Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2022.

It can be difficult for clinicians to stay updated on practice-changing articles.  Synthesis of relevant articles and guideline updates can facilitate staying informed on important new data impacting clinical practice.  The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded.  The New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association, The British Medical Journal (BMJ), the Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 5 practice-changing articles were included, along with a highlight of key guideline updates.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2021.

It can be challenging to identify new evidence that may shift clinical practice within internal medicine. Synthesis of relevant articles and guideline updates can facilitate staying informed of these changes. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 8 practice-changing articles were included.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2020.

In a time of rapidly shifting evidence-based medicine, it is challenging to stay informed of research that modifies clinical practice. To enhance knowledge of practice-changing literature, a group of 7 internists reviewed titles and abstracts in 7 internal medicine journals with the highest impact factors and relevance to outpatient general internal medicine. Coronavirus disease-19 research was purposely excluded to highlight practice changes beyond the pandemic. New England Journal of Medicine (NEJM), The Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine were reviewed. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on relevance to outpatient internal medicine, impact on practice, and strength of evidence. Clusters of articles pertaining to the same topic were considered together. In total, 7 practice-changing articles were included.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2019.

Clinicians are challenged to stay informed of new and changing medical literature. To facilitate knowledge updates and synthesis of practice-changing information, a group of 6 internists reviewed the titles and abstracts in the 7 outpatient general internal medicine journals with the highest impact factors and relevance to outpatient internal medicine physicians: New England Journal of Medicine (NEJM), Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertaining to the same topic were considered together. In total, 7 practice-changing articles were included.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2018.

The expansive scope of general internal medicine makes it difficult to identify practice-changing medical literature. Clinical updates can be facilitated by synthesizing relevant articles and implications for practice. Six internal medicine physicians reviewed the titles and abstracts in the 7 general internal medicine clinical outpatient journals with the highest impact factor and relevance to the internal medicine outpatient physician: New England Journal of Medicine (NEJM), Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA-Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus on articles based on clinical relevance to outpatient Internal Medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 7 practice-changing articles were included.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2017.

Clinicians are challenged to identify new practice-changing articles in the medical literature. To identify the practice-changing articles published in 2017 most relevant to outpatient general internal medicine, 5 internists reviewed the following sources: 1) titles and abstracts from internal medicine journals with the 7 highest impact factors, including New England Journal of Medicine, Lancet, Journal of the American Medical Association, British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine; 2) synopses and syntheses of individual studies, including collections in the American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine; 3) databases of synthesis, including Evidence Updates and the Cochrane Library. Inclusion criteria were perceived clinical relevance to outpatient general medicine, potential for practice change, and strength of evidence. This process yielded 140 articles. Clusters of important articles around one topic were considered as a single-candidate series. A modified Delphi method was utilized by the 5 authors to reach consensus on 7 topics to highlight and appraise from the 2017 literature.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2015.

Identifying new practice-changing articles is challenging. To determine the 2015 practice-changing articles most relevant to outpatient general internal medicine, 3 internists independently reviewed the titles and abstracts of original articles, synopses of single studies and syntheses, and databases of syntheses. For original articles, internal medicine journals with the 7 highest impact factors were reviewed: New England Journal of Medicine, Lancet, Journal of the American Medical Association (JAMA), British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine. For synopses of single studies and syntheses, collections in American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine were reviewed. For databases of synthesis, Evidence Updates and the Cochrane Library were reviewed. More than 100 articles were identified. Criteria for inclusion were as follows: clinical relevance, potential for practice change, and strength of evidence. Clusters of important articles around one topic were considered as a single-candidate series. The 5 authors used a modified Delphi method to reach consensus on inclusion of 7 topics for in-depth appraisal.

Rating the Quality of Entrustable Professional Activities: Content Validation and Associations with the Clinical Context.

BACKGROUND: Entrustable professional activities (EPAs) have been developed to assess resident physicians with respect to Accreditation Council for Graduate Medical Education (ACGME) competencies and milestones. Although the feasibility of using EPAs has been reported, we are unaware of previous validation studies on EPAs and potential associations between EPA quality scores and characteristics of educational programs. OBJECTIVES: Our aim was to validate an instrument for assessing the quality of EPAs for assessment of internal medicine residents, and to examine associations between EPA quality scores and features of rotations. DESIGN: This was a prospective content validation study to design an instrument to measure the quality of EPAs that were written for assessing internal medicine residents. PARTICIPANTS: Residency leadership at Mayo Clinic, Rochester participated in this study. This included the Program Director, Associate program directors and individual rotation directors. INTERVENTIONS: The authors reviewed salient literature. Items were developed to reflect domains of EPAs useful for assessment. The instrument underwent further testing and refinement. Each participating rotation director created EPAs that they felt would be meaningful to assess learner performance in their area. These 229 EPAs were then assessed with the QUEPA instrument to rate the quality of each EPA. MAIN MEASURES: Performance characteristics of the QUEPA are reported. Quality ratings of EPAs were compared to the primary ACGME competency, inpatient versus outpatient setting and specialty type. KEY RESULTS: QUEPA tool scores demonstrated excellent reliability (ICC range 0.72 to 0.94). Higher ratings were given to inpatient versus outpatient (3.88, 3.66; p = 0.03) focused EPAs. Medical knowledge EPAs scored significantly lower than EPAs assessing other competencies (3.34, 4.00; p < 0.0001). CONCLUSIONS: The QUEPA tool is supported by good validity evidence and may help in rating the quality of EPAs developed by individual programs. Programs should take care when writing EPAs for the outpatient setting or to assess medical knowledge, as these tended to be rated lower.

