Colleen Christmas

Educational Outcomes from a Novel House Call Curriculum for Internal Medicine Residents: Report of a 3‐Year Experience

Physician house calls are an important mode of healthcare delivery to frail homebound older adults and positively affect patient outcomes and learner education, but most physicians receive scant training in home care medicine. A novel longitudinal curriculum in house call medicine for internal medicine residents was implemented in July 2006, and educational outcomes were evaluated over the following 3 years. The 2‐year curriculum included didactic and experiential components. Residents made house calls with preceptors and alone and completed a series of computer modules outlining knowledge essential to providing home‐based care. They discussed the important features of the modules in regularly scheduled small groups throughout the 2‐year experience, and each taught a “house call morning report” in their senior resident year. Evaluation methods included surveys before, during, and at the end of the 2‐year curriculum (knowledge and attitudes); direct observation by preceptors during house calls (skills); and an online, anonymous survey at the end of each year (attitudes). Results show statistically significant increases in residents knowledge, skills, and attitudes relevant to home care medicine. Residents describe educationally significant and positive effects from their house call experiences. This novel curriculum improved medical residents knowledge, attitudes, and skills in performing house calls for frail elderly individuals. The longer‐term outcomes of this intervention will continue to be studied, with the hope that it may be used to help provide educational opportunities to prepare the physician workforce to meet the service needs of a growing segment of the population.

In the clinic. Hip fracture.

Section Editors Deborah Cotton, MD, MPH Darren Taichman, MD, PhD Sankey Williams, MD The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians’ Information and Education Resource) and MKSAP (Medical Knowledge and SelfAssessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP’s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://pier.acponline.org, http://www.acponline.org/products_services/ mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

Interrelationship of spontaneous growth hormone axis activity, body fat, and serum lipids is healthy elderly women and men☆

Aging is associated with decreased growth hormone (GH) secretion and plasma insulin-like growth factor-I (IGF-I) levels, increased total and abdominal fat, total and low-density lipoprotein (LDL) cholesterol, and triglycerides, and reduced high-density lipoprotein (HDL) cholesterol. Similar changes in lipids and body composition occur in nonelderly GH-deficient adults and are reversed with GH administration. To examine whether GHIGF-1 axis function in the elderly is related to the lipid profile independently of body fat, we evaluated GH secretion, serum IGF-I and IGF binding protein-3 (IGFBP-3) levels, adiposity via the body mass index (BMI), waist to hip ratio (WHR), dual-energy x-ray absorptiometry (DEXA), and magnetic resonance imaging (MRI), and circulating lipids in 101 healthy subjects older than 65 years. Integrated nocturnal GH secretion (log IAUPGH) was inversely related (P < .005) to DEXA total and abdominal fat and MRI visceral fat in both genders. Log IAUPGH was inversely related to visceral fat in women (P < .005) and men (P < .0001), but was not significantly related to total fat in either gender. In women, log IAUPGH was related inversely to total and LDL cholesterol and positively to HDL choleterol (P < .008). In men, log IAUPGH was inversely to total cholesterol and triglycerides (P < .005). In women, HDL cholesterol was inversely related to the WHR (P < .005). In men, triglycerides were positively relaed (P < .001) to the WHR and DEXA abdominal and MRI visceral fat. Multivariate regression revealed log IAUPGH, but not DEXA total body fat, to be an Independent determinant of total (P < .001 for women and P = .01 for men) and LDL (P < .007 and P = .05) cholesterol in both sexes and of HDL cholesterol (P < .005) and triglycerides (P < .03) in women. Log IAUPGH, but not DEXA abdominal fat, related to total (P < .005 and P < .03) and LDL (P < .03 and P = .05) cholesterol in both genders and to HDL in women (P < .05). Log IAUPGH, but not MRI visceral fat, was related to total cholesterol (P < .03 and P = .05) in women and men. Age, IGF-I, and IGFBP-3 were not significantly related to any body fat or lipid measures, except for a positive corelation of IGF-I with triglycerides in men. Thus, endogenous nocturnal GH secretion predicts total, LDL, and HDL cholesterol levels independently of total or abdominal fat, suggesting that it is an independent cardiometabolic risk factor in healthy elderly people.

