Cynthia Kay

The relationship between internal medicine residency graduate performance on the ABIM certifying examination, yearly in-service training examinations, and the USMLE Step 1 examination.

Purpose To explore the relationship between United States Medical Licensing Examination (USMLE) Step 1 scores, yearly in-service training exam (ITE) scores, and passing the American Board of Internal Medicine certifying examination (ABIM-CE). Method The authors conducted a retrospective database review of internal medicine residents from the Medical College of Wisconsin from 2004 through 2012. Residents’ USMLE Step 1, ITE, and ABIM-CE scores were extracted. Pearson rho, chi-square, and logistic regression were used to determine whether relationships existed between the scores and if Step 1 and ITE scores correlate with passing the ABIM-CE. Results There were 241 residents, who participated in 728 annual ITEs. There were Step 1 scores for 195 (81%) residents and ABIM-CE scores for 183 (76%). Step 1 and ABIM-CE scores had a modest correlation (rho: 0.59), as did ITE and ABIM-CE scores (rho: 0.48–0.67). Failing Step 1 or being in the bottom ITE quartile during any year of testing markedly increased likelihood of failing the boards (Step 1: relative risk [RR]: 2.4; 95% CI: 1.0–5.9; first-year residents’ RR: 1.3; 95% CI: 1.0–1.6; second-year residents’ RR: 1.3; 95% CI: 1.1–1.5; third-year residents’ RR: 1.3; 95% CI: 1.1–1.5). Conclusions USMLE Step 1 and ITE scores have a modest correlation with board scores. Failing Step 1 or scoring in the bottom quartile of the ITE increased the risk of failing the boards. What effective intervention, if any, program directors may use with at-risk residents is a question deserving further research.

Tricyclic and Tetracyclic Antidepressants for the Prevention of Frequent Episodic or Chronic Tension-Type Headache in Adults: A Systematic Review and Meta-Analysis

BackgroundTension-type headaches are a common source of pain and suffering. Our purpose was to assess the efficacy of tricyclic (TCA) and tetracyclic antidepressants in the prophylactic treatment of tension-type headache.MethodsWe searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the ISI Web of Science, and clinical trial registries through 11 March 2017 for randomized controlled studies of TCA or tetracyclic antidepressants in the prevention of tension-type headache in adults. Data were pooled using a random effects approach.Key ResultsAmong 22 randomized controlled trials, eight included a placebo comparison and 19 compared at least two active treatments. Eight studies compared TCAs to placebo, four compared TCAs to selective serotonin reuptake inhibitors (SSRIs), and two trials compared TCAs to behavioral therapies. Two trials compared tetracyclics to placebo. Single trials compared TCAs to tetracyclics, buspirone, spinal manipulation, transcutaneous electrical stimulation, massage, and intra-oral orthotics. High-quality evidence suggests that TCAs were superior to placebo in reducing headache frequency (weighted mean differences (WMD): −4.8 headaches/month, 95% CI: −6.63 to −2.95) and number of analgesic medications consumed (WMD: −21.0 doses/month, 95% CI: −38.2 to −3.8). TCAs were more effective than SSRIs. Low-quality studies suggest that TCAs are superior to buspirone, but equivalent to behavioral therapy, spinal manipulation, intra-oral orthotics, and massage. Tetracyclics were no better than placebo for chronic tension-type headache.ConclusionsTricyclic antidepressants are modestly effective in reducing chronic tension-type headache and are superior to buspirone. In limited studies, tetracyclics appear to be ineffective in the prophylactic treatment of chronic tension-type headache.

Utilization of Health Care Services and Ambulatory Resources Associated with Chronic Noncancer Pain

Objective Examine traditional and uncompensated health care utilization associated with chronic noncancer pain. Design Retrospective chart review. Setting Tertiary academic medical center. Subjects Internal medicine patients on long-term opioids for chronic noncancer pain with or without a pain agreement between April 1, 2014, and April 1, 2015 (N = 834). Patients without pain served as controls (N = 782). Methods Univariate statistics were used to compare health care utilization by the presence of chronic pain, pain agreement status, opioid dose, and schedule. Logistic regression was used to assess predictors of health care utilization, with emergency room visits, hospitalizations, and after-hour calls as binary outcomes and office visits and phone/e-mail contacts as ordinal outcomes. Results Patients with chronic pain used significantly more health care resources compared with patients without pain (all P  < 0.001). Patients on a pain agreement had more telephone and secure messages than patients without an agreement ( P  = 0.002). Controlling for demographics and other factors, patients with chronic pain had 2.6 (95% confidence interval [CI] = 2.1-3.4) times the odds of an emergency room visit, 5.0 (95% CI = 3.6-7.0) times the odds of a hospitalization, and 2.3 (95% CI = 1.7-3.0) times the odds of an after hour call, compared with nonpain controls. Ordinal logistic regression yield adjusted common odds ratios of 3.4 (95% CI = 2.7-4.2) and 2.9 (95% CI = 2.3-3.6) for total clinic visits and telephone or secure messages, respectively, indicating higher utilization for chronic pain patients. Conclusions Patients with chronic noncancer pain utilized more traditional and uncompensated health care resources compared with patients without chronic pain.

