Tratado de Medicina Geral / General Medicine Treaty

É comum que o médico generalista necessite consultar várias fontes para se informar, se atualizar e apoiar suas condutas. Isso cria uma desgastante rotina de pesquisas e estudos e demanda um tempo do qual, muitas vezes, esse profissional não dispõe. Em uma proposta inovadora, interdisciplinar e com o objetivo de abordar as situações mais relevantes e prevalentes no dia a dia do médico generalista, especialmente daquele que trabalha em unidades básicas de saúde e serviços de pronto atendimento, a Associação Médica Brasileira, que regula todas as especialidades médicas no país, desenvolveu o Tratado de Medicina Geral, com apoio das principais sociedades médicas do Brasil.

Self-Appraisal of Clinical Competence in Echocardiography of Chinese Intensivists Post Basic Echocardiography Training.

Objectives To learn the echocardiography skills of intensivists after receiving a basic critical care echocardiography training course, and investigate factors that may influence their performance. Methods We completed a web-based questionnaire that assessed the skills in ultrasound scanning techniques of intensivists who took a training course on basic critical care echocardiography held in 2019 and 2020. Mann-Whitney test was used to analyze the factors which might affect their performance on image acquisition, recognizing clinical syndrome, and measuring the diameter of inferior vena cava, left ventricular ejection fraction and left ventricular outflow tract velocity-time integral.Results We enrolled 554 physicians from 412 intensive care units across China. Among them, 185 (33.4%) reported that they had 10%-30% chance of being misled by critical care echocardiography when making therapeutic decision, and 34 (6.1%) reported that the chance was greater than 30%. Intensivists who performed echocardiography under the guidance of a mentor and finished ultrasound scanning more than 10 times per week reported significant higher scores in image acquisition, clinical syndrome recognition, and quantitative measurement of inferior vena cava diameter, left ventricular ejection fraction and left ventricular outflow tract velocity-time integral than those without mentor and performing echocardiography 10 times or less per week respectively (all P < 0.05).Conclusion The skills in diagnostic medical echocardiography of Chinese intensivists after a basic echocardiographic training course remain low, and further quality assurance training program is clearly warranted.

Self-Appraisal of Clinical Competence in Echocardiography of Chinese Intensivists Post Basic Echocardiography Training / 中国医学科学杂志(英文版)

Objectives To learn the echocardiography skills of intensivists after receiving a basic critical care echocardiography training course, and investigate factors that may influence their performance. Methods We completed a web-based questionnaire that assessed the skills in ultrasound scanning techniques of intensivists who took a training course on basic critical care echocardiography held in 2019 and 2020. Mann-Whitney test was used to analyze the factors which might affect their performance on image acquisition, recognizing clinical syndrome, and measuring the diameter of inferior vena cava, left ventricular ejection fraction and left ventricular outflow tract velocity-time integral.Results We enrolled 554 physicians from 412 intensive care units across China. Among them, 185 (33.4%) reported that they had 10%-30% chance of being misled by critical care echocardiography when making therapeutic decision, and 34 (6.1%) reported that the chance was greater than 30%. Intensivists who performed echocardiography under the guidance of a mentor and finished ultrasound scanning more than 10 times per week reported significant higher scores in image acquisition, clinical syndrome recognition, and quantitative measurement of inferior vena cava diameter, left ventricular ejection fraction and left ventricular outflow tract velocity-time integral than those without mentor and performing echocardiography 10 times or less per week respectively (all P < 0.05).Conclusion The skills in diagnostic medical echocardiography of Chinese intensivists after a basic echocardiographic training course remain low, and further quality assurance training program is clearly warranted.

Management of residents in difficulty in a Swiss general internal medicine outpatient clinic: Change is necessary!

