Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2023.

The expansive scope of internal medicine can make it challenging for clinicians to stay informed about new literature that changes practice. Guideline updates and synthesis of relevant evidence can facilitate incorporation of advancements into clinical practice. The titles and abstracts from the seven general medicine journals with highest impact factors and relevance to outpatient internal medicine were reviewed by six internal medicine physicians. Coronavirus disease 19 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 Mayo Clinic Proceedings were reviewed. Additionally, article synopsis collections and databases were evaluated: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster ACCESSSS/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, seven practice-changing articles were included.

Closing the gap: improving the percentage of Annual Wellness Visits among Medicare patients.

BACKGROUND: The Medicare Annual Wellness Visit (AWV) allows providers to acquire critical information about patients' health through a review of vitals, environmental risks, and medical and family history. These visits are free to those enrolled in Medicare and prioritize patient-provider relationship building and preventative care. Despite this, AWV completion rates are suboptimal. METHODS: A quality improvement project was aimed to increase the percentage of AWVs among Medicare patients in a primary care internal medicine practice from a baseline of 1.7% completion to 2.7% in 3 months from January to April 2023. INTERVENTION: With eligible patients identified, a standardized approach was created where an AWV appointment was ordered, and a patient message explaining the benefit of the appointment was sent by the patient portal. RESULTS: Our AWV intervention resulted in 72 patients being seen for an AWV, which increased the percentage of completed AWVs in the division by 2.1% from 1.7% to 3.8% in 3 months. CONCLUSION: This intervention will continue to improve AWV rates and improve patient care for Medicare patients in internal medicine. It could be applied to other areas of primary care and within other health systems.

Primary hepatic Epstein-Barr virus-positive diffuse large B-cell lymphoma associated with azathioprine immunosuppression: a case report.

BACKGROUND: Hepatic masses are relatively common findings, and the diagnostic approach often begins by identifying patient and mass characteristics that are risk factors for malignancy. Chronic immunosuppression is a known risk factor for various malignancies, and azathioprine in particular has been reported in association with solid and hematologic malignancies, including diffuse large B-cell lymphoma. CASE PRESENTATION: A 46-year-old white woman presented to clinic with several weeks of gastrointestinal symptoms and was found to have a hepatic mass on imaging. Her history was notable for neuromyelitis optica spectrum disorder on chronic immunosuppression with azathioprine. It was initially thought to be an inflammatory adenoma. On 6-month follow-up imaging, the mass had grown rapidly in size and was surgically resected. Further workup determined the mass to be an iatrogenic immunodeficiency-associated Epstein-Barr virus-positive diffuse large B-cell lymphoma confined to the liver. Azathioprine was discontinued and the patient underwent treatment with rituximab with no evidence of recurrence 2 years after the initiation of treatment. CONCLUSIONS: This case report describes the first time hepatic Epstein-Barr virus-positive diffuse large B-cell lymphoma has been reported with azathioprine, which highlights the unique sequelae of chronic immunosuppression, including atypical hematologic malignancies, and the importance of considering chronic immunosuppression in the diagnostic evaluation of a hepatic mass.

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.

A woman with recurrent umbilical bleeding: a case report.

BACKGROUND: Umbilical discharge in an adult is rare and generates broad diagnostic considerations. Umbilical anatomy is variable owing to congenital abnormalities and acquired pathology such as umbilical hernias. The umbilicus can be a site of primary or metastatic malignancy or endometriosis. CASE PRESENTATION: A 40-year-old white American woman came to the clinic with a 2-day history of spontaneous umbilical bleeding. She reported periumbilical pain associated with nausea and emesis. There were no visible skin abnormalities, but deep palpation of the abdomen produced a thin, watery, serosanguineous fluid from the umbilicus. She experienced a similar episode of umbilical bleeding 5 years prior without clear cause. Laboratory workup was notable for mildly elevated C-reactive protein . Computed tomography imaging revealed a fat-containing umbilical hernia with fat necrosis, necessitating complete surgical resection of the umbilicus. CONCLUSIONS: Umbilical hernia with fat necrosis is a rare condition that should be considered in adults with umbilical discharge. Additional diagnostic considerations in adults with spontaneous umbilical bleeding/discharge include embryonal remnants, omphalitis, and metastasis. If the cause is not readily apparent on physical exam, imaging with computed tomography should be considered to assess for hernia and embryonal anomalies.

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.

Perceptions of scheduled vs. unscheduled directly observed visits in an internal medicine residency outpatient clinic.