The validity and reliability of attending evaluations of medicine residents

Objectives: To assess the reliability and validity of faculty evaluations of medicine residents. Methods: We conducted a retrospective study (2004–2012) involving 228 internal medicine residency graduates at the Medical College of Wisconsin who were evaluated by 334 attendings. Measures included evaluations of residents by attendings, based on six competencies and interns and residents’ performance on the American Board of Internal Medicine certification exam and annual in-service training examination. All residents had at least one in-service training examination result and 80% allowed the American Board of Internal Medicine to release their scores. Results: Attending evaluations had good consistency (Cronbach’s α = 0.96). There was poor construct validity with modest inter-rater reliability and evidence that attendings were rating residents on a single factor rather than the six competencies intended to be measured. There was poor predictive validity as attending ratings correlated weakly with performance on the in-service training examination or American Board of Internal Medicine certification exam. Conclusion: We conclude that attending evaluations are poor measures for assessing progress toward competency. It may be time to move beyond evaluations that rely on global, end-of-rotation appraisals.

Examining Invasive Bedside Procedure Performance at an Academic Medical Center.

Objectives Explore the performance patterns of invasive bedside procedures at an academic medical center, evaluate whether patient characteristics predict referral, and examine procedure outcomes. Methods This was a prospective, observational, and retrospective chart review of adults admitted to a general medicine service who had a paracentesis, thoracentesis, or lumbar puncture between February 22, 2013 and February 21, 2014. Results Of a total of 399 procedures, 335 (84%) were referred to a service other than the primary team for completion. Patient characteristics did not predict referral status. Complication rates were low overall and did not differ, either by referral status or location of procedure. Model-based results showed a 41% increase in the average length of time until procedure completion for those referred to the hospital procedure service or radiology (7.9 vs 5.8 hours; P < 0.05) or done in radiology instead of at the bedside (9.0 vs 5.8 hours; P < 0.001). The average procedure cost increased 38% (

Heartsink Hotel, or “Oh No, Look Who’s on My Schedule this Afternoon!”

1489.70 vs

Pain Agreements and Healthcare Utilization in a Veterans Affairs Primary Care Population: A Retrospective Chart Review

1023.30; P < 0.001) for referred procedures and 56% (

Health care utilization by veterans prescribed chronic opioids

1625.77 vs

Migraine prophylactic management in neurology and primary care (2006–2015)

1150.98; P < 0.001) for radiology-performed procedures. Conclusions Although referral often is the easier option, our study shows its shortcomings, specifically pertaining to cost and time until completion. Procedure performance remains an important skill for residents and hospitalists to learn and use as a part of patient care.

Capsule Commentary on Gallo et al., Multimorbidity, Depression, and Mortality in Primary Care: Randomized Clinical Trial of an Evidence-Based Depression Care Management Program on Mortality Risk

