An uncommon infection in an uncommon host.

We present the case of an international traveller who was eventually diagnosed with amoebiasis and autosomal dominant polycystic kidney disease (ADPKD) after she presented with recurring fevers. The patient was also diagnosed with non-amoebic bacterial hepatitis. Positron emission tomography (PET) can play an important role in locating the source of infection in patients with ADPKD when hepatic or renal infection is suspected. It can also be used to document clinical resolution of infection in difficult cases. Hepatic parenchymal infections in ADPKD patients may warrant a prolonged course of rotating antibiotics.

Resident physicians' perspectives on effective outpatient teaching: a qualitative study.

Learning theories, which suggest that experienced faculty use collaborative teaching styles, are reflected in qualitative studies of learners in hospital settings. However, little research has used resident focus groups to explore characteristics of successful teachers in outpatient clinics. Therefore, focus group discussions with first through third-year internal medicine residents at a large academic medical center were conducted to better understand residents' perspectives on effective outpatient teaching. A group facilitator solicited residents' reflections, based on their lived experiences, on teaching domains from previous factor analytic studies: interpersonal, clinical-teaching, and efficiency. Researchers coded focus group transcripts and identified themes within the domains. Final themes were determined by consensus. Leading themes were "kindness" and "teacher-learner relationships." Junior residents were sensitive to faculty who were brusque, harsh, and degrading. Senior residents respected faculty who were humble, collaborative, and allowed residents to co-manage teaching encounters. Seniors emphasized the importance of faculty role-modelling and preferentially staffed with experts to "gain wisdom from experience." Overall, residents expressed that effective learning requires grounded teacher-learner relationships. These findings support learning theories and previous factor analytic studies. However, this qualitative study provided insights that could not be gleaned from assessment scores alone.

Immunization education for internal medicine residents: A cluster-randomized controlled trial.

PURPOSE: The aims of this study are to evaluate the impact of a novel immunization curriculum based on the Preferred Cognitive Styles and Decision Making Model (PCSDM) on internal medicine (IM) resident continuity clinic patient panel immunization rates, as well as resident immunization knowledge, attitudes, and practices (KAP). METHODS: A cluster-randomized controlled trial was performed among 143 IM residents at Mayo Clinic to evaluate the PCSDM curriculum plus fact-based immunization curriculum (intervention) compared to fact-based immunization curriculum alone (control) on the outcomes of resident continuity clinic patient panel immunization rates for influenza, pneumococcal, tetanus, pertussis, and zoster vaccines. Pre-study and post-study immunization KAP surveys were administered to IM residents. RESULTS: Ninety-nine residents participated in the study. Eighty-two residents completed pre-study and post-study surveys. Influenza and pertussis immunization rates improved for both intervention and control groups. There was no significant difference in immunization rate improvement between the groups. Influenza immunization rates improved significantly by 33.4% and 32.3% in the intervention and control groups, respectively. The odds of receiving influenza immunization at the end of the study relative to pre-study for the entire study cohort was 4.6 (p < 0.0001). The odds of having received pertussis immunization at the end of the study relative to pre-study for the entire study cohort was 1.2 (p = 0.0002). Both groups had significant improvements in immunization knowledge. The intervention group had significant improvements in multiple domains that assessed confidence in counseling patients on immunizations. CONCLUSIONS: Fact-based immunization education was useful in improving IM resident immunization rates for influenza and pertussis. The PCSDM immunization curriculum did not lead to increases in immunization rates compared with the fact-based curriculum, but it did significantly increase resident confidence in communicating with patients about vaccines.

Who makes the diagnosis? The role of clinical skills and diagnostic test results.

