Correction to: Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay.

This editorial, "Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay" (DOI: 10.1007/s11606-019-05268-0), was intended to accompany "Education Indicators for Internal Medicine Point-of-Care Ultrasound: a Consensus Report from the Canadian Internal Medicine Ultrasound (CIMUS) Group".

The Evolution of General Internal Medicine (GIM)in Canada: International Implications.

General internal medicine (GIM), like other generalist specialties, has struggled to maintain its identity in the face of mounting sub-specialization over the past few decades. In Canada, the path to licensure for general internists has been through the completion of an extra year of training after three core years of internal medicine. Until very recently, the Royal College of Physicians and Surgeons of Canada (RCPSC) did not recognize GIM as a distinct entity. In response to a societal need to train generalist practitioners who could care for complex patients in an increasingly complex health care setting, the majority of universities across Canada voluntarily developed structured GIM training programs independent of RCPSC recognition. However, interest amongst trainees in GIM was declining, and the GIM workforce in Canada, like that in many other countries, was in danger of serious shortfalls. After much deliberation and consultation, in 2010, the RCPSC recognized GIM as a distinct subspecialty of internal medicine. Since this time, despite the challenges in the educational implementation of GIM as a distinct discipline, there has been a resurgence of interest in this field of medicine. This paper outlines the journey of the Canadian GIM to educational implementation as a distinct discipline, the impact on the discipline, and the implications for the international GIM community.

A comparative analysis of graduate preparedness for a career in General Internal Medicine before and after national subspecialty recognition to inform curricular changes: have we met the mark?

Background: A survey of General Internal Medicine (GIM) graduates published in 2006 revealed large training gaps that informed the development of the first national GIM objectives of training in 2010. The first recognized GIM certification examination was written by candidates in 2014. The landscape is again changing with the introduction in 2019 of competency-by-design (CBD) to GIM training. This study aims to examine pre-existing and emerging training gaps with standardization of GIM curricula and identify new training needs to inform CBD curricula. Methods: GIM graduates from all 16 Canadian programs from 2014 -2019 were emailed a survey modeled after the original study published in 2006. Graduates were asked about their preparedness and importance ratings for various elements of practice. Results: Many of the previously identified gaps (difference between importance and preparedness ratings) have been resolved in specific clinical areas (obstetrical and perioperative medicine) and skills (exercise stress testing) although some still require ongoing work in areas such as substance use disorders. Importantly, gaps still exist in preparedness for some intrinsic roles (e.g. managerial skills). Conclusions: The development of a national GIM curriculum has helped close some educational gaps but some still exist. Our study provides data needed to meet the evolving needs of our graduates.

Contexte: Une enquête auprès des diplômés en médecine interne générale (MIG), publiée en 2006, a révélé d'importantes lacunes dans leur formation, menant à l'élaboration des premiers objectifs nationaux de formation en MIG en 2010. Le premier examen de certification en MIG a été organisé en 2014. La formation est à nouveau en train de changer avec l'introduction en 2019 de la compétence par conception (CPC) dans la formation en MIG. Cette étude vise à examiner les lacunes de formation préexistantes et émergentes avec la normalisation de la formation en MIG et à identifier les nouveaux besoins de formation pour éclairer la définition des programmes de formation selon l'approche fondée sur les compétences. Méthodes: Les diplômés des 16 programmes canadiens en MIG entre 2014 et 2019 ont reçu par courriel un sondage inspiré de l'étude originelle publiée en 2006. Les diplômés ont été interrogés sur leur état de préparation et sur l'importance qu'ils accordaient à divers éléments de la pratique. Résultats: Un grand nombre des lacunes décelées précédemment (différence entre les cotes d'importance et de préparation) ont été comblées dans des domaines cliniques spécifiques (médecine obstétrique et périopératoire) et par rapport à des compétences spécifiques (tests de stress à l'effort); dans certains domaines, comme les troubles liés à l'utilisation de substances psychoactives, les efforts doivent être poursuivis. Il est important de noter que des lacunes subsistent dans la préparation à certains rôles intrinsèques (par exemple, les compétences de gestionnaire). Conclusion: L'élaboration d'un programme national de formation en MIG a permis de combler certaines lacunes en matière de formation, mais des carences subsistent. Notre étude fournit les données nécessaires pour répondre aux besoins évolutifs de nos diplômés.

