Patrick Rendon

Addressing the Primary Care Shortage on a Shoestring: A Successful Track in an Internal Medicine Residency.

PROBLEM Nationally, shortages of primary care providers are of major concern. Internal medicine programs, once the major supplier of primary care physicians, are no longer producing large numbers of primary care providers to help meet the needs of the growing patient population. APPROACH In 2009, residents at the University of New Mexico created a resident-driven Primary Care Track (PCT) within the internal medicine residency, and after six years this track is thriving. The PCT allows residents to designate blocks of time specifically devoted to primary care training. Residents opt in to the track at the end of intern year and arrange their own schedules over large blocks of time in the last two years of training to allow for an individualized curriculum that prepares them for independent practice in primary care. OUTCOMES Approximately 85% (11/13) of residents who have graduated from the track have gone on to practice in primary care after graduation, and the internal medicine residency program as a whole has also seen an increase in the fraction of residents pursuing primary care since the inception of this track. NEXT STEPS The PCT is currently at maximum capacity and may be forced to turn away applicants. To expand while still maintaining the core principles of the track, the PCT will strive to find additional ways to use New Mexicos existing resources and to develop a more robust mentoring structure and didactic programs. Formalized financial, faculty, and administrative support of the program also will be needed.

Keys to career success: resources and barriers identified by early career academic hospitalists

Prior research in the field of academic hospital medicine has described challenges to achieving promotion for academic hospitalists. 2 A consensus conference identified barriers for academic hospitalist success including alignment of hospitalists with clinical priorities that may not be recognized for academic advancement, inadequate infrastructure to promote success, and lack of national funding for research in general inpatient medicine. Research is needed to better understand perspectives of academic hospitalists regarding the pathway to career success. This qualitative study explores the barriers and facilitators of career success as perceived by early career academic hospitalists.

Pulmonary Renal Syndrome After Streptococcal Pharyngitis: A Case Report.

Pulmonary renal syndrome is a class of small vessel vasculitides that are characterized by the dual presentation of diffuse alveolar hemorrhage (DAH) and glomerulonephritis. Pulmonary renal syndrome has multiple etiologies, but its development has been rarely reported following infection with group A streptococcus. We present the case of a 36-year-old Native American male who was transferred to our facility due to refractory hypoxic respiratory failure. He had been diagnosed with streptococcal pharyngitis 2 weeks prior to admission. Given the presence of hemoptysis, bronchoscopy was performed and was consistent with DAH. Urinalysis demonstrated hematuria and proteinuria, in the setting of elevated creatinine and blood urea nitrogen. Additionally, antistreptolysin O titer was positive. Given the constellation of laboratory findings and history of streptococcal pharyngitis, the patient was diagnosed with PRS secondary to streptococcal infection. High-dose methylprednisolone was initiated with concomitant plasmapheresis. He was extubated successfully after his respiratory status improved and was eventually discharged home after making a full recovery within 2 weeks after admission. This case illustrates the importance of clinically relevant sequelae of streptococcal infection as well as the appropriate treatment of PRS secondary to streptococcal pharyngitis with plasmapheresis and intravenous corticosteroids.

What Is Career Success for Academic Hospitalists? A Qualitative Analysis of Early-Career Faculty Perspectives

BACKGROUND Understanding the concept of career success is critical for hospital medicine groups seeking to create sustainably rewarding faculty positions. Conceptual models of career success describe both extrinsic (compensation and advancement) and intrinsic (career satisfaction and job satisfaction) domains. How hospitalists define career success for themselves is not well understood. In this study, we qualitatively explore perspectives on how early-career clinician-educators define career success. METHODS We developed a semistructured interview tool of open-ended questions validated by using cognitive interviewing. Transcribed interviews were conducted with 17 early-career academic hospitalists from 3 medical centers to thematic saturation. A mixed deductive-inductive, qualitative, analytic approach was used to code and map themes to the theoretical framework. RESULTS The single most dominant theme participants described was “excitement about daily work,” which mapped to the job satisfaction organizing theme. Participants frequently expressed the importance of “being respected and recognized” and “dissemination of work,” which were within the career satisfaction organizing theme. The extrinsic organizing themes of advancement and compensation were described as less important contributors to an individual’s sense of career success. Ambivalence toward the “academic value of clinical work,” “scholarship,” and especially “promotion” represented unexpected themes. CONCLUSIONS The future of academic hospital medicine is predicated upon faculty finding career success. Clinician-educator hospitalists view some traditional markers of career advancement as relevant to success. However, early-career faculty question the importance of some traditional external markers to their personal definitions of success. This work suggests that the self-concept of career success is complex and may not be captured by traditional academic metrics and milestones.

Optimizing diagnostic testing for venous thromboembolism

Diagnostic algorithms for venous thromboembolism exist, but most do not provide detailed guidance as to which patients, if any, may benefit from screening for thrombophilia. This article provides an overview of the optimized diagnosis of venous thromboembolism, with a focus on the appropriate use of thrombophilia screening. A thoughtful approach to diagnosing venous thromboembolism and screening for thrombophilic disorders.

