Comparing the efficacy of staff versus housestaff instruction in an intervention to improve hypertension management.

PURPOSE: To determine whether a resident physician can be as effective as a faculty opinion leader in changing physicians' compliance with a hypertension practice guideline. METHOD: At a general internal medicine clinic associated with an internal medicine residency program, sequential charts were reviewed for patients with uncontrolled or new-onset hypertension who were seen routinely during a two-week period. Subsequently, 23 providers were randomly assigned to an academic intervention to implement a hypertension practice guideline led by a single second-year resident instructor (RI), and 21 providers were assigned to the same intervention led by a single staff internist (SI) with an interest in hypertension. The intervention involved academic detailing, chart audit with feedback, and behavior reinforcement. Six weeks later, the chart audit was repeated to assess the change in practice patterns among providers taught by the RI compared with those taught by the SI. RESULTS: Overall, management consistent with the practice guideline improved from 32% (51/157) to 45% (56/123) (p < .01) after the intervention. This change was due to improvement in the care provided by providers from the SI-led intervention: 28% (17/60) to 57% (26/46) (p < .003). Providers from the RI-led intervention showed no improvement: 35% (34/97) to 39% (30/77) (p = NS). CONCLUSIONS: This intervention was effective in improving providers' compliance with a hypertension practice guideline, but only when led by a faculty opinion leader. A resident instructor using the same format was unable to change the providers' behaviors.     

Risk for delirium tremens in patients with alcohol withdrawal syndrome 1

To determine the characteristics associated with an increased risk for delirium tremens (DT) we performed a case‐control study at the detoxification units of two hospitals. Cases met DSM‐IV criteria for DT. For each case (n = 15), 3 controls (n = 45) were chosen. Eligibility criteria were applied equally to cases and controls. Cases were more likely than controls to report a prior complicated withdrawal (DT or alcohol withdrawal seizure) (53 vs. 27%, OR 3.1, 95% CI 0.94–10.55), have a systolic blood pressure greater than 145 mm Hg on admission (60 vs. 27%, OR 4.1, 95% CI 1.21–14.06), and have comorbidity scores of at least 1 (60 vs. 18%, OR 6.9, 95% CI 1.92–25.08). Zero cases (0%) and 15 (33%) controls had no prior complicated withdrawals and no adverse clinical features (systolic blood pressure >145 or comorbidity score >1). Compared to this group, the odds of being a case and having both prior complicated withdrawal and at least 1 adverse clinical feature was 44.8 (95% CI4.36–460). Elevated blood pressure, prior complicated alcohol withdrawal and medical comorbidity, alone and in combination, are associated with an increased risk of delirium tremens.     

Ambulatory-Based Education in Internal Medicine: Current Organization and Implications for Transformation. Results of A National Survey of Resident Continuity Clinic Directors

BACKGROUND  

Many have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide.     

Internal medicine residency redesign: proposal of the Internal Medicine Working Group

Concerned with the quality of internal medicine training, many leaders in the field assembled to assess the state of the residency, evaluate the decline in interest in the specialty, and create a framework for invigorating the discipline. Although many external factors are responsible, we also found ourselves culpable: allowing senior role models to opt out of important training activities, ignoring a progressive atrophy of bedside skills, and focusing on lock-step curricula, lectures, and compiled diagnostic and therapeutic strategies. The group affirmed its commitment to a vision of internal medicine rooted in science and learned with mentors at the bedside. Key factors for new emphasis include patient-centered small group teaching, greater incorporation of clinical epidemiology and health services research, and better schedule control for trainees. Because previous proposals were weakened by lack of evidence, we propose to organize the Cooperative Educational Studies Group, a pool of training programs that will collect a common data set describing their programs, design interventions to be tested rigorously in multi-methodological approaches, and at the same time produce knowledge about high-quality practice.