Lynne M. Kirk

Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: Recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer

Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer

The Future of General Internal Medicine: Report and Recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today’s medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.

Guidelines for colonoscopy surveillance after cancer resection: A consensus update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer

Patients with resected colorectal cancer are at risk for recurrent cancer and metachronous neoplasms in the colon. This joint update of guidelines by the American Cancer Society (ACS) and US Multi‐Society Task Force on Colorectal Cancer addresses only the use of endoscopy in the surveillance of these patients. Patients with endoscopically resected Stage I colorectal cancer, surgically resected Stage II and III cancers, and Stage IV cancer resected for cure (isolated hepatic or pulmonary metastasis) are candidates for endoscopic surveillance. The colorectum should be carefully cleared of synchronous neoplasia in the perioperative period. In nonobstructed colons, colonoscopy should be performed preoperatively. In obstructed colons, double contrast barium enema or computed tomography colonography should be done preoperatively, and colonoscopy should be performed 3 to 6 months after surgery. These steps complete the process of clearing synchronous disease. After clearing for synchronous disease, another colonoscopy should be performed in 1 year to look for metachronous lesions. This recommendation is based on reports of a high incidence of apparently metachronous second cancers in the first 2 years after resection. If the examination at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that colonoscopy is normal, then the interval before the next subsequent examination should be 5 years. Shorter intervals may be indicated by associated adenoma findings (see Postpolypectomy Surveillance Guideline). Shorter intervals are also indicated if the patients age, family history, or tumor testing indicate definite or probable hereditary nonpolyposis colorectal cancer. Patients undergoing low anterior resection of rectal cancer generally have higher rates of local cancer recurrence, compared with those with colon cancer. Although effectiveness is not proven, performance of endoscopic ultrasound or flexible sigmoidoscopy at 3‐ to 6‐month intervals for the first 2 years after resection can be considered for the purpose of detecting a surgically curable recurrence of the original rectal cancer.

Quality in the technical performance of screening flexible sigmoidoscopy: recommendations of an international multi-society task group

Background: Flexible sigmoidoscopy (FS) is a complex technical procedure performed in a variety of settings, by examiners with diverse professional backgrounds, training, and experience. Potential variation in technical quality may have a profound impact on the effectiveness of FS on the early detection and prevention of colorectal cancer. Aim: We propose a set of consensus and evidence based recommendations to assist the development of continuous quality improvement programmes around the delivery of FS for colorectal cancer screening. Recommendations: These recommendations address the intervals between FS examinations, documentation of results, training of endoscopists, decision making around referral for colonoscopy, policies for antibiotic prophylaxis and management of anticoagulation, insertion of the FS endoscope, bowel preparation, complications, the use of non-physicians as FS endoscopists, and FS endoscope reprocessing. For each of these areas, continuous quality improvement targets are recommended, and research questions are proposed.

Implementation of competency‐based medical education: are we addressing the concerns and challenges?

Competency‐based medical education (CBME) has emerged as a core strategy to educate and assess the next generation of physicians. Advantages of CBME include: a focus on outcomes and learner achievement; requirements for multifaceted assessment that embraces formative and summative approaches; support of a flexible, time‐independent trajectory through the curriculum; and increased accountability to stakeholders with a shared set of expectations and a common language for education, assessment and regulation.

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...

Patient education pamphlets about prevention, detection, and treatment of breast cancer for low literacy women

The objective of this project was to identify and assess readily available patient education literature about prevention, detection and treatment of breast cancer for the patient with low literacy skills. The target population had a reading comprehension level of sixth grade or lower. Nineteen pamphlets were analyzed using RightWriter and were found to have an average readability index of 9.15, therefore requiring at least a ninth grade level of reading comprehension. As a consequence, many pieces of the available literature were inappropriate for the target population. There are implications as a broader group of health care providers becomes more involved in the treatment of low literacy patients. In providing patient education literature to poorly educated patients, special emphasis should be given to determining readability. Both currently available and newly created literature should be analyzed for readability before assuming it is an aid to patient education.