Peer Observation of Rounds Leads to Collegial Discussion of Teaching

ABSTRACT Problem: Faculty in the Division of Hospital Medicine provide most of the clinical teaching for learners at our institution. The majority of these faculty are Assistant Professors with limited formal instruction in clinical teaching. Previous Divisional strategies to improve clinical teaching ability included discussion of effective teaching behaviors, developing written expectations for teaching faculty, and instituting seminars on effective clinical teaching. Heretofore, the Division had not utilized a direct observation exercise. Intervention: We developed a direct observation exercise to encourage discussion of teaching techniques and contemplation of change. Using a social learning model, we developed a peer-to-peer observation followed by a nonevaluative discussion. We created a tool for describing teaching behaviors in 5 domains that were similar to or different from the usual behavior of the observing peer: learner presentations, team leadership, bedside teaching, professionalism, and other. After the observation, the observing and observed faculty met to discuss observed teaching behaviors. Both faculty members discussed and then recorded any teaching behaviors that they planned to adopt or change. Context: We implemented this intervention in a 22-member Academic Division of Hospital Medicine at a tertiary care medical center in the United States. A high proportion were junior faculty and graduates of our residency program. Outcome: We reviewed records of 28 of 31 observations that were completed during the initial 9-month period of implementation and later surveyed faculty. The exercise resulted in planned changes in teaching behaviors that included instituting new methods to improve teaching team leadership, triaging of patients seen on rounds, faculty behaviors during oral presentations, giving real-time feedback, use of technology and humor, demonstrating physical examination findings, and modeling professional behaviors. Faculty later reported adoption of new teaching behaviors that were important to them. Lessons Learned: This exercise was easily implemented, resulted in planned changes by both observed and observing peers, and resulted in widespread adoption of some specific teaching behaviors. The most commonly planned change dealt with team leadership or organizational issues. When given the freedom to choose, junior faculty were more likely to observe senior faculty.

Ovarian Carcinoma With Isolated Spinal Cord Metastasis.

Ovarian cancer metastasis to the spinal cord is quite rare, and few case reports have been published previously. Herein, we present a case of a patient who was treated for ovarian cancer and was thought to be disease free for 17 months, then presented with lower limb weakness. She was found to have a T11-T12 metastatic intramedullary spinal cord lesion. On pathology, the diagnosis of metastatic ovarian adenocarcinoma was made. This report highlights the importance of maintaining a low threshold for ovarian cancer metastases to the spinal cord when patients present with neurologic sequelae, even in the setting of normal laboratory values, as early detection can prevent permanent neurological consequences.

Look No Further: An Exercise in Clinical Reasoning

Look No Further: An Exercise in Clinical Reasoning Patrick Rendon, MD, Gurpreet Dhaliwal, MD, Benjamin Kim, MD, MPhil, Alberto Aguayo, MD, and J. Rush Pierce Jr, MD, MPH Division of HospitalMedicine, Department of InternalMedicine, The University of NewMexico Health SciencesCenter,MSC10 5550 – 1 University of New Mexico, Albuquerque, NM, USA; Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Medical Service, San Francisco VA Medical Center, San Francisco, CA, USA.

Capsule Commentary on Nixon et al., Describing Failure in a Clinical Clerkship: Implications for Identifying, Assessing and Remediating Struggling Learners

F or some time, medical educators have sought the most robust method of identifying and successfully remediating struggling learners. In the study by Nixon et al., the authors conducted an in depth assessment of the reasons for failure within an internal medicine clerkship. They examined various critical deficiencies and the frequency of those deficiencies across multiple domains: knowledge for practice, interpersonal and communication skills, overall knowledge and skill, patient care, personal and professional development, professionalism, practice-based learning and improvement, interprofessional collaboration, systems-based practice and overall conduct. All students who failed had deficiencies in at least two competency domains, with the most frequently noted critical deficiencies being interpersonal and communication skills, insufficient knowledge and patient care. Findings were similar in a study of remediating learners and practicing physicians by Guerrasio et al., where subjects were found to have more than one deficit. Medical educators may then ask the very practical question, Bhow do educators identify such students?^ The authors submit that direct observation and a thorough assessment of medical students in the aforementioned competency domains are key in identifying such deficiencies. Thus, a model of direct observation to identify and remediate failing students could be essential, especially given the underutilization of direct observation that occurs on clerkships. The authors propose that once a student is identified as failing to meet expectations in one area, this should prompt an examination of competencies in other areas. Effective identification of the struggling learner will allow educators to design a remediation program of a proactive nature. A proposed model of remediation was suggested in a thematic review by Hauer et al., which includes development of a learning plan that integrates deliberate practice, feedback, reflection and reassessment. Although many questions remain in the search to determine the best approach to struggling learners, this study sets the stage for future research, which should examine methods to improve identification and remediation of medical students.F or some time, medical educators have sought the most robust method of identifying and successfully remediating struggling learners. In the study by Nixon et al., the authors conducted an in depth assessment of the reasons for failure within an internal medicine clerkship. They examined various critical deficiencies and the frequency of those deficiencies across multiple domains: knowledge for practice, interpersonal and communication skills, overall knowledge and skill, patient care, personal and professional development, professionalism, practice-based learning and improvement, interprofessional collaboration, systems-based practice and overall conduct. All students who failed had deficiencies in at least two competency domains, with the most frequently noted critical deficiencies being interpersonal and communication skills, insufficient knowledge and patient care. Findings were similar in a study of remediating learners and practicing physicians by Guerrasio et al., where subjects were found to have more than one deficit. Medical educators may then ask the very practical question, Bhow do educators identify such students?^ The authors submit that direct observation and a thorough assessment of medical students in the aforementioned competency domains are key in identifying such deficiencies. Thus, a model of direct observation to identify and remediate failing students could be essential, especially given the underutilization of direct observation that occurs on clerkships. The authors propose that once a student is identified as failing to meet expectations in one area, this should prompt an examination of competencies in other areas. Effective identification of the struggling learner will allow educators to design a remediation program of a proactive nature. A proposed model of remediation was suggested in a thematic review by Hauer et al., which includes development of a learning plan that integrates deliberate practice, feedback, reflection and reassessment. Although many questions remain in the search to determine the best approach to struggling learners, this study sets the stage for future research, which should examine methods to improve identification and remediation of medical students.