General internal medicine and geriatrics: building a foundation to improve the training of general internists in the care of older adults

Internists--"doctors for adults"--provide most of the medical care given to older Americans, especially those with serious chronic disease. Nonetheless, the United States lacks an adequate physician workforce with mastery in caring for older persons and with expertise in building knowledge about how best to provide this care. This supplement aims to strengthen the physician workforce by fostering incremental and sustained improvements in the training of internal medicine residents in the care of older adults and in the development of geriatrics-oriented general internal medicine faculty. It identifies 3 major barriers to these improvements: lack of adequately trained teachers and mentors, the belief that explicit training in geriatrics has little to offer the generalist, and inadequate funding. Three strategies offer particular promise in overcoming these barriers: engaging directors of internal medicine residency programs, funding centers to promote collaboration between teaching and research programs in general internal medicine and geriatrics, and providing substantial incremental funding on the national level to pay for the time required to care for frail older patients and to teach and do research about this care. The barriers and strategies identified in this supplement may also inform efforts to enhance the skills of practicing physicians and improve training and faculty development in family medicine and other disciplines.     

The effect of discussions about advance directives on patients’ satisfaction with primary care

BACKGROUND: Discussions of end-of-life care should be held prior to acute, disabling events. Many barriers to having such discussions during primary care exist. These barriers include time constraints, communication difficulties, and perhaps physicians' anxiety that patients might react negatively to such discussions. OBJECTIVE: To assess the impact of discussions of advance directives on patients' satisfaction with their primary care physicians and outpatient visits. DESIGN: Prospective cohort study of patients enrolled in a randomized, controlled trial of the use of computers to remind primary care physicians to discuss advance directives with their elderly, chronically ill patients. SETTING: Academic primary care general internal medicine practice affiliated with an urban teaching hospital. PARTICIPANTS: Six hundred eighty-six patients who were at least 75 years old, or at least 50 years old with serious underlying disease, and their 87 primary care physicians (57 residents, 30 faculty general internists) participated in the study. MEASUREMENTS AND MAIN RESULTS: We assessed patients' satisfaction with their primary care physicians and visits via interviews held in the waiting room after completed visits. Controlling for satisfaction at enrollment and physician, patient, and visit factors, discussing advance directives was associated with greater satisfaction with the physician (P =.052). At follow-up, the strongest predictor of satisfaction with the primary care visit was having previously discussed advance directives with that physician (P =.004), with a trend towards greater visit satisfaction when discussions were held during that visit (P =.069). The percentage of patients scoring a visit as "excellent" increased from 34% for visits without prior advance directive discussions to 51% for visits with such discussions (P =.003). CONCLUSIONS: Elderly patients with chronic illnesses were more satisfied with their primary care physicians and outpatient visits when advanced directives were discussed. The improvement in visit satisfaction was substantial and persistent. This should encourage physicians to initiate such discussions to overcome communication barriers might result in reduced patient satisfaction levels.     

Academic general internists’ work roles and motivations for learning

As part of an assessment of interests and needs for continuing medical education among academic general internists, a 20 per cent random sample of the 1985 physician membership of SREPCIM was asked to describe how they divided their time among basic work activities (patient care, teaching, housestaff supervision, administration, and research), how they perceived the importance of specific skills related to those basic activities, and how interested they were in participating in a faculty development program in order to improve those skills. Although respondents reported a great diversity of work roles, attitudes, and values, there was a strong and consistent tendency to value and want to improve upon only those skills related to basic activities in which physicians were already spending more time. Also, physicians who spent more time in direct patient care were significantly less likely to value classroom teaching or research, less likely to be doing teaching or research, and less motivated to improve their skills in those activities. Likewise, faculty who spent more time doing research were less interested in improving their patient care skills. The implications of these findings for meeting current and future manpower needs of divisions of general internal medicine are discussed. Received from the Department of Medicine, Division of General Internal Medicine, University of California, Los Angeles, CA 90024. Supported by a Faculty Development Contract from the Health Resources and Services Administration (240-84-0058).     