Development of Geriatrics-Oriented Faculty in General Internal Medicine

The need for all medical students and primary care housestaff to acquire skills in the care of the elderly has been recognized for decades (1, 2). More recently, studies have shown that fellows training in general internal medicine and internal medicine subspecialties need to develop these skills as well (3). It was hoped that faculty with geriatrics training or expertise could meet the educational needs of trainees; however, we continue to have insufficient numbers of academic geriatricians, and this shortage will worsen in the future (46). Clinicianeducators in general internal medicine do much of the teaching of trainees in both ambulatory and inpatient settings, where many of the patients are elderly. Thus, academic general internists have the opportunity to help impart the basic knowledge and skills necessary to care for older adults (7). To incorporate geriatrics into their already busy teaching agendas, general internists must have the necessary motivation, knowledge, and skills. We describe what is being done to develop geriatrics-oriented general internal medicine faculty. We identify current practices, best practices, goals and targets, and barriers to achieving those goals and targets. We then offer potential solutions for overcoming barriers to faculty development in geriatrics among academic general internists. Methods Literature Review We searched the literature using several databases: MEDLINE (1966 to February 2001), ERIC (Educational Resources Information Center) (1966 to February 2001), AgeLine (1978 to February 2001), Best Evidence (1991 to February 2001), Current Contents (1995 to February 2001), the Cochrane Database of Systematic Reviews, and Pre-MEDLINE. Abstracts from national meetings of the American Geriatrics Society and the Society of General Internal Medicine were reviewed for the years 1999 to 2001. Program reports on geriatrics-oriented faculty-development activities were requested from the John A. Hartford Foundation, Inc., and the Health Resources and Services Administration. We also asked leaders in geriatric medicine about their knowledge of programs related to geriatrics-oriented faculty development in general internal medicine. We reviewed titles and available abstracts for a match to at least 1 of 6 areas: current practices, best practices, goals and targets for optimal development of geriatrics-oriented general internal medicine faculty, barriers to achieving those goals and targets, solutions to identified barriers, and institutions that have programs and have published in the area of geriatrics-oriented faculty development. Two authors reviewed articles for the following inclusion criteria: 1) inclusion of general internal medicine faculty, 2) description of the educational interventions, 3) evaluation of the outcomes, and 4) description of the outcomes. The literature review identified a total of 504 references. We reviewed all titles and available abstracts (64%) and read 138 articles in their entirety. Four published articles and 3 program project reports (814) (Appendix Table) met the inclusion criteria. Focus Group and Structured Interviews As a convenience sample, 40 division heads of general internal medicine units at 38 medical schools in the southern United States were asked to participate in an 80-minute focus-group session on training general internists in geriatrics. We used a random-numbers table to select 34 other medical schools for interviewing. We sent letters to the general internal medicine chiefs at those schools, requesting their participation in a structured 15-minute telephone interview. We also sent letters to the directors and the heads of general internal medicine of 21 Hartford Centers of Excellence. Results Literature Review The faculty-development projects described in the literature or project reports were all funded by 1 of 2 sources: the Health Resources and Services Administration, as part of its Geriatrics Education Centers in the 1980s, or the John A. Hartford Foundation, Inc., in the 1990s. All faculty-development activities included faculty from more than 1 discipline. The interventions ranged from 9 evening sessions held over 3 years (9) to 1 year of on-site training (10). They all included educational modules related to geriatrics content and training in educational methods. A few included experiential training at geriatric clinical sites or teaching, or both (Appendix Table) (10, 11; Silliman R. John A. Hartford Foundation Progress Report. Boston University Center of Excellence in Geriatrics: 1/1/98 to 12/31/00, 2001, Personal communication; Stratos G. Final Report: Stanford Education Resource and Dissemination Center for the John A. Hartford Geriatrics in Primary Care Residency Training Initiatives, 2001, Personal communication). All of the faculty-development projects measured outcomes by using surveys and evaluations of educational offerings at or after the conclusion of the projects. They also measured either 1) the intent of participating faculty to change geriatrics practice or teaching or 2) self-reported change in the activities of participating faculty at some point after the training. Only 1 project (Stratos G. Personal communication) measured and reported change in knowledge, skills, and attitude by learners. None of the projects measured change in behavior by learners that might have resulted from the educational intervention. Focus Group and Structured Interviews Eleven of the 40 division heads, representing 10 schools, participated in the focus-group session. We completed interviews with 13 Hartford Center directors (62%), 21 general internal medicine unit chiefs at medical schools that are not Centers of Excellence (62%), and 9 general internal medicine unit chiefs at schools with a Hartford Center (43%). Between the focus group and the individual interviews, 49 medical schools were represented. According to general internal medicine unit chiefs, geriatrics was taught exclusively by geriatrics faculty at 24% of schools that are not Centers of Excellence and 67% of schools with Hartford Centers. It was taught by both general internal medicine and geriatrics faculty at 38% of schools that are not Centers of Excellence and 33% of schools with Hartford Centers. It was taught exclusively by general internal medicine faculty at 33% of schools that are not Centers of Excellence and none of the schools with Hartford Centers. At 1 school, internists did not teach geriatrics. At 3 of the 5 schools with Hartford Centers where both the Center director and the general internal medicine unit chief were interviewed, the director and the chief disagreed about who taught geriatrics. When asked whether geriatrics should be taught by general internal medicine faculty, general internal medicine unit chiefs said yes at 86% of schools that are not Centers of Excellence and at 56% of schools with Hartford Centers. When Center directors were asked the same question, 85% said yes. General internal medicine unit chiefs were asked whether their faculty perceived that they should teach geriatrics. At schools that are not Centers of Excellence, 57% said yes and 52% said that their faculty currently had the knowledge and skills to teach geriatrics (81% concordance). At schools with Hartford Centers, 22% said yes and 33% said that their faculty currently had the knowledge and skills to teach geriatrics (87.5% concordance). When Hartford Center directors were asked whether their general internal medicine faculty had the knowledge and skills to teach geriatrics, 46% said yes. Activities to increase clinical or teaching skills in geriatrics for general internal medicine faculty were reported by 5 (24%) of the general internal medicine unit chiefs at schools that are not Centers of Excellence, 5 (56%) of the general internal medicine unit chiefs at schools with Hartford Centers, and 4 (31%) of the Hartford Center directors. Some Center directors noted that although geriatrics-oriented faculty-development activities were offered to general internal medicine faculty, few or no faculty participated. The rest of the reported activities were done as part of ongoing general internal medicine unit activities, such as journal clubs, grand rounds, and conferences. Outcomes have not been measured or published for most of these activities, many of which were not sustained over time. At Hartford Centers, we identified 2 additional faculty-development programs for which outcomes have not been published. At 1 site, faculty members received a small stipend, participated in didactic work, and were paired with geriatricians who helped them develop a scholarly project. The intervention does not seem to have had a measurable effect on the teaching of geriatrics by general internal medicine faculty at this institution. Another program offered support to assist general internal medicine faculty with the development of core geriatrics content areas for teaching. As a result, general internal medicine faculty and geriatrics faculty provide didactic lectures during resident and student geriatrics rotations. The general internal medicine chiefs were asked in an open-ended manner to identify existing barriers that hinder their faculty from teaching geriatrics and participating in geriatrics-oriented faculty development. Nineteen (70%) specified lack of time, both for teaching and for participation in faculty development. Ten (37%) suggested that their faculty did not perceive a need to teach geriatrics or were not motivated to teach geriatrics. Some identified a lack of resources as a barrierspecifically, materials for geriatrics-oriented faculty development and clinical resources to enable interdisciplinary teams to teach geriatrics. Although the focus-group participants were a subset of a regional group of general internal medicine unit chiefs, their responses yielded information similar to that offered in the structured interviews. Discussion Our findings suggest a great