Update in outpatient general internal medicine: practice-changing evidence published in 2014.

The practice of outpatient general internal medicine requires a diverse and evolving knowledge base. General internists must identify practice-changing shifts in the literature and reflect on their impact. Accordingly, we conducted a review of practice-changing articles published in outpatient general internal medicine in 2014. To identify high-quality, clinically relevant publications, we reviewed all titles and abstracts published in the following primary data sources in 2014: New England Journal of Medicine, Journal of the American Medical Association (JAMA), Annals of Internal Medicine, JAMA Internal Medicine, and the Cochrane Database of Systematic Reviews. All 2014 primary data summaries from Journal Watch-General Internal Medicine and ACP JournalWise also were reviewed. The authors used a modified Delphi method to reach consensus on inclusion of 8 articles using the following criteria: clinical relevance to outpatient internal medicine, potential for practice change, and strength of evidence. Clusters of important articles around one clinical question were considered as a single-candidate series. The article merits were debated until consensus was reached on the final 8, spanning a variety of topics commonly encountered in outpatient general internal medicine.

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.

Update in internal medicine residency education: a review of the literature in 2010 and 2011.

BACKGROUND: Evidence-based practice in education requires high-quality evidence, and many in the medical education community have called for an improvement in the methodological quality of education research. OBJECTIVE: Our aim was to use a valid measure of medical education research quality to highlight the methodological quality of research publications and provide an overview of the recent internal medicine (IM) residency literature. METHODS: We searched MEDLINE and PreMEDLINE to identify English-language articles published in the United States and Canada between January 1, 2010, and December 31, 2011, focusing on IM residency education. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI), which has demonstrated reliability and validity. Qualitative articles were excluded. Articles were ranked by quality score, and the top 25% were examined for common themes, and 2 articles within each theme were selected for in-depth presentation. RESULTS: The search identified 731 abstracts of which 223 articles met our inclusion criteria. The mean (±SD) MERSQI score of the 223 studies included in the review was 11.07 (±2.48). Quality scores were highest for data analysis (2.70) and lowest for study design (1.41) and validity (1.29). The themes identified included resident well-being, duty hours and resident workload, career decisions and gender, simulation medicine, and patient-centered outcomes. CONCLUSIONS: Our review provides an overview of the IM medical education literature for 2010-2011, highlighting 5 themes of interest to the medical education community. Study design and validity are 2 areas where improvements in methodological quality are needed, and authors should consider these when designing research protocols.

Resident physician perspectives on outpatient continuity of care.

BACKGROUND: The outpatient continuity clinic is an essential component of internal medicine residency programs, yet continuity of patient care in these clinics is suboptimal. Reasons for this discontinuity have been inadequately explored. OBJECTIVE: We sought to assess perceived factors contributing to discontinuity in trainee ambulatory clinics. METHODS: The study encompassed 112 internal medicine residents at a large academic medical center in the Midwest. We conducted 2 hours of facilitated discussion with 18 small groups of residents. Residents were asked to reflect on factors that pose barriers to continuity in their ambulatory practice and potential mechanisms to reduce these barriers. Resident comments were transcribed and inductive analysis was performed to develop themes. We used these themes to derive recommendations for improving continuity of care in a resident ambulatory clinic. RESULTS: Key themes included an imbalance of clinic scheduling that favors access for patients with acute symptoms over continuity, clinic triage scripts that deemphasize continuity, inadequate communication among residents and faculty regarding shared patients, residents' inefficient use of nonphysician care resources, and a lack of shared values between patients and providers regarding continuity of care. CONCLUSIONS: The results offer important information that may be applied in iterative program changes to enhance continuity of care in resident clinics.

Nicotine percentage replacement among smokeless tobacco users with nicotine patch.

To obtain preliminary evidence on the safety and efficacy of high dose nicotine patch therapy among smokeless tobacco (ST) users who consume > or =3 cans of ST per week, we conducted a randomized, placebo-controlled clinical trial with 42 ST users randomized to nicotine patch doses of 21, 42, and 63 mg/day or placebo. Serum nicotine concentrations were measured during ad libitum ST use and nicotine replacement therapy, and percentages of nicotine replacement were calculated. We observed substantial inter-subject variability in nicotine concentrations with ad lib ST use. The mean percentage replacement of ad lib ST use serum nicotine concentrations approximated 100% with the 42 mg/day patch dose (mean+/-S.D., 98.4%+/-45%). Dosing with the 21 mg/day nicotine patch was associated with mean "under-replacement" (53.2%+/-17.1%), and the 63 mg/day nicotine was associated with mean "over-replacement" (159.2%+/-121.9%). We observed symptoms of nausea consistent with nicotine toxicity in two subjects in the 63 mg/day group while no subjects in the 42 mg/day reported these symptoms. We conclude that the use of 42 mg/day nicotine patch therapy is safe and should be considered as initial therapy in the clinical setting among ST users who use > or =3 cans/week.