A comparison of humanistic qualities among medical students, residents, and faculty physicians in internal medicine

Humanistic qualities of integrity, respect and compassion are important components of medical education. Studies, however, suggest that students may not perceive their faculty physicians as humanistic. Knowing how the perception of humanistic qualities varies by training level may offer insight on how we teach humanism. In this study, the authors compared humanistic quality scores of fourth-year medical students, internal medicine residents, and attending physicians on a general medicine ward of a teaching hospital. A validated nursing survey to assess humanistic qualities among physicians was distributed to randomly selected nurses on the medicine wards. The survey measured physician relationships with other medical staff, the patient, and family members. Each item was scored on a 5-point Likert scale. Composite scores for physician to staff relationships and physician to patient/family relationships, as well as an overall evaluation score, were compared across levels of physician training. A t test was done to determine statistical significance across training levels. No statistically significant differences were found between internal medicine residents and attending physicians. Subinterns appear to have better perceived qualities of humanism compared with resident and attending physicians. Because resident and attending physicians play an important role in medical education, efforts should be made to improve the perceived humanistic qualities of both resident and attending physicians.     

Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study

BACKGROUND: Cardiac examination is an essential aspect of the physical examination. Previous studies have shown poor diagnostic accuracy, but most used audio recordings, precluding correlation with visible observations. The training spectrum from medical students (MSs) to faculty has not been tested, to our knowledge. METHODS: A validated 50-question, computer-based test was used to assess 4 aspects of cardiac examination competency: (1) cardiac physiology knowledge, (2) auditory skills, (3) visual skills, and (4) integration of auditory and visual skills using computer graphic animations and virtual patient examinations (actual patients filmed at the bedside). We tested 860 participants: 318 MSs, 289 residents (225 internal medicine and 64 family medicine), 85 cardiology fellows, 131 physicians (50 full-time faculty, 12 volunteer clinical faculty, and 69 private practitioners), and 37 others. RESULTS: Mean scores improved from MS1-2 to MS3-4 (P = .003) but did not improve or differ significantly among MS3, MS4, internal medicine residents, family medicine residents, full-time faculty, volunteer clinical faculty, and private practitioners. Only cardiology fellows tested significantly better (P<.001), and they were the best in all 4 subcategories of competency, whereas MS1-2 were the worst in the auditory and visual subcategories. Participants demonstrated low specificity for systolic murmurs (0.35) and low sensitivity for diastolic murmurs (0.49). CONCLUSIONS: Cardiac examination skills do not improve after MS3 and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care, and continuing medical education. Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees.     

Are Internal Medicine Residency Programs Adequately Preparing Physicians to Care for the Baby Boomers? A National Survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P相似文献   

Perceived difficulty of diabetes treatment in primary care: does it differ by patient ethnicity?

PURPOSE: The purpose of this cross-sectional study was to determine the attitudes of internal medicine physicians toward treating diabetes in different patient ethnic groups and compared with treating common chronic medical conditions in primary care. METHODS: The survey instrument was administered to 55 internal medicine physicians. An e-mail message was sent to each physician with a hyperlink to a site where the survey could be completed. The instrument was a modified, quantitative 10-point scale designed to measure attitudes regarding the difficulty of treating diabetes. RESULTS: Diabetes was perceived to be more difficult to treat than hyperlipidemia and angina. African Americans with diabetes were perceived to be more difficult to treat than Caucasian patients. Difficulty in treating diabetes was comparable to that for hypertension, arthritis, and congestive heart failure. Physicians were confident about treatment efficacy for diabetes and changing diabetes outcomes, but not about the adequacy of time and resources for diabetes treatment. CONCLUSIONS: Diabetes was perceived as a difficult disease to treat, African American patients were more difficult to treat, and time and resources were inadequate for diabetes treatment. To improve diabetes care, there is a need to address these attitudes and concerns of internal medicine physicians.     

Do physicians spend more time with non-english-speaking patients?

