Gregory C. Kane

Charting the road to competence: developmental milestones for internal medicine residency training.

BACKGROUNDnThe Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice.nnnINTERVENTIONnIn November 2007, the American Board of Internal Medicine (ABIM) and the ACGME initiated the development of milestones for internal medicine residency training. ABIM and ACGME convened a 33-member milestones task force made up of program directors, experts in evaluation and quality, and representatives of internal medicine stakeholder organizations. This article reports on the development process and the resulting list of proposed milestones for each ACGME competency.nnnOUTCOMESnThe task force adopted the Dreyfus model of skill acquisition as a framework the internal medicine milestones, and calibrated the milestones with the expectation that residents achieve, at a minimum, the competency level in the 5-step progression by the completion of residency. The task force also developed general recommendations for strategies to evaluate the milestones.nnnDISCUSSIONnThe milestones resulting from this effort will promote competency-based resident education in internal medicine, and will allow program directors to track the progress of residents and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking, and assist remediation by facilitating identification of specific deficits. Finally, by making explicit the professions expectations for graduates and providing a degree of national standardization in evaluation, the milestones may improve public accountability for residency training.

The Internal Medicine Reporting Milestones and the Next Accreditation System

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones Project to facilitate more synthetic and narrative-based assessments of educational outcomes. This commenta...

Prevalence of obstructive lung disease in HIV population: A cross sectional study

BACKGROUNDnObservational studies have suggested an association between HIV infection and emphysema.nnnAIMSnThe primary aim of this study was to estimate the prevalence of obstructive lung disease in HIV-infected patients seen in an outpatient infectious disease clinic. The secondary aim was to estimate the prevalence of Obstructive Lung Disease (OLD) in smokers and non smokers in this population.nnnMETHODSnThis was a prospective cross-sectional study. Consecutive patients who were seen for routine HIV care underwent spirometry and answered the St. Georges Respiratory Questionnaire (SGRQ). Further, we collected information from the charts on demographics, co-morbidities, CD4 cell count, and HIV viral load (current, baseline, etc).nnnRESULTSnThis study included 98 HIV-infected patients with mean age of 45 years, (SD: 11) and 84% male. They were seen from November 2008 to May 2009 at Thomas Jefferson University in Philadelphia. According to established criteria, spirometry results were classified as normal in 69% and obstructive in 16.3%. Among those who never smoked, the prevalence of obstructive lung disease on spirometry was 13.6%. The prevalence of obstruction in HIV patients with a history of smoking was 18.5%. Current and ever smokers comprised 21.4% and 55% of the patients respectively. The mean SGRQ total score was 7. The mean SGRQ score in active smokers was 17 and 15 in those subjects with a prior history of smoking. The mean SGRQ score among patients with obstruction in spiromerty was 27.7 in patients with obstruction on spirometry.nnnCONCLUSIONnThis urban population of HIV-infected persons has a relatively high prevalence of obstructive lung disease as assessed by spirometry. Furthermore, the high prevalence of obstructive lung disease in never smokers may suggest a possible association between HIV infection and emphysema. In addition the SGRQ total score was comparatively higher in patients with obstruction on spirometry. Our data suggests that potentially all patients with HIV should be screened a for OLD.

The Anticipated Physician Shortage: Meeting the Nation's Need for Physician Services

he Anticipated Physician Shortage: Meeting the ation’s Need for Physician Services regory C. Kane, MD, Michael R. Grever, MD, John I. Kennedy, MD, Mary Ann Kuzma, MD, lan R. Saltzman, MD, Peter H. Wiernik, MD, Nicole V. Baptista, BS Division of Pulmonary Medicine and Critical Care, Department of Medicine, Jefferson Medical College, Philadelphia, Pa; Department of Internal Medicine, Ohio State University College of Medicine, Columbus; Department of Medicine, niversity of Alabama at Birmingham School of Medicine, Birmingham; Birmingham VA Medical Center; Department of edicine, Drexel University College of Medicine, Philadelphia, Pa; Department of Medicine, State University of New York t Buffalo School of Medicine and Biomedical Sciences, Buffalo; Division of Hematology and Oncology, Department of nternal Medicine, New York Medical College (Our Lady of Mercy), Bronx, NY; Alliance for Academic Internal Medicine, ashington, DC.

Early feedback on the use of the internal medicine reporting milestones in assessment of resident performance.

BACKGROUNDnThe educational milestones were designed as a criterion-based framework for assessing resident progression on the 6 Accreditation Council for Graduate Medical Education competencies.nnnOBJECTIVEnWe obtained feedback on, and assessed the construct validity and perceived feasibility and utility of, draft Internal Medicine Milestones for Patient Care and Systems-Based Practice.nnnMETHODSnAll participants in our mixed-methods study were members of competency committees in internal medicine residency programs. An initial survey assessed participant and program demographics; focus groups obtained feedback on the draft milestones and explored their perceived utility in resident assessment, and an exit survey elicited input on the value of the draft milestones in resident assessment. Surveys were tabulated using descriptive statistics. Conventional content analysis method was used to assess the focus group data.nnnRESULTSnThirty-four participants from 17 programs completed surveys and participated in 1 of 6 focus groups. Overall, the milestones were perceived as useful in formative and summative assessment of residents. Participants raised concerns about the length and complexity of some draft milestones and suggested specific changes. The focus groups also identified a need for faculty development. In the exit survey, most participants agreed that the Patient Care and Systems-Based Practice Milestones would help competency committees assess trainee progress toward independent practice.nnnCONCLUSIONSnDraft reporting milestones for 2 competencies demonstrated significant construct validity in both the content and response process and the perceived utility for the assessment of resident performance. To ensure success, additional feedback from the internal medicine community and faculty development will be necessary.