AIMS OF THE STUDY: Residents in difficulty are a major cause for concern in medical education, with a prevalence of 7-15%. They are often detected late in their training and cannot make use of remediation plans. Nowadays, most training hospitals in Switzerland do not have a specific program to identify and manage residents in difficulty. The aim of the study was to explore the challenges perceived by physicians regarding the process of identifying, diagnosing, and supporting residents in difficulty in a structured and programmatic way. We explored perceptions of physicians at different hierarchical levels (residents (R), Chief residents (CR), attending physicians (A), Chief Physician (CP)) in order to better understand these challenges. METHODS: We conducted an exploratory qualitative study between December 2015 and July 2016. We asked volunteers from the Primary Care Division of the Geneva University Hospitals to partake to three focus groups (with CR, A, R) and one interview with the division's CP. We transcribed, coded, and qualitatively analyzed the three focus groups and the interview, using a content thematic approach and Fishbein's conceptual framework. RESULTS: We identified similarities and differences in the challenges of the management of residents in difficulty on a programmatic way amongst physicians of different hierarchical levels. Our main findings: Supervisors (CR, A, CP) have good identification skills of residents in difficulty, but they did not put in place systematic remediation strategies.Supervisors (CR, A) were concerned about managing residents in difficulty. They were aware of the possible adverse effects on patient care, but "feared to harm" resident's career by documenting a poor institutional assessment.Residents "feared to share" their own difficulties with their supervisors. They thought that it would impact their career negatively.The four physician's hierarchical level reported environmental constraints (lack of funding, time constraint, lack of time and resources…). CONCLUSION: Our results add two perspectives to specialized recommendations regarding the implementation of remediation programs for residents in difficulty. The first revolves around the need to identify and fully understand not only the beliefs but also the implicit norms and the feeling of self-efficacy that are shared by teachers and that are likely to motivate them to engage in the management of residents in difficulty. The second emphasizes the importance of analyzing these elements that constitute the context for a change and of identifying, in close contact with the heads of the institutions, which factors may favor or hinder it. This research action process has fostered awareness and discussions at different levels. Since then, various actions and processes have been put in place at the Faculty of Medicine in Geneva.

A Dynamic Risk Management Approach for Reducing Harm From Invasive Bedside Procedures Performed During Residency.

Internal medicine (IM) residents frequently perform invasive bedside procedures during residency training. Bedside procedure training in IM programs may compromise patient safety. Current evidence suggests that IM training programs rely heavily on the number of procedures completed during training as a proxy for resident competence instead of using objective postprocedure patient outcomes. The authors posit that the results of procedural training effectiveness should be reframed with outcome metrics rather than process measures alone. This article introduces the as low as reasonably achievable (ALARA) approach, which originated in the nuclear industry to increase safety margins, to help assess and reduce bedside procedural risks. Training program directors are encouraged to use ALARA calculations to define the risk trade-offs inherent in current procedural training and assess how best to reliably improve patient outcomes. The authors describe 5 options to consider: training all residents in bedside procedures, training only select residents in bedside procedures, training no residents in bedside procedures, deploying 24-hour procedure teams supervised by IM faculty, and deploying 24-hour procedure teams supervised by non-IM faculty. The authors explore how quality improvement approaches using process maps, fishbone diagrams, failure mode effects and analyses, and risk matrices can be effectively implemented to assess training resources, choices, and aims. Future research should address the drivers behind developing optimal training programs that support independent practice, correlations with patient outcomes, and methods that enable faculty to justify their supervisory decisions while adhering to ALARA risk management standards.

Assessing Competence in Critical Care Echocardiography: Development and Initial Results of an Examination and Certification Processes.

OBJECTIVES: To describe the development and initial results of an examination and certification process assessing competence in critical care echocardiography. DESIGN: A test writing committee of content experts from eight professional societies invested in critical care echocardiography was convened, with the Executive Director representing the National Board of Echocardiography. Using an examination content outline, the writing committee was assigned topics relevant to their areas of expertise. The examination items underwent extensive review, editing, and discussion in several face-to-face meetings supervised by National Board of Medical Examiners editors and psychometricians. A separate certification committee was tasked with establishing criteria required to achieve National Board of Echocardiography certification in critical care echocardiography through detailed review of required supporting material submitted by candidates seeking to fulfill these criteria. SETTING: The writing committee met twice a year in person at the National Board of Medical Examiner office in Philadelphia, PA. SUBJECTS: Physicians enrolled in the examination of Special Competence in Critical Care Electrocardiography (CCEeXAM). MEASUREMENTS AND MAIN RESULTS: A total of 524 physicians sat for the examination, and 426 (81.3%) achieved a passing score. Of the examinees, 41% were anesthesiology trained, 33.2% had pulmonary/critical care background, and the majority had graduated training within the 10 years (91.6%). Most candidates work full-time at an academic hospital (46.9%). CONCLUSIONS: The CCEeXAM is designed to assess a knowledge base that is shared with echocardiologists in addition to that which is unique to critical care. The National Board of Echocardiography certification establishes that the physician has achieved the ability to independently perform and interpret critical care echocardiography at a standard recognized by critical care professional societies encompassing a wide spectrum of backgrounds. The interest shown and the success achieved on the CCEeXAM by practitioners of critical care echocardiography support the standards set by the National Board of Echocardiography for testamur status and certification in this imaging specialty area.