Advantages and Challenges of Working as a Clinician in an Academic Department of Medicine: Academic Clinicians' Perspectives

BACKGROUNDnThe provision of high-quality clinical care is critical to the mission of academic and nonacademic clinical settings and is of foremost importance to academic and nonacademic physicians. Concern has been increasingly raised that the rewards systems at most academic institutions may discourage those with a passion for clinical care over research or teaching from staying in academia. In addition to the advantages afforded by academic institutions, academic physicians may perceive important challenges, disincentives, and limitations to providing excellent clinical care. To better understand these views, we conducted a qualitative study to explore the perspectives of clinical faculty in prominent departments of medicine.nnnMETHODSnBetween March and May 2007, 2 investigators conducted in-depth, semistructured interviews with 24 clinically excellent internal medicine physicians at 8 academic institutions across the nation. Transcripts were independently coded by 2 investigators and compared for agreement. Content analysis was performed to identify emerging themes.nnnRESULTSnTwenty interviewees (83%) were associate professors or professors, 33% were women, and participants represented a wide range of internal medicine subspecialties. Mean time currently spent in clinical care by the physicians was 48%. Domains that emerged related to facultys perception of clinical care in the academic setting included competing obligations, teamwork and collaboration, types of patients and productivity expectations, resources for clinical services, emphasis on discovery, and bureaucratic challenges.nnnCONCLUSIONSnExpert clinicians at academic medical centers perceive barriers to providing excellent patient care related to competing demands on their time, competing academic missions, and bureaucratic challenges. They also believe there are differences in the types of patients seen in academic settings compared with those in the private sector, that there is a public nature in their clinical work, that productivity expectations are likely different from those of private practitioners, and that resource allocation both facilitates and limits excellent care in the academic setting. These findings have important implications for patients, learners, and faculty and academic leaders, and suggest challenges as well as opportunities in fostering clinical medicine at academic institutions.

A Model Intensive Course in Geriatric Teaching for Non-geriatrician Educators

SummaryIntroductionBecause of the aging demographics nearly all medical specialties require faculty who are competent to teach geriatric care principles to learners, yet many non-geriatrician physician faculty members report they are not prepared for this role.AimsTo determine the impact of a new educational intervention designed to improve the self-efficacy and ability of non-geriatrician clinician-educators to teach geriatric medicine principles to medical students and residents.DescriptionForty-two non-geriatrician clinician-educator faculty from17 academic centers self-selected to participate in a 3-day on-site interactive intensive course designed to increase knowledge of specific geriatric medicine principles and to enhance teaching efficacy followed by up to a year of mentorship by geriatrics faculty after participants return to their home institutions. On average, 24% of their faculty time was spent teaching and 57% of their clinical practices involved patients aged over 65xa0years. Half of all participants were in General Internal Medicine, and the remaining were from diverse areas of medicine.EvaluationTests of geriatrics medical knowledge and attitudes were high at baseline and did not significantly change after the intervention. Self-rated knowledge about specific geriatric syndromes, self-efficacy to teach geriatrics, and reported value for learning about geriatrics all improved significantly after the intervention. A quarter of the participants reported they had achieved at least one of their self-selected 6-month teaching goals.DiscussionAn intensive 3-day on-site course was effective in improving self-reported knowledge, value, and confidence for teaching geriatrics principles but not in changing standardized tests of geriatrics knowledge and attitudes in a diverse group of clinician-educator faculty. This intervention was somewhat associated with new teaching behaviors 6xa0months after the intervention. Longer-term investigations are underway to determine the sustainability of the effect and to determine which factors predict the faculty who most benefit from this innovative model.

