Milestones-based direct observation tools in internal medicine resident continuity clinic.

BACKGROUND: With milestones-based assessment, there is an increased need for tools to facilitate direct observation of clinical trainees. This study was designed to compare a Mini-CEX tool to new direct observation tools (DOTs) linked to internal medicine milestones. METHODS: A web based survey was used to examine satisfaction and usefulness of DOTs compared to the Mini-CEX. Residents and preceptors were surveyed three times over 6 months with half serving as control (using mini-CEX) compared to those using the DOTs. Likert scale quantitative answers and qualitative comments were analyzed using generalized estimating equations. RESULTS: Out of 94 residents and 32 faculty 81 and 90% completed the survey for at least one time point. In adjusted models, there was no significant change in resident evaluation comparing the tools on a number of questions including overall satisfaction and resident perception of receiving high quality feedback. By contrast, faculty preceptors reported increased ratings on many of the questions evaluating their use of the new tools including ability to provide higher quality feedback and overall satisfaction. A number of challenges and benefits of the new tools were identified in qualitative feedback by both residents and preceptors. CONCLUSIONS: All parties recognized the value and limitations of direct observation. Overall these new office based DOTs were perceived similarly to the mini-CEX by residents while faculty reported higher satisfaction. The DOTs are a useful addition to the tool box available for the assessment of clinical skills of medical trainees, especially from the viewpoint of faculty preceptors.

The influence of black race on treatment and mortality for early-stage breast cancer.

BACKGROUND: Black Americans have higher mortality from breast cancer than white Americans. This study explores the influence of socioeconomic factors and black race on treatment and mortality for early-stage breast cancer. METHODS: A cohort of 21,848 female black and white, non-Hispanic subjects from the Massachusetts Cancer Registry diagnosed with stage I or II breast cancer between 1999-2004 was studied. Subjects with tumors larger than 5 cm were excluded. We used mixed modeling methods to assess the impact of race on guideline concordant care (GCC), defined as receipt of mastectomy or breast conserving surgery plus radiation. Cox proportional hazard regression was used to assess disease-specific mortality. RESULTS: Blacks were less likely to receive GCC after adjusting for age and clinical variables (OR: 0.75; 95% CI: 0.61, 0.92). Marital status and insurance were predictors of receipt of GCC. After adjustment for all covariates, there were no longer significant differences between black and white women regarding the receipt of GCC. Nevertheless, black women were more likely to die of early-stage breast cancer than white women after adjusting for clinical, treatment, socioeconomic variables, and reporting hospital (HR: 1.6; 95% CI: 1.1-2.1). CONCLUSIONS: Socioeconomic factors are mediators of racial differences in treatment outcomes. Significant racial differences exist in disease-specific mortality for women with early-stage breast cancer. Attention to reducing socioeconomic barriers to care may influence racial differences in breast cancer treatment and mortality.

Prolonged cerebellar ataxia: an unusual complication of hypoglycemia.

A 51-year-old male with a history of insulin-dependent diabetes and polysubstance abuse presented after overdose on insulin. Soon after resuscitation, he displayed a severe ataxia in all 4 limbs and was unable to walk; all of which persisted for at least 5 days. Laboratory testing was unrevealing, including relatively normal brain magnetic resonance imaging. He had recovered full neurologic function 3 months after the event. This report describes a case of reversible cerebellar ataxia as a rare complication of severe hypoglycemia that may occur in patients with abnormal cerebellar glucose metabolism. Thus, this phenomenon should be included in the differential diagnosis of patients with a history of hypoglycemia who present with ataxia. In this context, the differential diagnosis of cerebellar ataxia is discussed, as is the proposed mechanism for hypoglycemia-induced cerebellar dysfunction.

Integrative Medicine in a Preventive Medicine Residency: A Program for the Urban Underserved.

The Preventive Medicine Residency Program collaborated with the Department of Family Medicine's Program for Integrative Medicine and Health Disparities at Boston Medical Center to create a new rotation for preventive medicine residents starting in autumn 2012. Residents participated in integrative medicine group visits and consults, completed an online curriculum in dietary supplements, and participated in seminars all in the context of an urban safety net hospital. This collaboration was made possible by a federal Health Resources and Services Administration grant for integrative medicine in preventive medicine residencies and helped meet a need of the program to increase residents' exposure to clinical preventive medicine and integrative health clinical skills and principles. The collaboration has resulted in a required rotation for all residents that continues after the grant period and has fostered additional collaborations related to integrative medicine across the programs.

Use of a DASH food group score to predict excess weight gain in adolescent girls in the National Growth and Health Study.

OBJECTIVE: To study the effects of selected dietary patterns, particularly a DASH (Dietary Approach to Stop Hypertension) eating pattern, on body mass index (BMI) throughout adolescence. DESIGN: Prospective National Growth and Health Study. SETTING: Washington, DC; Cincinnati, Ohio; and Berkeley, California. PARTICIPANTS: A total of 2327 girls with 10 annual visits starting at age 9 years. MAIN EXPOSURES: Individual DASH-related food groups and a modified DASH adherence score. MAIN OUTCOME MEASURE: The BMI value from measured yearly height and weight over 10 years. RESULTS: Longitudinal mixed modeling methods were used to assess the effects of individual DASH food groups and a DASH adherence score on BMI during 10 years of follow-up, adjusting for race, height, socioeconomic status, television viewing and video game playing hours, physical activity level, and total energy intake. Girls in the highest vs lowest quintile of the DASH score had an adjusted mean BMI of 24.4 vs 26.3 (calculated as weight in kilograms divided by height in meters squared) (P < .05). The strongest individual food group predictors of BMI were total fruit (mean BMI, 26.0 vs 23.6 for <1 vs ≥2 servings per day; P < .001) and low-fat dairy (mean BMI, 25.7 vs 23.2 for <1 vs ≥2 servings per day; P < .001). Whole grain consumption was more weakly but beneficially associated with BMI. CONCLUSIONS: Adolescent girls whose diet more closely resembled the DASH eating pattern had smaller gains in BMI over 10 years. Such an eating pattern may help prevent excess weight gain during adolescence.