OBJECTIVE: To determine whether physicians at a general internal medicine clinic spend more time with non-English-speaking patients. DESIGN: A time-motion study comparing physician time spent with non-English-speaking patients and time spent with English-speaking patients during 5 months of observation. We also tested physicians' perceptions of their time use with a questionnaire. SETTING: Primary care internal medicine clinic at a county hospital. PATIENTS/PARTICIPANTS: One hundred sixty-six established clinic patients, of whom 57 were non-English speaking and 109 were English speaking, and 15 attending physicians and 8 third-year resident physicians. MEASUREMENTS AND MAIN RESULTS: Outcome measures included total patient time in clinic, wait for first nurse or physician contact, time in contact with the nurse or physician, physician time spent on the visit, and physician perceptions of time use with non-English-speaking patients. After adjustment for demographic and comorbidity variables, non-English-speaking and English-speaking patients did not differ on any time-motion variables, including physician time spent on the visit (26.0 vs 25.8 minutes). A significant number of clinic physicians believed that they spent more time during a visit with non-English-speaking patients (85.7%) and needed more time to address important issues during a visit (90. 4%), (both p <.01). Physicians did not perceive differences in the amount they accomplished during a visit with non-English-speaking patients. CONCLUSIONS: There were no differences in the time these physicians spent providing care to non-English-speaking patients and English-speaking patients. An important limitation of this study is that we were unable to measure quality of care provided or patients' satisfaction with their care. Physicians may believe that they are spending more time with non-English-speaking patients because of the challenges of language and cultural barriers.     

Training generalist physicians

To train more generalist physicians, structural changes must be made along the continuum of medical education. Future generalists require in-depth exposure to primary care practice, with substantive experience in the longitudinal management of patient panels and the opportunity to work with successful generalist role models. Clinical training and course work must incorporate a wide range of skills and disciplines, including areas now under-emphasized, such as epidemiology, health services, and psychosocial medicine. Recommendations for structural changes to increase the generalist focus of medical education include: 1) the development within institutions of central authorities, involving departments of internal medicine, family medicine, and pediatrics, in joint efforts to foster all aspects of generalist training, including recruitment, curriculum development, community linkages, innovative approaches to training, and recognition and support for successful generalist teachers; 2) commitment of a minimum of 50% of clinical training to ambulatory care settings at both medical school and residency levels; 3) required longitudinal care experiences for all medical students and a 20% or greater time commitment to longitudinal care for internal medicine, pediatrics, and family medicine residents; and 4) increased numbers of generalist faculty and enhanced teaching skills among faculty in the outpatient environment, to guarantee increased exposure of medical students and residents to generalist role models.     

Evaluating humanistic attributes of internal medicine residents

OBJECTIVE: Methods of assessing humanism in internal medicine residents have not been completely designed or evaluated. This study used patient satisfaction as a measure of humanism, and assessed the validity of using faculty physicians to evaluate residents' humanistic behavior. Residents' ability to assess themselves was also evaluated. SETTING: A university-affiliated internal medicine training program. SUBJECTS: Forty-seven internal medicine residents were evaluated by patients, faculty, and themselves. DESIGN: Faculty physicians were given standard faculty evaluation and patient satisfaction forms, and were asked to evaluate residents. These evaluations were compared with the patients' responses on the same satisfaction forms. Residents performed self-assessment using identical forms; these responses were compared with those of the faculty and patients. RESULTS: There was no correlation between patients' responses and those of the faculty or residents. There was a significant inverse correlation between resident and faculty responses, especially for the female residents (r = 0.71). CONCLUSION: These findings suggest the need for further study of the evaluation process, including what factors influence individuals to respond as they do. It appears that the use of one rating group is not sufficient to achieve an accurate assessment of residents' humanistic skills. The present status of the process of evaluating humanism is discussed.     