Influence of Testosterone on the GH—IGF-I Axis in Healthy Elderly Men

Numerous in vivo and in vitro animal studies attest to the complex interplay between gonadal steroids and the GHRH—somatostatin-GH—IGF-I axis in the male and female, a topic that has been excellently and extensively reviewed (1–3). In male rats, consensus exists that the daily secretion of growth hormone (GH) is severalfold greater than that of females; that males release GH in high-amplitude, regular pulses, with low interpulse GH concentrations, whereas females secrete GH in low-amplitude, irregular pulses, with higher interpulse GH levels; and that there are many gender-distinct differences in the central nervous system and peripheral regulatory components of the GH axis, both in the absence and presence of endogenous or exogenous testosterone (1–3).

Podcast Pearls in Residency Training

Background: Morning report has remained a popular venue for medical resident training for decades, in part because residents rank its educational value highly (1, 2). Despite its popularity, challenges exist to morning report. Some are old (when residents control case selection, they overemphasize rare medical conditions at the expense of more common diagnoses), and some are new (residents have less time for education as a result of work-hour restrictions from the Accreditation Council for Graduate Medical Education) (24). We recently reexamined our morning report format and set out to create an educational tool that addressed some of these challenges. We started creating an audio file (podcast) every week containing teaching pearls from each morning report. We thought that this format would take advantage of our residents interest in technology because, in other settings, learners rate podcasts highly when they are used for teaching (5). We are not aware of other reports describing the regular use of podcasts in internal medicine residency training programs; here, we describe a proof of principle that shows that podcasts can be produced and shared easily for residency teaching. Objective: To help residents identify and learn important clinical information regardless of whether they attended morning report and to provide a catalog of clinical pearls that residents could review at their convenience. Methods: We conduct a 45-minute morning report 5 days per week as part of an internal medicine residency training program accredited by the Accreditation Council for Graduate Medical Education at a tertiary care university hospital. A total of 80% of our morning reports involve a resident presenting a case to medical students and other residents, with an invited faculty member or a chief resident (whom we call an assistant chief of service [ACS]) guiding the discussion. After each morning report, the ACS uses a smartphone to record a 1- to 2-minute structured conversation with the presenting resident. Before the recording, the ACS helps the resident identify salient teaching pearls and provides guidance about how to summarize them succinctly. At the end of each week, the ACS uploads the audio files onto a desktop computer; converts them to MP3 format using iTunes, Version 11 (Apple, Cupertino, California); and then manually edits them for brevity and clarity and splices them together using a freeware program (www.wavosaur.com). Music written and recorded by one of our residents provides interludes between the interviews, and the ACS adds an introduction and table of contents at the beginning of each podcast. The finalized recording, called Podcast Pearls, is then sent to residents and faculty each week via secure intranet e-mail that provides an index of the topics and presenters for that podcast. We also archive the recordings on a secure intranet Web site to facilitate review. Appropriate measures protect patient confidentiality. Findings: Weekly podcasts can be created relatively cheaply and quickly with existing personnel, a smartphone, a desktop computer, and free software programs. Each podcast averages 8 minutes and requires 5 to 10 MB of computer memory. The ACSs estimate spending 2 hours per week on each podcast; roughly 10 hours were spent in the beginning exploring how to make and refine the podcasts. We encountered no major technical problems in creating and disseminating the podcasts, and residents did not report problems accessing them from e-mails or the Web site. No resident presenter declined to participate in the interview recordings, and most enjoyed working with the ACS to summarize the teaching pearls and playing an active role in creating an educational tool for their peers. After 4 months, we sent a voluntary, anonymous, electronic survey to all 57 residents and 49 faculty members who asked to receive the weekly podcasts. A total of 53% of residents and 37% of faculty members responded. Among residents, 70% reported using the podcasts and 23% reported using one half or more of the podcasts. All of the residents who used the relevant podcast when not able to attend morning report learned something new, with 46% reporting that they learned something new often or always in this situation. All of the faculty members who responded to the survey reported listening to 1 or more podcast. A total of 94% of faculty reported that the Podcast Pearls made them feel more connected to residents, and 56% reported that the podcasts improved their learning. Discussion: Creating a weekly podcast of teaching pearls from daily morning reports within internal medicine residency programs is feasible. We found that the Podcast Pearl was an effective educational supplement for residents who were unable to attend morning report and a unique way to enhance connectedness between faculty and residents. Legal and practical considerations prevent us from distributing our podcasts to other residency programs, but we encourage chief residents and program directors from other residency programs to consider creating their own podcasts. Although further study of objective educational outcomes is needed to determine the value that these podcasts provide, our experience suggests that they help minimize the lost learning opportunities in residency training programs that new residency work-hour regulations have created.