RATIONALE, AIMS AND OBJECTIVES: Advances in medicine have led to a multitude of diagnostic tests. The contribution of the clinical skills of the general internist in the context of all these advances is unknown. Our objective was to assess the relative contributions of clinical skills and diagnostic test results in arriving at a final diagnosis. METHODS: Records were retrospectively reviewed from 248 consecutive patients admitted to a general internal medicine hospital service during a 3-month period in 2000. All diagnostic evaluations that yielded the final diagnosis were recorded along with the date and time they were performed. Diagnostic credit was given to the evaluation that yielded the diagnosis at the earliest point in time. RESULTS: All cases had a firm diagnosis by 3 months after hospitalization. Of the 248 patients, 246 received a final diagnosis during hospitalization. The diagnoses were made by use of the clinical judgement of the general internist in 50.4% of the cases, a radiologic study in 31.7%, a blood test or culture result in 9.4%, biopsy findings in 3.3% and various other diagnostic studies (endoscopy, echocardiography, electromyography and electroencephalography) in 5.2%. Clinicians provided the correct diagnosis significantly more often than radiologic studies (P = 0.0015), which was the next most useful type of diagnostic evaluation. CONCLUSION: Although technology has become increasingly available in clinical practice, clinical expertise and skills are still important factors with respect to making correct, timely diagnoses in hospitalized patients.

Screening for cervical cancer and initial treatment of patients with abnormal results from papanicolaou testing.

New techniques for cervical cancer screening and a better understanding of the natural history of human papillomavirus (HPV) and cervical neoplasia have inspired a quest for more rational screening strategies for cervical cancer. Often, screening intervals for women older than 30 years can be expanded safely to every 3 years, and experts now agree that screening may cease after hysterectomy and in elderly women (provided certain criteria have been met). Liquid-based cytology produces more satisfactory specimens than conventional testing and offers the valuable option of treating atypical squamous cells of undetermined significance by "reflex" testing for high-risk types of HPV on the original specimen. Testing for HPV as an adjunct to cervical cytology for primary screening is now considered reasonable for many women older than 30 years.

Increased faculty presence on inpatient teaching services.

OBJECTIVES: To determine whether the level of presence of faculty in the afternoon or evening influences residents' perception of learning, "autonomy," or satisfaction, and if so whether the effect is positive or negative. SUBJECTS AND METHODS: A survey of internal medicine residents was conducted from January 1 through June 30, 1999. Primary outcome was residents' satisfaction and its relationship to the degree of (resident-observed) faculty presence. RESULTS: A total of 156 (86.7%) of the 180 surveys distributed were returned. Residents rated the individual faculty members' frequency of afternoon or evening presence as "most/all of the time" (47%), "occasionally" (32%), or "never/rarely" (21%). Increased faculty presence was positively associated with higher resident "satisfaction with faculty" (P < .001), "educational value of time spent with the faculty member" (P = .001), "team dynamics" (P = .002), "(quality of) overall medical care provided" (P = .03), and "sufficient autonomy" (P = .04). Residents were less likely to report concerns (difficulties) with teaching (P < .001) and efficiency (P = .008) of faculty whose level of presence was increased. CONCLUSION: Contrary to some concerns expressed, increased faculty presence is associated with higher resident satisfaction and a more favorable learning experience.

Clinical pearls in perioperative medicine.

At the 2001 annual meeting of the American College of Physicians (ACP), a new and innovative teaching format, the "Clinical Pearls" session, was introduced. Clinical Pearls sessions were designed to teach physicians using clinical cases. The session format involves specialty speakers presenting a number of short cases to a physician audience. Each case is followed by a multiple-choice question, answered by each attendee using an electronic audience-response system. After a summary of the answer distribution is shown, the correct answer is displayed and the speaker discusses important teaching points and clarifies why one answer is most clinically appropriate. Each case presentation ends with 1 or 2 "Clinical Pearls," defined as a practical teaching point, supported by the literature, and generally not well known to most internists. The Clinical Pearls sessions are consistently one the most popular and well attended sessions at the American College of Physicians' national meeting each year. Herein, we present the Clinical Pearls in Perioperative Medicine, presented at the ACP National Meeting in San Francisco, California, April 11-13, 2013.

Improved resident physician confidence with advance care planning after an ambulatory clinic intervention.

Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents' advance care planning (ACP) practices and improve residents' ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.