[Acquired angioedema due to C1-inhibitor deficiency: CREAK recommendations for diagnosis and treatment]. / Angiœdèmes par déficit acquis en C1-inhibiteur : recommandations du CREAK pour le diagnostic et la prise en charge.

Acquired angioedema with C1-inhibitor deficiency is a rare and peculiar entity belonging to the spectrum of bradykinin angioedemas. It usually occurs in subjects over 60 years old, and is mostly associated with a B-cell lymphoid hemopathy or a monoclonal gammopathy. The diagnosis relies on at least one angioedema episode, lasting more than 24 h, and on the decrease of functional C1-inhibitor. Low C1q is observed in 90% of patients, and an anti C1-inhibitor antibody is found in 50% of patients. The treatment of severe attacks relies on icatibant or C1-inhibitor perfusions. Long term prophylaxis in patients with frequent attacks requires treatment of the associated hemopathy if so. In case of idiopathic angioedema, tranexamic acid and danazol may be used, provided that there is-no thrombophilia; as well as rituximab as second-line treatment. Inhibitors of kallikrein still need to be evaluated in this therapeutic indication.

Evaluation of a multidisciplinary approach to reduce internal medicine readmissions using a readmission prediction index.

PURPOSE: Readmission prediction indices are used to stratify patients by the risk of hospital readmission. We describe the integration of a 30-day hospital readmission prediction index into the electronic medical record (EMR) and its impact on pharmacist interventions during transitions of care (TOC). METHODS: A retrospective cohort study was conducted to compare 30-day readmission rates between adult internal medicine inpatients admitted by a multidisciplinary team providing TOC services (the TOC group) and those who received usual care (the control group). Interventions by a pharmacist serving on the TOC team were guided by an EMR-integrated readmission index, with patients at the highest risk for readmission receiving targeted pharmacist interventions. Inpatient encounters (n = 374) during the 5-month study period were retrospectively identified. Chi-square and Mann-Whitney U tests were performed to analyze differences in nominal and nonparametric continuous variables, respectively. Logistic regression was performed to identify variables associated with 30-day readmissions. The log-rank test was used to analyze hazard ratios for readmission outcomes in the 2 cohorts. RESULTS: Thirty-day readmission rates did not differ significantly in the TOC group and the control group (20.9% vs 18.3%, P = 0.52). However, patients who received additional direct pharmacist interventions, as guided by use of a hospital readmission index, had a lower 30-day readmission rate than patients who did not (11.4% vs 21.7%, P = 0.04). The readmission index score was significantly associated with the likelihood of 30-day readmission (odds ratio for readmission, 1.25; 95% confidence interval, 1.16-1.34; P < 0.01). The difference in unadjusted log-rank scores at 30 days with and without pharmacist intervention was not significant (P = 0.05). A mean of 4.5 medication changes were identified per medication reconciliation performed by the TOC pharmacist. CONCLUSION: A multidisciplinary TOC team approach did not reduce the 30-day readmission rate on an internal medicine service. However, patients who received additional direct pharmacist interventions guided by a readmission prediction index had a reduced readmission rate.

Rapid Implementation of an Adult Coronavirus Disease 2019 Unit in a Children's Hospital.