Fitness for Reducing Osteoporosis

The incidence and prevalence of osteoporosis and fractures increase substantially with age in both women and men ((1)), such that one in five women older than age 50 has osteoporosis ((2)). This translates to nearly 1.5 million fractures of all types attributable to osteoporosis each year in the United States, a total that exacts an astounding toll on healthcare costs. Postfracture outcomes are also disappointing. Less than one third of those who fracture their hip recover sufficiently to do basic and instrumental activities of life ((3)). Many become dependent on others for their care. Finally, the mortality rate of those with hip fractures from osteoporosis is higher than that of their unaffected peers ((4)).

Medical students’ perceptions of the patient-centredness of the learning environment

BackgroundPatient-centred care is an important aspect of quality health care. The learning environment may impact medical students’ adoption of patient-centred behaviours.MethodsAll medical students at axa0single institution received an anonymous, modified version of the Communication, Curriculum, and Culture instrument that measures patient-centredness in the training environment along three domains: role modelling, students’ experience, and support for patient-centred behaviours. We compared domain scores and individual items by class year and gender, and qualitatively analyzed responses to two additional items that asked students to describe experiences that demonstrated varying degrees of patient-centredness.ResultsYearxa01 and 2 students reported greater patient-centredness than yearxa03 and 4 students in each domain: role modelling (pxa0= 0.03), students’ experience (pxa0= <0.001), and support for patient-centred behaviours (pxa0< 0.001). Female students reported less support for patient-centred behaviours compared with male students (pxa0= 0.03). Qualitative analysis revealed that explicit patient-centred curricula and positive role modelling fostered patient-centredness. Themes relating to low degrees of patient-centredness included negative role modelling and students being discouraged from being patient-centred.ConclusionsStudents’ perceptions of the patient-centredness of the learning environment decreased as students progressed through medical school, despite increasing exposure to patients. Qualitative analysis found that explicit patient-centred curricula cultivated patient-centred attitudes. Role modelling impacted student perceptions of patient-centredness within the learning environment.

A Call to Bridge Across Silos during Care Transitions

BACKGROUNDnOlder adults with complex medical conditions are vulnerable during care transitions. Poor care transitions can lead to poor patient outcomes and frequent readmissions to the hospital.nnnFACTORS CONTRIBUTING TO SUBOPTIMAL CARE TRANSITIONSnKey factors related to ineffective care transitions, which can lead to suboptimal patient outcomes, include poor cross-site communication and collaboration; lack of awareness of patient wishes, abilities, and goals of care; and incomplete medication reconciliation. Fundamental elements for effective care transitions put forth by The Joint Commission for effective care transitions include interdisciplinary coordination and collaboration of patient care in care transitions, shared accountability by all clinicians involved in care transitions, and provision of appropriate support and follow-up after discharge.nnnREVIEW OF FOUR EXISTING MODELS OF CARE TRANSITIONSnConsideration of four existing care transitions models representing different health care settings-Care Transitions Intervention® Guided Care, Interventions to Reduce Acute Care Transfers (INTERACT®), Home Health Model of Care Transitions-revealed that they are important but limited in their impact on transitions across health care settings.nnnPROPOSAL OF THE INTEGRATED CARE TRANSITIONS APPROACHnAn innovative approach, Integrated Care Transitions Approach (ICTA), is proposed that incorporates the best practices of the four models discussed in this article and factors identified as essential for an effective care transition while addressing limitations of existing transitional care models. ICTAs four key characteristics and seven key elements are unique and stem from factors that help achieve effective care transitions.