Disruptions and Satisfaction in Internal Medicine Resident Continuity Clinic Differ Between Inpatient and Outpatient Rotations

Abstract

Background: Little is known about whether assignment to simultaneous inpatient and outpatient clinical duties causes disruptions during internal medicine resident continuity clinic and impacts trainee satisfaction.

Purpose: Our purpose was to determine whether dual inpatient and continuity clinic responsibilities impact resident stress and document the number, type, and immediacy of interruptions in continuity clinics.

Methods: Methods included a prospective 2-residency survey of 70 internal medicine residents performing 240 half-day continuity clinic sessions.

Results: More than half (52%) of trainees on inpatient rotations felt pressured to return to their ward duties. Half (50%) of residents thought clinic increased work hours, and the majority (70%) did not think continuity clinic detracted from their education on inpatient or elective rotations. Disturbances were more likely to occur on inpatient rotations (odds ratio 4.52, 95% confidence interval = 2.29-8.92) than on outpatient rotations. The time required to address an interruption was 3.9 ± 4.51 min. Residents thought many (46%) problems addressed during clinic could have waited until clinic completion.

Conclusions: Residents on inpatient rotations who were commonly interrupted in clinic felt pressured to return to ward duties and unable to focus on their clinic patients. Internal medicine faculty should modify curriculum to minimize the interference of other duties in resident clinics.     

Rolandic encephalopathy and epilepsia partialis continua following bone marrow transplant

Epilepsia partialis continua (EPC) is a condition defined by prolonged focal myoclonus. Often resistant to therapy, EPC in children is frequently present in Rasmussen encephalitis, a form of chronic encephalitis of uncertain etiology. We discuss a child who developed bilateral EPC 5 months after a bone marrow transplant. Neuroimaging studies showed signal abnormalities on both sensory-motor areas. An extensive search failed to reveal the etiology of the disorder, but treatment with a broad-spectrum anti-viral agent was associated with resolution of the process. An unidentified infectious agent may be responsible for an encephalitis of the motor strip in immunosuppressed patients.     

Drug problem recognition, desire for help, and treatment readiness in a soup kitchen population

This study determined hypothesized predictors of three components of motivation for change--drug problem recognition, desire for help, and treatment readiness--in a high-risk, drug-using population. The sample consisted of 190 guests at two inner-city soup kitchens in Brooklyn, NY who reported drug/alcohol use and were not participating in substance dependency treatment. Ever receiving addiction treatment, having no trade/job skills, and more severe symptoms of depression were associated with greater drug problem recognition. More recent days of drug/alcohol use, intensive pattern of drug use, and greater problem recognition were associated with greater desire for help. Caring for children, more recent days of drug/alcohol use, physical health problems, and desire for help were the direct predictors of treatment readiness. Problem recognition had a strong indirect effect on readiness mediated through desire for help. Knowledge of a drug user's motivational state and the factors leading to it can help guide the development of more effective interventions.     

Medical outreach to homeless substance users in New York City: preliminary results

An innovative, experimental, medical out-reach initiative, using a fully-equipped mobile medical van with a staff of 2 part-time physicians, a physician assistant, a social worker, and a driver/medical aid serving the needs of 1048, mostly male, minority group, high-level, homeless New York City substance users with infectious diseases is described. The study sample (N = 250) was divided into experimental S's who received Intensive case management and a control group who could choose to refer themselves to the SW. Biological tests revealed high rates of cocaine use and infectious diseases. Preliminary 4-month outcomes (N = 128) showed reductions in drug use, homelessness and health complaints in both groups; experimental subjects compared with controls received more Public Assistance and had fewer emergency room visits.     

Predictors of drinking outcomes among alcoholics

Predicting outcomes for individual patients entering substance abuse treatment has long been a clinical goal in the addictions field. Intake data from the Addiction Severity Index and other standardized scales were collected on 248 alcohol dependent/abusing patients entering an urban hospital treatment program. The outcome measure was frequency of drinking days in the past 30 days. Baseline data were used to identify predictors of posttreatment drinking frequency at two follow-up interviews (3 and 12 months postbaseline). Stepwise multiple regressions indicated that a set of baseline predictors accounted for similar and substantial proportions of outcome variance at the two follow-ups. When psychosocial predictors were combined with an index of alcohol use severity (which included drinking frequency), the proportions of variance explained were 31% and 28% at 3 and 12 months, respectively. Two psychosocial predictors were significant at both time periods, and thus most likely to be replicated in future research: a treatment motivation index (a combination of measures of commitment to treatment success and internal motivation to seek treatment) and an index of 12-step (self-help) participation (a combination of measures of frequency of 12-step meeting attendance and perceived helpfulness of 12-step participation). While the predictability of short-term (3 month) outcomes could help clinicians tailor treatment strategies to maximize patient motivation and reduce drinking behavior, the predictability of longer term (12 month) outcomes could help counselors plan aftercare programs, encourage self-help participation, and promote recovery-oriented activities to sustain initial treatment-induced gains.     