Enhancing self-efficacy and patient care with cardiovascular nutrition eduction

BACKGROUND Provision of medical education that develops nutrition knowledge and self-efficacy is critical if physicians are to incorporate nutrition in preventive care. We studied the impact of a cardiovascular nutrition module on the knowledge, attitudes, and self-efficacy of fourth-year medical students and the relationship of these attributes to patient care practices. METHODS Based on national practice guidelines and learner needs, an educational intervention consisting of two web-based cases, pocket reference cards, and classroom discussion was developed and implemented. Knowledge, attitudes, and self-efficacy were measured at the beginning and end of the 4-week ambulatory care rotation for 40 control and 156 experimental students. Performance in patient care was approximated using a self-report; chart audits were performed for a subset of students. CONCLUSIONS Knowledge scores of experimental students increased significantly from a mean of 10.3 to 14.4 (p<0.001), while the change for control students from 9.2 to 9.8 was not significant (p=0.20). The increase in self-efficacy scores from 26.2 to 35.7 in the experimental group (p<0.001) was twice that of the increase from 25.8 to 29.9 in the control group (p=0.001). Small but significant increases in attitude scores were similar for both groups. Limited data on student performance revealed that students with greater cardiovascular nutrition self-efficacy were more likely to address nutrition with cardiovascular patients. CONCLUSIONS Incorporation of cardiovascular nutrition concepts in an ambulatory care rotation including use of computer-based cases improved student knowledge and self-efficacy, which may translate to increased frequency of future physicians addressing nutrition with patients.

What Is a Geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs End-of-Training Entrustable Professional Activities for Geriatric Medicine

Entrustable professional activities (EPAs) describe the core work that constitutes a disciplines specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end‐of‐training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatricians fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.