INTRODUCTION: Learners may subconsciously change their behavior once they know they are being observed, and this Hawthorne effect should be considered when designing assessments of learner behavior. While there is a growing body of literature to suggest direct observation is the ideal standard for formative assessment, the best method to directly observe learners is unknown. We explored scheduled and unscheduled methods of direct observation among internal medicine residents in the outpatient continuity clinic to advance the understanding of both observation methods. METHODS: We conducted a thematic analysis of faculty and internal medicine residents in an outpatient clinic setting. A semi-structured interview guide for focus group sessions was created. Focus groups were used to explore the internal medicine resident and core teaching faculty perceptions of the scheduled and unscheduled direct observation methods in the outpatient clinc. An experienced qualitative research interviewer external to the internal medicine residency was moderating the sessions. Eight peer focus groups were held. Abstraction of themes from focus group transcripts identified resident and faculty perceptions of the different observation methods. RESULTS: Focus groups had 14 resident participants and 14 faculty participants. Unscheduled observations were felt to be more authentic than scheduled observations since residents perceived their behavior to be unmodified. Unscheduled observations allowed for increased numbers of observations per resident, which permitted more frequent formative assessments. Residents and faculty preferred remote video observation compared to in-room observation. Participants found direct observation a useful learning tool for high-yield, specific feedback. CONCLUSIONS: Unscheduled remote direct observation captures authentic clinical encounters while minimizing learner behavior modification. An unscheduled observation approach results in more frequent formative assessment and therefore in more instances of valuable feedback compared to scheduled observations. These findings can help guide the best practice approaches to direct clinical observation in order to enhance residents learning and experience.

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.

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.

Assessment and improvement of HIV screening rates in a Midwest primary care practice using an electronic clinical decision support system: a quality improvement study.

BACKGROUND: Universal human immunodeficiency virus (HIV) screening remains low in many clinical practices despite published guidelines recommending screening for all patients between ages 13-65. Electronic clinical decision support tools have improved screening rates for many chronic diseases. We designed a quality improvement project to improve the rate of universal HIV screening of adult patients in a Midwest primary care practice using a clinical decision support tool. METHODS: We conducted this quality improvement project in Rochester, Minnesota from January 1, 2014 to December 31, 2014. Baseline primary care practice HIV screening data were acquired from January 1, 2014 to April 30, 2014. We surveyed providers and educated them about current CDC recommended screening guidelines. We then added an HIV screening alert to an existing electronic clinical decision support tool and post-intervention HIV screening rates were obtained from May 1, 2014 to December 31, 2014. The primary quality outcome being assessed was change in universal HIV screening rates. RESULTS: Twelve thousand five hundred ninety-six unique patients were eligible for HIV screening in 2014; 327 were screened for HIV. 6,070 and 6,526 patients were seen before and after the intervention, respectively. 1.80 % of eligible patients and 3.34 % of eligible patients were screened prior to and after the intervention, respectively (difference of -1.54 % [-2.1 %, -0.99 %], p < 0.0001); OR 1.89 (1.50, 2.38). Prior to the intervention, African Americans were more likely to have been screened for HIV (OR 3.86 (2.22, 6.71; p < 0.001) than Whites, but this effect decreased significantly after the intervention (OR 1.90 (1.12, 3.21; p = 0.03). CONCLUSIONS: These data showed that an electronic alert almost doubled the rates of universal HIV screening by primary care providers in a Midwestern practice and reduced racial disparities, but there is still substantial room for improvement in universal screening practices. Opportunities for universal HIV screening remain abundant, as many providers either do not understand the importance of screening average risk patients or do not remember to discuss it. Alerts to remind providers of current guidelines and help identify screening opportunities can be helpful.

Associations between attending physician workload, teaching effectiveness, and patient safety.

BACKGROUND: Prior studies suggest that high workload among attending physicians may be associated with reduced teaching effectiveness and poor patient outcomes, but these relationships have not been investigated using objective measures of workload and safety. OBJECTIVE: To examine associations between attending workload, teaching effectiveness, and patient safety, hypothesizing that higher workload would be associated with lower teaching effectiveness and negative patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective study of 69,386 teaching evaluation items submitted by 543 internal medicine residents for 107 attending physicians who supervised inpatient teaching services from July 2, 2005 to July 1, 2011. MEASUREMENTS: Attending workload measures included hospital service census, patient length of stay, daily admissions, daily discharges, and concurrent outpatient duties. Teaching effectiveness was measured using residents' evaluations of attendings. Patient outcomes considered were applicable patient safety indicators (PSIs), intensive care unit transfers, cardiopulmonary resuscitation/rapid response team calls, and patient deaths. Mixed linear models and generalized linear regression models were used for statistical analysis. RESULTS: Workload measures of midnight census and daily discharges were associated with lower teaching evaluation scores (both ß = -0.026, P < 0.0001). The number of daily admissions was associated with higher teaching scores (ß = 0.021, P = 0.001) and increased PSIs (odds ratio = 1.81, P = 0.0001). CONCLUSION: Several measures of attending physician workload were associated with slightly lower teaching effectiveness, and patient safety may be compromised when teams are managing new admissions. Ongoing efforts by residency programs to optimize the learning environment should include strategies to manage the workload of supervising attendings.