Psychotic ideation and receipt of government entitlements among homeless persons in New York City

OBJECTIVE: This study compared changes in receipt of government entitlements by homeless persons with and without psychotic ideation in New York City between January 1997 and July 1998, a period characterized by changing state government policies and greater bureaucratic monitoring of eligibility. METHODS: In conjunction with an experimental study of the efficacy of social work services provided to homeless persons in Manhattan by a mobile medical van, 25 persons who were assessed as having experienced psychotic ideation in the previous year and 134 nonpsychotic persons were followed up after four months to identify changes in their receipt of Medicaid benefits, Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), food stamps, and home relief (state welfare for single persons). The social work intervention was designed to help eligible clients gain access to entitlements and substance abuse treatment. RESULTS: The proportion of clients with psychotic ideation who received Medicaid, food stamps, or home relief decreased during the study period, while the proportion of nonpsychotic clients who received these entitlements increased. Little change was observed in receipt of SSI or SSDI by either group. CONCLUSIONS: Psychotic ideation among homeless persons may be a significant factor in access to and maintenance of government entitlements. In the context of an increasingly restrictive and bureaucratic welfare system, providing assistance to homeless persons who have severe psychopathology presents new challenges to service providers.     

Personality traits and existential concerns as predictors of the functions of reminiscence in older adults

This study examines to what extent personality and existential constructs predict the frequency of reminiscence, in general, and its various functions, in particular. Eighty-nine older adults completed the NEO-Five Factor Inventory, the Life Attitude Profile--Revised, and the Reminiscence Functions Scale. Neuroticism predicted total reminiscence frequency, as well as reminiscence for self-understanding and ruminating about a negative past. Extraversion predicted total reminiscence frequency, as well as reminiscence for generating stimulation, conversation, and maintaining memories of departed loved ones. Openness to experience predicted total reminiscence frequency and reminiscence for addressing life meaning and death. Existential concerns, and in particular low desire to seek new challenges, added significant additional predictive power for total reminiscence frequency and for such uses as generating stimulation, preparing for death, and ruminating about the past. The discussion draws the implications of the finding that the combination of personality traits and existential concerns predicted the overall reminiscence frequency together with the intrapersonal functions of reminiscence.     

Renal abnormalities in beckwith-wiedemann syndrome are associated with 11p15.5 uniparental disomy

Beckwith-Wiedemann syndrome (BWS) is a somatic overgrowth syndrome characterized by a variable incidence of congenital anomalies, including hemihyperplasia and renal malformations. BWS is associated with disruption of genomic imprinting and/or mutations in one or more genes encoded on 11p15.5, including CDKN1C (p57(KIP2)). It was hypothesized that genotypic and epigenotypic abnormalities of the 11p15.5 region affecting CDKN1C were associated with renal abnormalities. Medical records for 159 individuals with BWS were reviewed. All underwent at least one abdominal ultrasonographic evaluation. Testing for paternal uniparental disomy (UPD) at 11p15.5, CDKN1C mutations, and imprinting defects at KvDMR1 was performed for 96, 32, and 47 patients, respectively. Of the 159 patients, 67 (42%) exhibited renal abnormalities, mainly nephromegaly (25%), collecting system abnormalities (11%), and renal cysts (10.5%). The frequency of renal lesions among patients who were tested for genetic abnormalities did not differ from that among patients who were not tested. Paternal UPD was demonstrated in 22 of 96 cases (23%), CDKN1C mutations in eight of 32 cases (25%), and KvDMR1 imprinting defects in 21 of 47 cases (45%). The 22 UPD-positive patients exhibited a significantly higher incidence of renal abnormalities (P = 0.0026). Surprisingly, the eight patients with CDKN1C mutations exhibited no significant increase in the incidence of renal lesions (P = 0.29). Imprinting defects at KvDMR1, which might downregulate CDKN1C, were also not associated with a significant difference in the incidence of renal disease. Whereas UPD at 11p15.5 in BWS was associated with a higher incidence of renal abnormalities, mutations at CDKN1C and KvDMR1 imprinting defects were not, suggesting that imprinted genes on 11p15.5 other than CDKN1C are critical for renal development.