 17th annual meeting of the Society of General Internal Medicine, Washington, DC, April 28, 1994.     

Internal Medicine chief residents suggest need to improve health care delivery and public policy education. Internal Medicine Center to Advance Research and Education

The primary objective in medical training remains skill development in the delivery of medical care through the understanding of bedside data collection, natural history of disease, use of diagnostic tools and the influence of therapy--all applied to a specific patient. More recently, also considered important is training on the broader issues of health care delivery and public policy, especially since the environment of medicine is changing rapidly. With limited curricular time these issues must compete with the traditional and important clinical training. To evaluate how these subjects have been included in internal medicine training, the Resident Physicians Section (RPS) of the American Society of Internal Medicine (ASIM) sponsored a survey of United States internal medicine chief residents which was conducted by the Internal Medicine Center to Advance Research and Education (IMCARE). The objectives of the study were to 1) study the extent of training on health care delivery and public policy issues offered to residents by internal medicine residency programs; 2) assess training opportunities now available; and 3) determine areas of study not fulfilling perceived needs. The questionnaire contained 12 questions. Chief residents rated the 1) quality of their program in preparing residents on health care delivery, public policy issues and practice management; 2) level of instruction provided on 12 topics; and 3) degree of priority these same topics should have. Respondents were asked to identify 1) any other relevant areas their residency program covered particularly well; 2) the amount of time which should be devoted to these socioeconomic topics in each year of training; and 3) the most appealing formats for learning about these topics. Despite the rapidly growing influence of socioeconomic issues on medical practice, many chief residents perceive that important topics are not being addressed adequately. This study provides information on areas addressed well and topics that should receive greater attention. Recommendations are made for further studies and strategies to increase the emphasis on socioeconomic topics during medical education.     

Teaching residents to read the medical literature

Objective:To teach internal medicine residents key principles of clinical epidemiology that are necessary to read critically the medical literature. Design:Two-phase, non-randomized, controlled educational trial. Setting:University-based training program for residents (PGY-l-PGY-3) in internal medicine. Participants:All 83 residents participated in the trial. Seventy residents completed a test in clinical epidemiology at the end of Phases I and II. Interventions:Residents were assigned to one of eight ambulatory care clinics for half a day each week. A literature-based curriculum in critical appraisal was the subject of a weekly pre-clinic conference for four clinics (Group A). The other four clinics (Group B) had a weekly conference on topics in ambulatory care medicine. At the end of Phase I, both groups were given a test of basic knowledge of clinical epidemiology. The curriculum was then modified with the addition of written questions to emphasize important educational points and to stimulate resident participation. The modified curriculum became the subject of the preclinic conference for Group B, while Group A changed to topics in ambulatory medicine. At the end of Phase II both groups were again tested on basic knowledge of clinical epidemiology. Results:Group B performed significantly better on the second test than on the first, 68.5% vs. 63.3% (p=0.034), while Group A did not improve (64.5% vs. 65.9%). The differences in test scores for Test II minus Test I were+5.17% in Group B and −1.44% in Group A (p=0.019). Twenty-one percent of Group B residents vs. 5% of Group A residents improved their scores by 18% or more. Conclusions:The residency period is a difficult but important time to teach critical appraisal skills. Educational gains may be small and need to be critically evaluated to stimulate the development of more effective educational programs. Received from the Division of General Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky.     

Divisions of general medicine

To evaluate caring for the poor and uninsured in divisions of general medicine (DGMs), and to document the impact of recent reimbursement changes on division ambulatory care activity, the authors conducted a survey of DGM directors. Questionnaires mailed to directors of 214 divisions or residency programs yielded 120 responses. DGMs staffed, on average, three ambulatory sites, with a median of 17,000 visits per site. Overall, 66% of visits were by poor, underinsured, and uninsured patients. The majority of directors (75%) considered care of the poor a goal of their divisions. The most commonly reported response to the cost containment environment was implementation of revenue-generating measures (66%); 19% reported reductions in care to the poor; and 20% reported increased service to this group. It is concluded that DGMs care for large numbers of poor and uninsured patients and therefore must carefully evaluate the impacts of current policy proposals on their future ambulatory care activities Received from the Task Force for Social Responsibility. Society for Research and Education in Primary Care Internal Medicine (Society of General Internal Medicine). Presented at the ninth annual meeting of the Society for Research and Education in Primary Care Internal Medicine, May 2, 1986, Washington, DC.     

Reduction of polypharmacy by feedback to clinicians

Objective:To determine whether two different educational interventions would reduce polypharmacy in outpatients receiving ten (10) or more active medications at the Denver Veterans Affairs Center. Design:292 patients were randomized into three (3) groups: Control (n=88); simple notification of primary care provider (n=102); intensive notification, provision of pharmacy profiles, compliance index, and chart review by senior clinician with recommendations (n=104). Setting:Veterans Affairs Medical Center affiliated with the University of Colorado Health Sciences Center. Patients/Participants:All patients receiving greater than ten (10) active medications who are followed by clinic staff at the Denver VAMC. The mean age was 62 years (range 26–88) and 96% were male. Interventions:The simple notification group received only a single letter recommending that the patient’s number of medications be reduced. The intensive notification group received more sophisticated intervention with a chart review, two letters with calculation of patient compliance, and individualized suggestions for reduction in polypharmacy. The control group received no intervention. Measurements and main results:Control patients had significantly less reduction in polypharmacy then either the simple or intensive intervention groups at four months (p=0.028). There was no significant difference between the intervention groups (p=0.189). By six months the difference was no longer significant. Conclusions:A simple intervention can result in a significant reduction in the number of medications prescribed to patients with polypharmacy. The authors were unable to show that a more complex intervention resulted in a further reduction in polypharmacy. Received from the Department of Medicine, Denver VA Medical Center, and Division of General Medicine, University of Colorado Health Sciences Center, Denver, Colorado. Presented as a poster at the annual meeting of the Society of General Internal Medicine in April 1989, Washington, D.C. Supported by the Denver Veterans Affairs Medical Center and the Division of General Internal Medicine at the University of Colorado Health Sciences Center.     

Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization

U.S. Veterans Affairs (VA) patients’ multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans’ use of non-VA care, including VA-purchased care (“Community Care”) and Medicare.To examine the relationship between drive distance and time—key eligibility criteria for Community Care—and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care.Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran''s reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility.Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk.Key explanatory variables were patients’ drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria).Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05–1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care.VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.     

How primary care providers talk to patients about alcohol a qualitative study

BACKGROUND: Alcohol misuse is a common and well-documented source of morbidity and mortality. Brief primary care alcohol counseling has been shown to benefit patients with alcohol misuse. OBJECTIVE: To describe alcohol-related discussions between primary care providers and patients who screened positive for alcohol misuse. DESIGN: An exploratory, qualitative analysis of audiotaped primary care visits containing discussions of alcohol use. PARTICIPANTS: Participants were 29 male outpatients at a Veterans Affairs (VA) General Internal Medicine Clinic who screened positive for alcohol misuse and their 14 primary care providers, all of whom were participating in a larger quality improvement trial. MEASUREMENTS: Audiotaped visits with any alcohol-related discussion were transcribed and coded using grounded theory and conversation analysis, both qualitative research techniques. RESULTS: Three themes were identified: (1) patients disclosed information regarding their alcohol use, but providers often did not explore these disclosures; (2) advice about alcohol use was typically vague and/or tentative in contrast to smoking-related advice, which was more common and usually more clear and firm; and (3) discomfort on the part of the provider was evident during alcohol-related discussions. LIMITATIONS: Generalizability of findings from this single-site VA study is unknown. CONCLUSION: Findings from this single site study suggest that provider discomfort and avoidance are important barriers to evidence-based brief alcohol counseling. Further investigation into current alcohol counseling practices is needed to determine whether these patterns extend to other primary care settings, and to inform future educational efforts.     

Post-call transfer of resident responsibility

Objective:To determine whether transferring the care of patients to another senior resident the day after admission to the bospital adversely affects the efficiency and quality of care. Design:Retrospective analysis of a natural experiment. Setting:The general medical service of the Minneapolis Veterans Affairs Medical Center, a major tertiary teaching hospital of the University of Minnesota internal medicine residency program. Patients/participants:Subjects were all the patients admitted to the medicine service from 5:00 PM to 6:00 AM over an eight-month period. Intervention:After 5:00 PM, half of the patients were admitted to the hospital by a cross-covering senior resident (CC group of patients), and their care was transferred to a different senior resident the following day. The other patients were initially evaluated by the primary senior resident (PE group of patients). Assignment to the different services was a random, sequential process. Measurements and main results:The CC group had significantly more laboratory tests performed during their hospital stay than did the PE group of patients (44 vs. 32, p=0.01), even when adjusted for length of stay. Using multiple linear regression to adjust for other clinical parameters including length of stay, DRG weight, and number of consults, the authors found that being a CC subject was a significant predictor of the number of laboratory tests obtained (p=0.01). Furthermore, the median length of stay in the CC group (n=74) was longer than that in the PE group (n=72) (eight days vs. six days); this was of borderline statistical significance, using a two-sample median test (p=0.06). Conclusion:Patients transferred to a different resident the day after admission had more laboratory tests performed and longer inpatient stays. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, D.C., April 28, 1988.     

Do resident and staff physicians differ in the types and costs of antihypertensive drugs they select?

Objective:To compare the types and costs of drugs prescribed by resident and staff physicians treating patients with uncomplicated essential hypertension. Design:Cross-sectional study, using a computer-based medical record database. Setting:Primary care internal medicine clinic in a large teaching hospital. Patients/participants:Hypertensive patients seen by ten postgraduate year-1 (PGY-1) and PGY-2 primary care internal medicine residents and four staff physicians practicing in the same clinic. Measurements and main results:The types and costs of antihypertensive drugs prescribed for the patients treated by resident and staff physicians were compared. A larger proportion of patients of resident physicians than of staff physicians were treated with calcium channel blockers [19(15%) vs. 40(4%), p<0.001]; residents prescribed thiazide diuretics less frequently and beta-blockers more frequently than did staff physicians, although these differences were not significant. The estimated average wholesale price of antihypertensive drugs for patients cared for by residents was 35% higher than that for patients cared for by staff physicians ($0.73 vs. $0.54, p=0.048). This difference was not fully explained by differences in practice composition. Conclusions:Resident physicians in this study selected more expensive medications to treat hypertension than did their faculty preceptors, even when differences in practice composition were considered. Received from the Laboratory of Computer Science and Primary Care Program of the General Internal Medicine Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts. Presented at the Twelfth Annual Symposium on Computer Applications in Medical Care, Washington, DC, November 5–8, 1989. Supported by postdoctoral training grant number T15-LM07037 from the National Library of Medicine (Dr. Payne) and by an educational grant from the Hewlett-Packard Corporation.     

The future of general internal medicine

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.