Amit Pahwa

Medical students’ perceptions of low-value care

Medical schools are creating high‐value care (HVC) curricula in undergraduate medical education; however, there are few studies identifying what are the most pressing low‐value care (LVC) practices, as observed by students. This study is a multicentre, targeted needs assessment comparing medical student perceptions of LVC at four institutions, after completion of their internal medicine clerkship, to identify areas of focus for future HVC curriculum development.

A Department of Medicine Infrastructure for Patient Safety and Clinical Quality Improvement

Payers, providers, and patients increasingly recognize the importance of quality and safety in health care. Academic Departments of Medicine can advance quality and safety given the large populations they serve and the broad spectrum of diseases they treat. However, there are only few detailed examples of how quality and safety can be organized. This article describes a practical model at The Johns Hopkins Hospital Department of Medicine and details its structure and operation within a large academic health system. It is based on a fractal model that integrates multiple smaller units similar in structure (composition of faculty/staff), process (use of similar tools), and approach (using a common framework to address issues). This organization stresses local, multidisciplinary leadership, facilitates horizontal connections for peer learning, and maintains vertical connections for broader accountability.

The Use of Clinical Decision Support in Reducing Diagnosis of and Treatment of Asymptomatic Bacteriuria

Clinical decision support (CDS) embedded within the electronic health record (EHR) is a potential antibiotic stewardship strategy for hospitalized patients. Reduction in urine testing and treating asymptomatic bacteriuria (ASB) is an important strategy to promote antibiotic stewardship. We created an intervention focused on reducing urine testing for asymptomatic patients at a large tertiary care center. The objective of this study was to design an intervention to reduce unnecessary urinalysis and urine culture (UC) orders as well as the treatment of ASB. We performed a quasiexperimental study among adult inpatients at a single academic institution. We implemented a bundled intervention, including information broadcast in newsletters, hospital-wide screensavers, and passive CDS messages in the EHR. We investigated the impact of this strategy on urinalysis, UC orders, and on the treatment of ASB by using an interrupted time series analysis. Our intervention led to reduced UC order as well as reduced antibiotic orders in response to urinalysis orders and UC results. This easily implementable bundle may play an important role as an antibiotic stewardship strategy.

Student perceptions of high-value care education in internal medicine clerkships

1Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; 2Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; 3Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana; 4Division of Infectious Disease, University of Alabama School of Medicine, Birmingham, Alabama; 5Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York.

Further Misanalysis of Urinalysis-Reply.

Not All High-Dose Opioid Users Are Addicts To the Editor Dr Katz’s excellent summary of opioid prescribing for chronic pain1 in a recent issue of JAMA Internal Medicine hits the mark on all points and lays out a reasonable recommendation for physicians, but I disagree with his characterization of the patient who is on high-dose opioids as “addicted” and presents to his practice owing to insurance change, relocation, or other factors. The use of high-dose opioids does not indicate addiction. The National Institute of Drug Abuse defines drug addiction as “a chronic disease characterized by compulsive, or uncontrollable, drug seeking and use despite harmful consequences and changes in the brain, which can be long lasting.”2 The patient profile presented demonstrates none of those characteristics; in fact, many patients on high-dose opioids are on high-dose opioids solely because their physician prescribed them when they indicated that their pain was not controlled rather than offering adjunctive treatments. These patients are often very compliant with their treatment regimen knowing that the consequence of missing appointments, self-escalating their doses, or using other controlled substances is that they will be labeled an addict, and that label will follow them through all future encounters with the health care system, tainting the view of every physician they see. Dr Katz describes a patient who we could possibly call a victim of the many forces that led to our current opioid crisis3 or perhaps label them as physiologically dependent, but without further details, that patient is far from being an addict.

Primary colonic adenocarcinoma diagnosed with cutaneous shave biopsy.

A 67-year-old man presented to the emergency department with chronic weakness, fatigue and failure to thrive. On physical examination, he was found to have multifocal exophytic cutaneous masses in the pubic and scrotal regions. We obtained a shave biopsy, and subsequent histopathology demonstrated non-native tissue consistent with metastasis from a primary adenocarcinoma. We report this novel case of anogenital cutaneous metastases of colorectal adenocarcinoma.