Model for End-Stage Liver Disease score for predicting outcome in critically ill medical patients with liver cirrhosis.

PURPOSEnWe hypothesized that the Model for End-Stage Liver Disease (MELD) score at admission to the intensive care unit (ICU) can predict in-hospital mortality for patients with liver cirrhosis. We also tested the MELD-natremia (Na) score and compared the predictive value of the 2 models.nnnMATERIALS AND METHODSnThis is a retrospective cohort study. A total of 441 consecutive patients with liver cirrhosis admitted to the ICU were included. The MELD and MELD-Na scores and other variables were obtained upon patients admission to the ICU.nnnRESULTSnThe area under the receiver operating characteristic curve to predict in-hospital mortality was 0.77 (95% confidence interval, 0.73-0.82) for the MELD score and 0.77 (95% confidence interval, 0.73-0.81) for the MELD-Na score.nnnCONCLUSIONnThe MELD scoring system provides useful prognostic information for critically ill patients with liver cirrhosis admitted to an ICU. The MELD and MELD-Na scores had similar predictive value.

Important Skills for Internship and the Fourth-year Medical School Courses to Acquire Them: A National Survey of Internal Medicine Residents

Purpose To obtain feedback from internal medicine residents, a key stakeholder group, regarding both the skills needed for internship and the fourth-year medical school courses that prepared them for residency. This feedback could inform fourth-year curriculum redesign efforts. Method All internal medicine residents taking the 2013–2014 Internal Medicine In-Training Examination were asked to rank the importance of learning 10 predefined skills prior to internship and to use a dropdown menu of 11 common fourth-year courses to rank the 3 most helpful in preparing for internship. The predefined skills were chosen based on a review of the literature, a national subinternship curriculum, and expert consensus. Chi-square statistics were used to test for differences in responses between training levels. Results Of the 24,820 internal medicine residents who completed the exam, 20,484 (83%) completed the survey, had complete identification numbers, and consented to have their responses used for research. The three skills most frequently rated as very important were identifying when to seek additional help and expertise, prioritizing clinical tasks and managing time efficiently, and communicating with other providers around care transitions. The subinternship/acting internship was most often selected as being the most helpful course in preparing for internship. Conclusions These findings indicate which skills and fourth-year medical school courses internal medicine residents found most helpful in preparing for internship and confirm the findings of prior studies highlighting the perceived value of subinternships. Internal medicine residents and medical educators agree on the skills students should learn prior to internship.

Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.

The fourth year of medical school remains controversial, despite efforts to reform it. A committee from the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine examined transitions from medical school to internship with the goal of better academic advising for students. In 2013 and 2014, the committee examined published literature and the Web sites of 136 Liaison Committee on Medical Education–accredited schools for information on current course offerings for the fourth year of medical school. The authors summarized temporal trends and outcomes when available. Subinternships were required by 122 (90%) of the 136 schools and allow students to experience the intern’s role. Capstone courses are increasingly used to fill curricular gaps. Revisiting basic sciences in fourth-year rotations helps to reinforce concepts from earlier years. Many schools require rotations in specific settings, like emergency departments, intensive care units, or ambulatory clinics. A growing number of schools require participation in research, including during the fourth year. Students traditionally take fourth-year clinical electives to improve skills, both within their chosen specialties and in other disciplines. Some students work with underserved populations or seek experiences that will be henceforth unavailable, whereas others use electives to “audition” at desired residency sites. Fourth-year requirements vary considerably among medical schools, reflecting different missions and varied student needs. Few objective outcomes data exist to guide students’ choices. Nevertheless, both medical students and educators value the fourth year of medical school and feel it can fill diverse functions in preparing for residency.

Influence of malignancy on the decision to withhold or withdraw life-sustaining therapy in critically ill patients.

Purpose: To evaluate the influence of malignancy on the decision to limit life-sustaining therapy in the intensive care unit (ICU). Methods: At the day of patients’ admission to the ICU, we prospectively collected information on demographics, acute physiology and chronic health evaluation (APACHE) II score, and features related to malignancy. We retrospectively collected information on in-hospital survival and decision to withhold or withdraw life-sustaining treatment. Results: This study included 122 adult critically ill patients. After adjusting for age and APACHE II score, patients with malignancy had 3.02 (95% CI 1.19 to 7.62) higher odds of having life-sustaining therapy withdrawn or withheld as compared to patients without active malignancy. Conclusion: Our study showed that critically ill patients with malignancy are more likely to have their life-sustaining therapy withheld or withdrawn than those without malignancy after adjusting for severity of disease. This finding may be related to a perception that critically ill patients with malignancy have worse prognosis as compared with those without malignancy.

Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper

Social determinants of health, which are defined as the conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life (1), are responsible for most health inequalities. Social determinants are primarily rooted in resource allocation and affect factors at the local, national, and global levels (2). Evidence gathered over the past 30 years supports the substantial effect of nonmedical factors on overall physical and mental health. An analysis of studies measuring adult deaths attributable to social factors found that, in 2000, approximately 245000 deaths were attributable to low education, 176000 were due to racial segregation, 162000 were due to low social support, 133000 were due to individual-level poverty, and 119000 were due to income inequality (3). The number of annual deaths attributable to low social support was similar to the number from lung cancer (n= 155521). The United States, despite ranking among the 10 richest countries in the world per capita, experiences sizable health disparities among its citizens that are rooted in social, economic, and environmental factors. In the United States, place of birth is more strongly associated with life expectancy than race or genetics (4). On average, there is a 15-year difference in life expectancy between the most advantaged and disadvantaged citizens (5). This difference is correlated with geographic characteristics and health behaviors (2) that are influenced by historical and social factors. Population-level inequalities in health care result in