Addressing the Primary Care Shortage on a Shoestring: A Successful Track in an Internal Medicine Residency.

PROBLEM: Nationally, shortages of primary care providers are of major concern. Internal medicine programs, once the major supplier of primary care physicians, are no longer producing large numbers of primary care providers to help meet the needs of the growing patient population. APPROACH: In 2009, residents at the University of New Mexico created a resident-driven Primary Care Track (PCT) within the internal medicine residency, and after six years this track is thriving. The PCT allows residents to designate blocks of time specifically devoted to primary care training. Residents opt in to the track at the end of intern year and arrange their own schedules over large blocks of time in the last two years of training to allow for an individualized curriculum that prepares them for independent practice in primary care. OUTCOMES: Approximately 85% (11/13) of residents who have graduated from the track have gone on to practice in primary care after graduation, and the internal medicine residency program as a whole has also seen an increase in the fraction of residents pursuing primary care since the inception of this track. NEXT STEPS: The PCT is currently at maximum capacity and may be forced to turn away applicants. To expand while still maintaining the core principles of the track, the PCT will strive to find additional ways to use New Mexico's existing resources and to develop a more robust mentoring structure and didactic programs. Formalized financial, faculty, and administrative support of the program also will be needed.

Ethnic Disparities in Emergency Severity Index Scores among U.S. Veteran's Affairs Emergency Department Patients.

BACKGROUND: The goal of these analyses was to determine whether there were systematic differences in Emergency Severity Index (ESI) scores, which are intended to determine priority of treatment and anticipate resource needs, across categories of race and ethnicity, after accounting for patient-presenting vital signs and examiner characteristics, and whether these differences varied among male and female Veterans Affairs (VA) ED patients. METHODS AND FINDINGS: We used a large national database of electronic medical records of ED patients from twenty-two U.S. Department of Veterans Affairs ED stations to determine whether ESI assignments differ systematically by race or ethnicity. Multi-level, random effects linear modeling was used to control for demographic characteristics and patient's vital signs (heart rate, respiratory rate, and pain level), as well as age, gender, and experience of triage nurses. The dataset included 129,991 VA patients presenting for emergency care between 2008 and 2012 (91% males; 61% non-Hispanic White, 28% Black, 7% Hispanic, 2% Asian, <1% American Indian/Alaska Native, 1% mixed ethnicity) and 774 nurses for a total of 359,642 patient/examiner encounters. Approximately 13% of the variance in ESI scores was due to patient characteristics and 21% was due to the nurse characteristics. After controlling for characteristics of nurses and patients, Black patients were assigned less urgent ESI scores than White patients, and this effect was more prominent for Black males compared with Black females. A similar interaction was found for Hispanic males. It remains unclear how these results may generalize to EDs and patient populations outside of the U.S. VA Health Care system. CONCLUSIONS: The findings suggest the possibility that subgroups of VA patients receive different ESI ratings in triage, which may have cascading, downstream consequences for patient treatment quality, satisfaction with care, and trust in the health equity of emergency care.

Viewpoint: learning professionalism: a view from the trenches.

The authors, medical students immersed in learning professionalism, observe that most of the professionalism literature misses the mark. Their views on professionalism education, although not the result of qualitative research, were gained from four years of conversations with students from a dozen medical schools, plus online student discussions, focus groups, and meetings with supervisors from five schools. The authors propose that the chief barrier to medical professionalism education is unprofessional conduct by medical educators, which is protected by an established hierarchy of academic authority. Students feel no such protection, and the current structure of professionalism education and evaluation does more to harm students' virtue, confidence, and ethics than is generally acknowledged. The authors maintain that deficiencies in the learning environment, combined with the subjective nature of professionalism evaluation, can leave students feeling persecuted, unfairly judged, and genuinely and tragically confused. They recommend that administrators, medical educators, residents, and students alike must show a personal commitment to the explicit professionalism curriculum and address the hidden curriculum openly and proactively. Educators must assure transparency in the academic process, treat students respectfully, and demonstrate their own professional and ethical behavior. Students overwhelmingly desire to become professional, proficient, and caring physicians. They seek professional instruction, good role models, and fair evaluation. Students struggle profoundly to understand the disconnect between the explicit professional values they are taught and the implicit values of the hidden curriculum. Evaluation of professionalism, when practiced in an often unprofessional learning environment, invites conflict and compromise by students that would otherwise tend naturally toward avowed professional virtues.