OBJECTIVE: To describe the rapid implementation of an adult coronavirus disease 2019 (COVID-19) unit using pediatric physician and nurse providers in a children's hospital and to examine the characteristics and outcomes of the first 100 adult patients admitted. STUDY DESIGN: We describe our approach to surge-in-place at a children's hospital to meet the local demands of the COVID-19 pandemic. Instead of redeploying pediatric providers to work with internist-led teams throughout a medical center, pediatric physicians and nurses organized and staffed a 40-bed adult COVID-19 treatment unit within a children's hospital. We adapted internal medicine protocols, developed screening criteria to select appropriate patients for admission, and reorganized staffing and equipment to accommodate adult patients with COVID-19. We used patient counts and descriptive statistics to report sociodemographic, system, and clinical outcomes. RESULTS: The median patient age was 46 years; 69% were male. On admission, 78 (78%) required oxygen supplementation. During hospitalization, 13 (13%) eventually were intubated. Of the first 100 patients, 14 are still admitted to a medical unit, 6 are in the intensive care unit, 74 have been discharged, 4 died after transfer to the intensive care unit, and 2 died on the unit. The median length of stay for discharged or deceased patients was 4 days (IQR 2, 7). CONCLUSIONS: Our pediatric team screened, admitted, and cared for hospitalized adults by leveraging the familiarity of our system, adaptability of our staff, and high-quality infrastructure. This experience may be informative for other healthcare systems that will be redeploying pediatric providers and nurses to address a regional COVID-19 surge elsewhere.

[Introduction to debriefing for internists: how to transform real or simulated clinical situations into learning moments]. / Initiation au débriefing pour les internistes : état des connaissances et mise en pratique pour transformer des situations cliniques réelles ou simulées en moments d'apprentissage.

Debriefing is a phase of synthesis and reflection that immediately follows a real-life or simulated situation. It is an essential educational step that forces the learners to reflect upon the thought processes that underlie their actions. Debriefing encourages a personal and collective reflection in order to remodel erroneous mental schemas and rectify actions done in context. Debriefing cannot be improvised; it requires a sound structure and regular practice in order to be truly effective. The debriefer must be considerate, choose appropriate learning objectives and dedicate ample time to the learners. Debriefing is focused on learning acquired in context-in other words, on the actions that were performed within a real-life or simulated clinical practice situation-and immediately follows the situation. After an initial phase of emotional release, the debriefer will help learners analyse their actions to identify their underlying rationale (contextualization), extract the overarching principles related to the lived situation in order to modify the rationale if needed (decontextualization) and assist the transfer of learning to real life (in the case of simulation) and to similar situations (recontextualization). A final summary of learning achieved during the training session concludes the debriefing. Debriefing is useful in any learning situation, including in internal medicine. Even if simulation is still underused in internal medicine, post-event debriefing can be implanted in our clinical services. Indeed, training our students and shaping them into healthcare professionals rest in no small part on hospital rotations where the intern is confronted with real-patient situations that are suitable to learning. Some in-hospital clinical encounters can be actively transformed into learning opportunities thanks to post-event debriefing, but can also passively morph into bad daily practice if no supporting action is implemented. Debriefing can thus provide an opportunity to develop non-technical skills in critical situations, or doctor-patient communication skills, within a team or between colleagues. These competencies are the hallmark of well-trained interns and are indispensable for the proper functioning of a care team. We will not develop the emotional and psychological management of debriefing in this article. We hope we will helpfully introduce as many of our colleagues as possible to the art of debriefing in most circumstances.

Performance of the Ebel standard-setting method in spring 2019 Royal College of Physicians and Surgeons of Canada internal medicine certification examination consisted of multiple-choice questions.