The residency-practice training mismatch. A primary care education dilemma

Primary care practice requires clinical skills and knowledge that differ greatly from those required for successful completion of residency training. Discrepant clinical settings and physician responsibilities have thus created a mismatch between the educational content of residency training and the content of clinical practice, which may result in suboptimal preparation of internists, family practitioners, and pediatricians for patient care. Of equal concern, the psychosocial environment of residency does not prepare physicians for their future community and personal adult roles. Barriers to correcting this worsening mismatch include the following: (1) economic pressures to use house staff to meet service needs of hospitals, (2) changes in patient demographics and the focus of hospital-based medicine that are making hospitals progressively more unsuitable as the principal training site for primary care physicians, (3) the deemphasis of practicing physicians as role models and teachers in postgraduate training, and (4) the often heated disagreement among medical educators regarding the purpose and content of residency training. Efforts to resolve this mismatch should include the following: reexamining the educational objectives of the current system of postgraduate training, better counseling of physicians in training regarding career goals, and emphasizing the primary care physician as role models and faculty.     

Malpractice risk prevention for primary care physicians

The recent medical malpractice "crisis" has seen skyrocketing liability premiums and increasing fear of liability. Primary care physicians, especially family medicine and internal medicine physicians, have historically experienced low rates of malpractice claims, both in number and amount of payment. This can be attributed to several factors: the esteem held by internal medicine and family medicine physicians in their communities, relatively low numbers of invasive procedures, reluctance of patients to include "their" primary care physician in any potential litigation, and, probably most importantly, the atmosphere of mutual trust and communication between the internist or family physician and the patient. Recent years have seen this trend erased, as insurance industry data suggest primary care physicians presently face significant potential exposure for medical malpractice claims. It is imperative that primary care physicians take steps to insure they are adequately covered in case of a malpractice claim and that they practice aggressive but appropriate risk management to lessen the likelihood of a claim.     

Evidence-based medicine knowledge,attitudes, and skills of community faculty

CONTEXT: As medical schools turn to community physicians for ambulatory care teaching, assessing the preparation of these faculty in principles of evidence-based medicine (EBM) becomes important. OBJECTIVE: To determine the knowledge and attitudes of community faculty concerning EBM and their use of EBM in patient care and teaching. DESIGN: Cross-sectional survey conducted from January to March of 2000. SETTING: A clinical campus of a state medical school; a midwestern city of a half-million people with demographics close to national means. MAIN OUTCOME MEASURES: Comparisons of community faculty with full-time faculty in perceived importance and understanding of EBM (5-point scale), knowledge of EBM, and use of EBM in patient care and teaching. MAIN RESULTS: Responses were obtained from 63% (177) of eligible community faculty and 71% (22) of full-time faculty. Community faculty considered EBM skills to be less important for daily practice than did full-time faculty (3.1 vs 4.0; P < .01). Primary care community faculty were less confident of their EBM knowledge than were subspecialty community or full-time faculty (2.9 vs 3.3 vs 3.6; P < .01). Objective measures of EBM knowledge showed primary care and subspecialty community faculty about equal and significantly below full-time faculty (P < .01). Thirty-three percent of community faculty versus 5% of full-time faculty do not incorporate EBM principles into their teaching (P < .01). CONCLUSIONS: Community faculty are not as equipped or motivated to incorporate EBM into their clinical teaching as are full-time faculty. Faculty development programs for community faculty should feature how to use and teach basic EBM concepts.     

Effects of an educational intervention on residents’ knowledge and attitudes toward interactions with pharmaceutical representatives

To assess primary care resident and faculty knowledge and attitudes concerning interactions between physicians and pharmaceutical representatives (PRs) and to measure changes in residents' knowledge and attitudes after an educational intervention, we conducted preintervention and postintervention surveys with a causal-comparative group in a university-based primary care residency program. All primary care internal medicine and internal medicine-pediatrics residents and faculty were given the voluntary survey. In general, residents and faculty demonstrated similar responses for the preintervention survey. Differences between faculty and resident opinions were seen in two areas. Faculty were more likely than residents to believe that PRs sometimes use unethical marketing practices ( p < .05) and that the amount of contact with PRs in the outpatient clinic is excessive ( p < .01). The postintervention survey of residents demonstrated significant differences between the control and intervention groups for three attitude scales. After the intervention, residents showed an increased belief that PRs may use unethical marketing practices ( p < .01), that marketing gifts with no patient benefit may be inappropriate ( p = .05), and that other physicians' prescribing patterns could be negatively influenced through the acceptance of gifts ( p < .05). A brief educational intervention can change resident attitudes concerning physician interactions with PRs.     