It is a dirty little secret that every provider has patients that make their “heart sink” when they see them on their schedule.1 Such patients have been variously called “black holes,”2 “difficult,”3 “frustrating,”4 “disliked”5 and in the sentinel 1978 article, even “hateful.”6 What is perhaps surprising is that they are so common, accounting for up to 15 % of primary care patients worldwide. At first, we tried to blame the patients. We “discovered” that dreaded patients share a number of characteristics. They usually have medically unexplainable symptoms,7 even after an exhaustive, expensive and fruitless search. They often have excessive worry,7 low functional status,8 personality disorders9 and poor functional status.3 Making matters worse from the doctor’s perspective, they are high utilizers;3 they visit their primary care provider more often than the provider would like and are also well known to local urgent care clinics and emergency departments. A typical phone call from the ER provider to the primary care provider is “Your patient, Mr. Smith is here in our ER…[pregnant pause]…again!” What the ER provider doesn’t know is that instead of provoking a guilty feeling that we haven’t done a better job of managing Mr. Smith so he wouldn’t need to be a burden to the emergency room provider, we’re just glad he’s not in our clinic this morning. Only recently have we begun to turn the mirror upon ourselves. “Difficult” is a label we have applied to describe a particular, and deeply personal, emotional experience. Viewed through this lens, it’s odd that it’s taken so long to recognize that it might not just be the patient’s problem. Less experienced clinicians3,7 and those reporting greater workload and less communication training report having more “difficult” patients.10 Both parties to these “difficult” encounters are troubled. Both patients and providers emerge from these encounters with lower rates of satisfaction. Patients have less trust, more unmet expectations and are less likely to experience symptom improvement.3,7 It is fruitless to turn to psychiatry for an answer. First, only a small fraction of “difficult” primary care patients meet criteria for a major DSM-IV somatoform disorder11 and “undifferentiated somatoform disorder” requires only one unexplained symptom for 6 months, so it is too broad to be clinically helpful. Secondly, these patients will tend to reject any intimation that it “might be in their head” and are loath to accept referrals to mental health providers. Finally, psychiatrists also find these patients frustrating and are not eager to accept them in their practice. Out of a sense that there might be something universal underlying these patient’s problems, primary care providers have proposed a new diagnosis, multisomatoform disorder.12 This is defined as the presence of more than three unexplained physical symptoms for more than 2 years and most “difficult patients” would meet this criterion. Patients with multisomatoform disordrs have similar decrement in health-related quality of life, more disability and higher utilization than patients with mood or anxiety disorders,12 and are less likely to either receive a medical explanation or experience symptom improvement over 5 years of follow-up.13 Labeling “difficult” patients as having multisomatoform disorder might help; labels can provide a structure for managing and thinking about such patients. Rather than having undifferentiated fear responses, vague feelings of frustration, dread, dislike, and even hate, providers can use structured diagnosis as a means to shift their emotional response to an empathic one. Mr. Smith isn’t hateful; he has a multisomatoform disorder. In this issue of JGIM, Barsky and colleagues randomized high utilizing somatizing patients to office based cognitive behavior therapy (CBT) or to relaxation therapy.11 Over 1 year of follow-up, both groups experienced significant and equivalent improvements in somatization, distress, role impairment and hypochondriacal symptoms. They also experienced a decrease in health utilization (from 10.3 to 8.8 visits at 1 year). Similar to previous studies, only a minority of patients met DSM IV criteria for hypochondriasis. Also similar to other studies that have evaluated CBT for patients with medically unexplained symptoms,14 the benefit was modest. What is not clear in this and other studies is whether patients became less “difficult” for providers. So, what is a primary care provider to do? First, every provider can expect to have several multisomatoform patients in their practice. Improved training in communication skills helps, 14 and as a profession, we should be doing a better job of preparing our young, eager doctors to deal with Mr. Smith. After all, if 15 % of our primary care patients had disease X, it would be disturbing if we failed to teach graduating providers how to manage it. Simple measures, like spending time eliciting underlying stress, mental disorders and patient expectations reduces difficulty and improves patient satisfaction. Directly addressing and discussing distress, anger, sadness and troublesome medical experiences is more effective than ignoring it. One proposed model is to “Name the emotion, Understand it, Respect and Support it (NURSs).14 Sharing responsibility with patients rather than shouldering the burden of “fixing the patient” is an important step in motivating patients and encouraging patients to move from a state of “victimhood” to one of control. The greatest benefit in clinical trials has been through a combination of reorienting both provider and patient goals and expectations for the visits. The former can happen through communication training, the latter through CBT. CBT is most effective when it is delivered in the primary care setting, particularly since patients with somatization are unwilling to be seen in mental health venues. We need to make CBT available in every primary care setting. There are limited data that antidepressants can help,15 though their benefit appears less than CBT. While antidepressants may work directly on the unexplained symptom syndrome, these patients often also have depressive or anxiety disorders that amplify their symptoms and distress. Whether the combination of antidepressants and CBT would be better than either individually is unknown. What is clear is that somatizing patients who develop or have comorbid anxiety or depression should receive appropriate antidepressant treatment. Much of the work in this area has focused on a single patient and a single provider. Patient care is evolving rapidly. This could provide new opportunities for improving the care of “difficult” patients. A team approach is likely to be helpful and the patient-centered medical home might provide a method of sharing care that could improve both how providers feel about these patients and improve outcomes. Though it is also possible that less continuity, more handoffs could provide more opportunities for such patients to doctor shop and fall through cracks. CBT needs to be available in the primary care clinic. More research is needed. It is criminal that we fail to teach our young providers the lessons we do know about approaches that are effective.