PURPOSE: It aimed to know the performance of the Ebel standard-setting method in in spring 2019 Royal College of Physicians and Surgeons of Canada internal medicine certification examination consisted of multiple-choice questions. Specifically followings were searched: the inter-rater agreement; the correlation between Ebel scores and item facility indices; raters' knowledge of correct answers' impact on the Ebel score; and affection of rater's specialty on theinter-rater agreement and Ebel scores. METHODS: Data were drawn from a Royal College of Physicians and Surgeons of Canada certification exam. Ebel's method was applied to 203 MCQs by 49 raters. Facility indices came from 194 candidates. We computed Fleiss' kappa and the Pearson correlation between Ebel scores and item facility indices. We investigated differences in the Ebel score (correct answers provided or not) and differences between internists and other specialists with t-tests. RESULTS: Kappa was below 0.15 for facility and relevance. The correlation between Ebel scores and facility indices was low when correct answers were provided and negligible when they were not. The Ebel score was the same, whether the correct answers were provided or not. Inter-rater agreement and Ebel scores was not differentbetween internists and other specialists. CONCLUSION: Inter-rater agreement and correlations between item Ebel scores and facility indices wee consistently low; furthermore, raters' knowledge of correct answer and rater specialty had no effect on Ebel scores in the present setting.

Association of Regional Practice Environment Intensity and the Ability of Internists to Practice High-Value Care After Residency.

Importance: Use of health care services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns-in particular, physicians' ability to provide high-quality, high-value care-develop during training, the association of a physician's regional practice environment with that ability is less well understood. Objective: To examine the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians whose practice environment changed due to relocation after residency. Design, Setting, and Participants: This cohort study included a national sample of 3896 internal medicine physicians who took the 2002 American Board of Internal Medicine initial certification examination followed approximately 1 decade (April 21, 2011, to May 7, 2015) later by the Maintenance of Certification (MOC) examination. At the time of the MOC examination, 2714 of these internists were practicing in a new region. Data were analyzed from March 6, 2016, to May 21, 2018. Exposures: Intensity of care in the Dartmouth Atlas hospital referral region (HRR), measured by per-enrollee end-of-life physician visits (primary) and current practice type (secondary). Main Outcomes and Measures: The outcome, a physician's ability to practice high-value care, was assessed using the Appropriately Conservative Management (ACM) score on the MOC examination, measuring performance across all questions for which the correct answer was the most conservative option. The exposure, regional health care intensity, was measured as per-enrollee end-of-life physician visits in the Dartmouth Atlas HRR of the physician's practice. Results: Among the 3860 participating internists included in the analysis (2030 men [52.6%]; mean [SD] age, 45.6 [4.5] years), those who moved to regions in the quintile of highest health care intensity had an ACM score 0.22 SD lower (95% CI, -0.32 to -0.12) than internists who moved to regions in the quintile of lowest intensity, controlling for postresidency ACM scores. This difference reflected scoring in the 44th compared with the 53rd percentile of all examinees. This association was mildly attenuated (0.18 SD less; 95% CI, -0.28 to -0.09) after adjustment for physician and practice characteristics. Conclusions and Relevance: This study found that practice patterns of internists who relocate after residency training appear to migrate toward norms of the new region. The demands of practicing in high-intensity regions may erode the ability to practice high-value conservative care.

The Role of Gender in the Experience and Impact of Recertification Exam Preparation: A Qualitative Study of Primary Care Physicians.

Background: Little is known about how physicians experience preparing for board recertification examinations. As women make up a growing proportion of the primary care physician workforce, we aimed to explore how primary care physicians experience the personal and professional impacts of recertification examination preparation activities, and whether these impacts differ by gender. Materials and Methods: We conducted exploratory qualitative semistructured interviews with 80 primary care physicians, who had recently taken either the American Board of Family Medicine or American Board of Internal Medicine recertification examination and who practice outpatient care. We used an iterative recruitment approach to obtain a representative sample. We applied a team-based constant comparative analytic approach to identify and categorize themes related to how preparing for the recertification examination impacted their personal or professional lives, and then compared these themes by physician gender. Results: We interviewed 41 male and 39 female participants. Physicians most frequently described taking time from personal rather than professional activities to study, but often said this was "no big deal." Physicians described impacts on personal life such as missing out on family or leisure time, conflicts with parenting responsibilities, and an increased reliance on their spouse for domestic and childcare duties. Female physicians more frequently described parenting and leisure time impacts than males did. Conclusions: Recertification examination preparation impacts physicians' personal lives in a variety of ways and are sometimes experienced differently along gendered lines. These findings suggest opportunities for employers, payers, and specialty boards to help physicians ease potential burdens related to maintaining board certification.