Internal medicine patients’ expectations for care during office visits

Objective: To describe internal medicine patients’ expectations for care during office visits and to examine the relationship between fulfillment of expectations for care and visit satisfaction. Design: Survey of patients and their physicians. Setting: The internal medicine practice of faculty and housestaff at a large academic center in Southern California. Patients: 396 patients aged 18 to 65 years were approached in the clinic waiting room prior to their scheduled visits; 337 (85% ) agreed to participate and 304 (77%) turned in completed questionnaires. Postvisit physician surveys were received in 88% of the cases. Main measurements: The patients’ previsit reports of the elements of care they thought necessary for their physicians to provide; the patients’ and physicians’ postvisit reports of the elements of care actually provided; and the patients’ satisfaction with care. Results: Among 28 specific elements of care, seven were considered necessary by a majority of the patients (examination of the eyes/ears/nose/throat, lungs, heart, and abdomen; blood testing; prognostic counseling; and discussion of patients’ own ideas about management). A higher number of elements of care were thought necessary by patients who were nonwhite and had not completed college. Up to 38% of the patients reported not receiving elements of care they had considered necessary; specific agreement between physicians and patients about care not received ranged from 63% to 100%. Not receiving certain “necessary” elements of care was associated with lower visit satisfaction. Conclusion: Internal medicine patients at the center studied had specific expectations for the content of their physician visits. However, they routinely failed to receive some of the items they thought necessary. Unless patients’ expectations are carefully elicited and dealt with, the physician-patient relationship may be adversely affected.     

Development of geriatrics-oriented faculty in general internal medicine

The need for adequate geriatrics training for the physician workforce has been recognized for decades. However, there are not enough academic geriatricians to provide for the educational needs of trainees, and this situation is not expected to change in the future. General internists are often responsible for teaching medical students and internal medicine residents to care for elderly patients in inpatient and ambulatory settings. These academic general internists could play a pivotal role in providing geriatrics instruction. To characterize what is being done to develop geriatrics-oriented general internal medicine faculty, we identified current practices, "best practices," goals and targets, and barriers to achieving those goals and targets. We reviewed the literature on faculty-development programs for general internal medicine faculty, and we held focus groups and structured interviews with general internal medicine unit chiefs and directors of Geriatric Centers of Excellence at 46 medical schools throughout the United States. We found a need for programs to develop geriatrics-oriented academic general internists. Although general internal medicine faculties seem receptive to further geriatrics training, important obstacles exist. These include inadequate time and resources as well as motivational and attitudinal challenges. We discuss potential solutions for overcoming these barriers and the implications of these solutions for stakeholders.     

Listening to older adults: elderly patients' experience of care in residency and practicing physician outpatient clinics

The population of people aged 65 and older is rapidly growing. Research has demonstrated significant quality gaps in the clinical care of older patients in the United States, especially in training programs. Little is known about how older patients' experience with care delivered in residency clinics compares with that delivered by practicing physicians. Using patient surveys from the American Board of Internal Medicine Care of the Vulnerable Elderly Practice Improvement Module, the quality of care provided to adults aged 65 and older by 52 internal medicine and family medicine residency clinics and by a group of 144 practicing physicians was studied. The residency clinics received 2,213 patient surveys, and the practicing physicians received 4,204. Controlling for age and overall health status, patients from the residency clinic sample were less likely to report receiving guidance and interventions for important aspects of care for older adults than patients from the practicing physician sample. The largest difference was observed in providing ways to help patients prevent falls or treat problems with balance or walking (42.1% vs 61.8%, P<.001). Patients from the residency clinic sample were less likely to rate their overall care as high (77.5% vs 88.8%, P<.001). Patient surveys reveal important deficiencies in processes of care that are more pronounced for patients cared for in residency clinics. Quality of patient experience and communication are vital aspects of overall quality of care, especially for older adults. Physician education at all levels, faculty development, and practice system redesign are needed to ensure that the care needs of older adults are met.     