An internist's role in perioperative medicine: a survey of surgeons' opinions.

BACKGROUND: Literature exists regarding the perioperative role of internists. Internists rely on this literature assuming it meets the needs of surgeons without actually knowing their perspective. We sought to understand why surgeons ask for preoperative consultations and their view on the internist's role in perioperative medicine. METHODS: Survey of surgeons in Saskatoon, Saskatchewan, Canada regarding an internist's potential role in perioperative care. RESULTS: Fifty-nine percent responded. The majority request a preoperative consultation for a difficult case (83%) or specific problem (81%). While almost half feel that a preoperative consultation is to "clear" a patient for surgery, 33% disagree with this statement. The majority believe the internist should discuss risk with the patient. Aspects of the preoperative consultation deemed most important are cardiac medication optimization (93%), cardiac risk stratification (83%), addition of beta-blockers (76%), and diabetes management (74%). CONCLUSION: Surgeons perceive the most important roles for the internist as cardiac risk stratification and medication management. Areas of controversy identified amongst the surgeons included who should inform the patient of their operative risk, and whether the internist should follow the patient daily postoperatively. Unclear expectations have the potential to impact on patient safety and informed consent unless acknowledged and acted on by all. We recommend that internists performing perioperative consults communicate directly with the consulting physician to ensure that all parties are in accordance as to each others duties. We also recommend that the teaching of perioperative consults emphasizes the interdisciplinary communication needed to ensure that patient needs are not neglected when one specialty assumes the other will perform a function.

Are Canadian General Internal Medicine training program graduates well prepared for their future careers?

BACKGROUND: At a time of increased need and demand for general internists in Canada, the attractiveness of generalist careers (including general internal medicine, GIM) has been falling as evidenced by the low number of residents choosing this specialty. One hypothesis for the lack of interest in a generalist career is lack of comfort with the skills needed to practice after training, and the mismatch between the tertiary care, inpatient training environment and "real life". This project was designed to determine perceived effectiveness of training for 10 years of graduates of Canadian GIM programs to assist in the development of curriculum and objectives for general internists that will meet the needs of graduates and ultimately society. METHODS: Mailed survey designed to explore perceived importance of training for and preparation for various aspects of Canadian GIM practice. After extensive piloting of the survey, including a pilot survey of two universities to improve the questionnaire, all graduates of the 16 universities over the previous ten years were surveyed. RESULTS: Gaps (difference between importance and preparation) were demonstrated in many of the CanMEDS 2000/2005 competencies. Medical problems of pregnancy, perioperative care, pain management, chronic care, ambulatory care and community GIM rotations were the medical expert areas with the largest gaps. Exposure to procedural skills was perceived to be lacking. Some procedural skills valued as important for current GIM trainees and performed frequently (example ambulatory ECG interpretation) had low preparation ratings by trainees. Other areas of perceived discrepancy between training and practice included: manager role (set up of an office), health advocate (counseling for prevention, for example smoking cessation), and professional (end of life issues, ethics). CONCLUSION: Graduates of Canadian GIM training programs over the last ten years have identified perceived gaps between training and important areas for practice. They have identified competencies that should be emphasized in Canadian GIM programs. Ongoing review of graduate's perceptions of training programs as it applies to their current practice is important to ensure ongoing appropriateness of training programs. This information will be used to strengthen GIM training programs in Canada.

Informed consent skills in internal medicine residency: how are residents taught, and what do they learn?