Addressing the Interprofessional Collaboration Competencies of the Association of American Medical Colleges: A Systematic Review of Assessment Instruments in Undergraduate Medical Education.

PURPOSE: To summarize characteristics and validity evidence of tools that assess teamwork in undergraduate medical education (UME), and provide recommendations for addressing the interprofessional collaboration competencies of the Association of American Medical Colleges (AAMC). METHOD: The authors conducted a systematic review, searching MEDLINE, MEDLINE In-process, CINAHL, and PsycINFO from January 1, 1979, through April 1, 2014; they searched reference lists and national meeting abstracts. They included original research reports that described a quantitative tool used to assess teamwork in UME. They abstracted characteristics and validity evidence for the tools, plus study quality, according to established frameworks. Two authors independently abstracted 25% of articles and calculated agreement. Authors then applied predefined criteria to identify tools best suited to address the AAMC's teamwork competencies. RESULTS: Of 13,549 citations, 70 articles describing 64 teamwork assessment tools were included. Of these 64 tools, 27 (42%) assessed teamwork in classroom, 31 (48%) in simulation, and only 7 (11%) in actual clinical settings. The majority (47; 73%) of tools assessed medical students' teamwork in interprofessional teams. On the basis of content concordance, strength of validity evidence, generalizability of scores, and level of outcomes, four published tools were recommended to assess the AAMC's teamwork competencies: the Collaborative Healthcare Interdisciplinary Relationship Planning Scale, Readiness for Interprofessional Learning Scale, Communication and Teamwork Skills assessment, and Teamwork Mini-Clinical Evaluation Exercise. CONCLUSIONS: Substantial validity evidence supports the use of several UME teamwork assessments. Four tools have been appropriately designed and sufficiently studied to constitute appropriate assessments of the AAMC's teamwork competencies.

Interprofessional collaboration milestones: advocating for common assessment criteria in graduate medical education.

BACKGROUND: Milestone-based assessments of resident physicians inform critical decisions regarding resident competence and advancement. Thus, it is essential that milestone evaluations are based upon strong validity evidence and that consistent evaluation criteria are used across residency programs. A common approach to assessment of interprofessional collaboration milestones is particularly important since standardized measures of individual resident competence in interprofessional collaboration have not been established. DISCUSSION: We propose that assessments of interprofessional collaboration in graduate medical education meet common criteria, namely, these assessments should: 1) measure competency of an individual resident, 2) occur in the context of an interprofessional team, 3) be ascertained via direct observation of the resident, 4) be performed in a real-world clinical practice setting (such as a hospital ward, outpatient clinic, or operating room). We present the evidence-based rationale for these criteria and cite examples of published assessment instruments that fulfill one or more of the criteria, however further research is needed to ensure fidelity of assessments. The proposed criteria may assist residency educators as they endeavor to provide robust and consistent assessments of interprofessional collaboration milestones.

Enhancing motivation with the "virtual" supervisory role: a randomized trial.

BACKGROUND: We aimed to explore the influence of a motivationally-enhanced instructional design on motivation to learn and knowledge, hypothesizing that outcomes would be higher for the enhanced instructional format. METHODS: Medicine residents completed four online learning modules on primary care topics. Using a crossover design, learners were randomized to receive two standard and two motivationally-enhanced learning modules. Both formats had self-assessment questions, but the enhanced format questions were framed to place learners in a supervisory/teaching role. Learners received a baseline motivation questionnaire, a short motivation survey before and after each module, and a knowledge posttest. RESULTS: One hundred twenty seven residents were randomized. 123 residents (97%) completed at least one knowledge posttest and 119 (94%) completed all four posttests. Across all modules, a one-point increase in the pretest short motivation survey was associated with a 2.1-point increase in posttest knowledge. The change in motivation was significantly higher for the motivationally enhanced format (standard mean change -0.01, enhanced mean change +0.09, difference = 0.10, CI 0.001 to 0.19; p = 0.048). Mean posttest knowledge score was similar (standard mean 72.8, enhanced mean 73.0, difference = 0.2, CI -1.9 to 2.1; p = 0.90). CONCLUSIONS: The motivationally enhanced instructional format improved motivation more than the standard format, but impact on knowledge scores was small and not statistically significant. Learners with higher pre-intervention motivation scored better on post-intervention knowledge tests, suggesting that motivation may prove a viable target for future instructional enhancements.