Integrating addiction medicine into graduate medical education in primary care: the time has come

Substance use disorders create an enormous burden of medical, behavioral, and social problems and pose a major and costly public health challenge. Despite the high prevalence of substance use and its consequences, physicians often do not recognize these conditions and, as a result, provide inadequate patient care. At the center of this failure is insufficient training for physicians about substance use disorders. To address this deficit, the Betty Ford Institute convened a meeting of experts who developed the following 5 recommendations focused on improving training in substance abuse in primary care residency programs in internal medicine and family medicine: 1) integrating substance abuse competencies into training, 2) assigning substance abuse teaching the same priority as teaching about other chronic diseases, 3) enhancing faculty development, 4) creating addiction medicine divisions or programs in academic medical centers, and 5) making substance abuse screening and management routine care in new models of primary care practice. This enhanced primary care residency training should represent a major step forward in improving patient care.     

Computers in the Exam Room: Differences in Physician–Patient Interaction May Be Due to Physician Experience

Background The use of electronic medical records can improve the technical quality of care, but requires a computer in the exam room. This could adversely affect interpersonal aspects of care, particularly when physicians are inexperienced users of exam room computers. Objective To determine whether physician experience modifies the impact of exam room computers on the physician–patient interaction. Design Cross-sectional surveys of patients and physicians. Setting and Participants One hundred fifty five adults seen for scheduled visits by 11 faculty internists and 12 internal medicine residents in a VA primary care clinic. Measurements Physician and patient assessment of the effect of the computer on the clinical encounter. Main Results Patients seeing residents, compared to those seeing faculty, were more likely to agree that the computer adversely affected the amount of time the physician spent talking to (34% vs 15%, P = 0.01), looking at (45% vs 24%, P = 0.02), and examining them (32% vs 13%, P = 0.009). Moreover, they were more likely to agree that the computer made the visit feel less personal (20% vs 5%, P = 0.017). Few patients thought the computer interfered with their relationship with their physicians (8% vs 8%). Residents were more likely than faculty to report these same adverse effects, but these differences were smaller and not statistically significant. Conclusion Patients seen by residents more often agreed that exam room computers decreased the amount of interpersonal contact. More research is needed to elucidate key tasks and behaviors that facilitate doctor–patient communication in such a setting.     

The role of cultural diversity climate in recruitment,promotion, and retention of faculty in academic medicine

Background: Ethnic diversity among physicians may be linked to improved access and quality of care for minorities. Academic medical institutions are challenged to increase representation of ethnic minorities among health professionals. Objectives: To explore the perceptions of physician faculty regarding the following: (1) the institution's cultural diversity climate and (2) facilitators and barriers to success and professional satisfaction in academic medicine within this context. Design: Qualitative study using focus groups and semi-structured interviews. Participants: Nontenured physicians in the tenure track at the Johns Hopkins University School of Medicine. Approach: Focus groups and interviews were audio-taped, transcribed verbatim, and reviewed for thematic content in a 3-stage independent review/adjudication process. Results: Study participants included 29 faculty representing 9 clinical departments, 4 career tracks, and 4 ethnic groups. In defining cultural diversity, faculty noted visible (race/ethnicity, foreign-born status, gender) and invisible (religion, sexual orientation) dimensions. They believe visible dimensions provoke bias and cumulative advantages or disadvantages in the workplace. Minority and foreign-born faculty report ethnicity-based disparities in recruitment and subtle manifestations of bias in the promotion process. Minority and majority faculty agree that ethnic differences in prior educational opportunities lead to disparities in exposure to career options, and qualifications for and subsequent recruitment to training programs and faculty positions. Minority faculty also describe structural barriers (poor retention efforts, lack of mentorship) that hinder their success and professional satisfaction after recruitment. To effectively manage the diversity climate, our faculty recommended 4 strategies for improving the psychological climate and structural diversity of the institution. Conclusions: Soliciting input from faculty provides tangible ideas regarding interventions to improve an institution's diversity climate.