PURPOSE: Obtaining informed consent is an essential skill in internal medicine (IM). The authors' informal observations and formal testing revealed deficiencies in residents' informed consent skills. This study evaluated how residents acquire informed consent skills and how informed consent skills are addressed in Canadian IM residency programs. METHOD: A questionnaire was delivered to all 16 IM program directors in Canada, asking how informed consent is taught and assessed. At the University of Saskatchewan IM residency program, residents were assessed through an objective structured clinical examination station, written examination, and a self-assessment questionnaire. RESULTS: No consistent approach to teaching or evaluating informed consent skills exists within Canadian IM programs. Program directors and residents identified informal mentoring by residents as an important learning modality. Although residents performed well in discussing procedural indications and techniques, discussing risks was inadequate. Residents focused on general and minor risks but avoided discussing serious risks and had difficulty discussing the frequency of complications. Residents lacked a structured approach to assessing capacity and often assessed only comprehension. Residents were unfamiliar with concepts such as material risk, implied consent, and therapeutic privilege. CONCLUSION: Explicit training in informed consent skills is urgently needed. Informal mentoring must be recognized as an important training method for informed consent and supported by appropriate teaching and evaluation strategies to ensure that resident-instructors do so effectively.

Trimethoprim-sulfamethoxazole-associated hepatotoxicity - part of a hypersensitivity syndrome.

Trimethoprim-sulfamethoxazole is a commonly used medication. Side effects are numerous and include drug hypersensitivity syndrome. The case of a 24-year-old woman with severe liver failure is presented. Erythema multiforme and thrombocytopenia developed after the acute onset of hepatotoxicity and after all medications had been stopped. Clinical resolution of all features occurred over weeks but laboratory abnormalities persisted up to eight months later. A causal link with sulfamethoxazole was supported by timing, liver biopsy and lymphocyte toxicity test. This case illustrates one presentation and the possible severity of the drug hypersensitivity syndrome associated with trimethoprim-sulfamethoxazole.

Determining specific competencies for General Internal Medicine residents (PGY 4 and PGY 5). What are they and are programs currently teaching them? A survey of practicing Canadian General Internists.

BACKGROUND: General Internal Medicine (GIM) has recently been approved as a subspecialty by the Royal College of Physicians and Surgeons of Canada. As such, there is a need to define areas of knowledge that a General Internist must learn in those two years of training. There is limited literature as to what competencies are needed in a GIM practice. Draft competencies for GIM (4th and 5th year residents in internal medicine) training were developed over eight years with input from many stakeholders. Practicing General Internists were surveyed and asked their perspective as to the level of importance of each of these competencies for GIM training. They were also asked if training gaps exist in current training programs. The survey was offered widely online in both English and French to gain perspectives from as many different contexts as possible. RESULTS: 157 General Internists, in practice on average for 15 years, responded from all of Canada's provinces and territories. Practice profiles were diverse (large urban centers to rural centers). The majority of the competencies surveyed were perceived as important to attain at least proficiency in. Perioperative care, risk reduction, and the management of common, emergent, and complex internal medicine problems were identified as key areas to focus training programs on, with respondents perceiving these should be mastered to an expert level. Training gaps were identified, most frequently in that of the manager role (example managing practice). CONCLUSIONS: This is the first study we are aware of to attempt to isolate the opinions of practicing Canadian General Internists as to the major competencies that should be mastered as a General Internist. We suggest that "generalism" in the context of GIM, does not mean a bit of knowledge about everything but that defined objectives for training in this 'newest' of Royal College subspecialties can be identified. This includes mastery of core areas such as perioperative care, risk reduction, and management of common, emergent and multiple internal medicine problems. The training gaps identified need to be addressed to ensure that General Internists continue to provide excellence in health care delivery.

Are longer hospital stays beneficial for the elderly?

Utilization review is a way to manage healthcare costs and is widespread in Canada, as managers attempt to use available acute-care beds in a best practice manner. As we reduce beds and decrease length of stay, we often wonder if the outcomes for patients are affected, particularly if the patients are elderly.