Internally versus externally trained residents and fellows hired as attendings at a large integrated healthcare system: a 20-year retrospective study.

BACKGROUND: There remains a question of whether graduates trained internally are different than those trained elsewhere. We examine the difference between physicians trained within our Graduate Medical Education (GME) programs versus physicians trained elsewhere. Our large integrated healthcare system is unique in addressing this objective due to its large physician labor hiring needs across different specialties of GME graduates. METHODS: A retrospective review was performed from Jan 2000 to August 2020 of Kaiser Permanente Southern California (KPSC) physicians hired: KPSC GME trained versus non-KPSC GME trained. We examined five variables: retention, leadership (current or historical), physician relations cases, member appraisal of physician and provider services survey (MAPPS) scores, and rate of board certification. Chi-square test of proportions was used for comparison, p < 0.05 was significant. RESULTS: From Jan 2000 to August 2020, 2940 residents and fellows graduated from KPSC GME programs, of which 1127 (38%) were hired on at KPSC as full time attendings. Across all five metrics (Retention 82% vs 76% (p = < 0.01), Leadership [current 13% vs 10% (p = < 0.01)or historical 17% vs 14% (p = 0.01)], Physician Relations 23% vs 26% (p = 0.04), MAPPS 75% vs 69% (p = < 0.01), and Board Certification 81% vs 74% (p = < 0.01)), KPSC outperformed non-KPSC GME-trained physicians to a statistically significant degree. CONCLUSIONS: We have shown that an internally sponsored GME program can represent an opportunity for recruitment of physicians that may have higher retention rates, higher probability of being physician leaders, decreased likelihood of physician relations issues, improved patient satisfaction, and increased rates of board certification.

Non-metastatic castration resistant prostate cancer: a review of current and emerging medical therapies.

BACKGROUND: Non-metastatic castration resistant prostate cancer (M0CRPC) is a heterogenous disease state affecting an estimated 100,000 men in the United States. Development of more sensitive modalities for detection of metastasis has altered the landscape of advanced prostate cancer, but M0CRPC has remained a condition that previously lacked FDA-approved treatment. The emerging data on new generation Androgen Receptor (AR) pathway inhibitors should address this gap in the management of such patients. METHODS: We reviewed and summarized the current literature for the definition, diagnosis and treatment of M0CRPC. We highlight the results of recent Phase III trials that show significant impact on the outcomes of M0CRPC. RESULTS: Androgen deprivation therapy remains the foundation of therapy for M0CRPC. Recently published Phase III trials provided data on improved progression free survival when ADT is augmented with newer AR pathway inhibitors. The SPARTAN trial showed that metastasis-free survival (MFS) for patients treated with apalutamide plus ADT is 40.5 months compared to 16.2 months for patients who received standard ADT plus placebo, a 72% reduction in the risk of distant metastasis or death in apalutamide plus ADT compared to ADT plus placebo. The PROSPER trial demonstrated that MFS for patients treated with enzalutamide plus ADT was 36.6 months compared to 14.7 months for patients who received standard ADT only indicating a 71% reduction in the risk of developing metastatic CRPC or death compared to ADT alone. The ARAMIS trial on darolutamide, another AR pathway inhibitor, is also ongoing, and can potentially be another fitting option for M0CRPC. CONCLUSION: The recent Phase III trials SPARTAN and PROPSER demonstrate effective treatment options for the M0CRPC disease state that has historically lacked treatment from high level evidence. In particular, an FDA-approved treatment, Apalutamide, can finally be offered for M0CRPC patients. The newer AR pathway inhibitors should provide a basis for further investigation into treatments for M0CRPC.

The DACRON Ureter: A Case of Ureter to Aorto-Femoral Dacron Graft Fistulization.

We present a case of chronic, severe, intermittent hematuria found to be associated with a ureteral to aorto-femoral bypass fistulization. The graft was directly visualized on ureteroscopy and identified as the source of hematuria during exploratory laparotomy. Ureteral fistulization is a rare etiology of hematuria. Ureteral fistulization to an arterial graft has been reported several times in past decades. However, no cases have reported direct visualization of the dacron graft on ureteroscopy.