Suzanne Brandenburg

Changing habits of practice. Transforming internal medicine residency education in ambulatory settings.

PURPOSE: The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.METHODS: The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.RESULTS: Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.CONCLUSION: This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident’s level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.

Cardiovascular risk in women with type 2 diabetes

Type 2 DM appears to eliminate the relative survival advantage experienced by premenopausal nondiabetic women compared with men with regard to CVD. The role of traditional cardiovascular risk factors, while important, cannot fully account for the disparate increase in CVD among women with type 2 DM compared with nondiabetic women. The interplay between type 2 DM and female hormones may prove important. Other less traditional risk factors such as endothelial dysfunction and impaired fibrinolysis may also play a role. Impairments in cardiovascular exercise performance in women with type 2 DM may provide insight in the future as representative of a pre-CVD state. Future research should focus on the specific causes of CVD in women with DM. In the meantime, it is important to aggressively treat modifiable risk factors in this population (Table 1). The impact of this health problem will continue to increase in our aging society, because a steadily increasing proportion of the population will be women; furthermore, an increasing percentage of these women will have diabetes if current trends continue.

Determining Need for Remediation Through Postrotation Evaluations

INTRODUCTION Postrotation evaluations are frequently used by residency program directors for early detection of residents with academic difficulties; however, the accuracy of these evaluations in assessing resident performance has been questioned. METHODS This retrospective case-control study examines the ability of postrotation evaluation characteristics to predict the need for remediation. We compared the evaluations of 17 residents who were placed on academic warning or probation, from 2000 to 2007, with those for a group of peers matched on sex, postgraduate year (PGY), and entering class. RESULTS The presence of an outlier evaluation, the number of words written in the comments section, and the percentage of evaluations with negative or ambiguous comments were all associated with the need for remediation (P  =  .01, P  =  .001, P  =  .002, P  =  < .001, respectively). In contrast, United States Medical Licensing Examination step 1 and step 2 scores, total number of evaluations received, and percentage of positive comments on the evaluations were not associated with the need for remediation (P  =  .06, P  =  .87, P  =  .55, respectively). DISCUSSION Despite ambiguous evaluation comments, the length and percentage of ambiguous or negative comments did indicate future need for remediation. CONCLUSIONS Our study demonstrates that postrotation evaluation characteristics can be used to identify residents as risk. However, larger prospective studies, encompassing multiple institutions, are needed to validate various evaluation methods in measuring resident performance and to accurately predict the need for remediation.

BRIEF REPORT: Multiprogram Evaluation of Reading Habits of Primary Care Internal Medicine Residents on Ambulatory Rotations

OBJECTIVE: To assess the reading habits and educational resources of primary care internal medicine residents for their ambulatory medicine education.DESIGN: Cross-sectional, multiprogram survey of primary care internal medicine residents.PARTICIPANTS/SETTING: Second- and third-year residents on ambulatory care rotations at 9 primary care medicine programs (124 eligible residents; 71% response rate).MEASUREMENTS AND MAIN RESULTS: Participants were asked open-ended and 5-point Likert-scaled questions about reading habits: time spent reading, preferred resources, and motivating and inhibiting factors. Participants reported reading medical topics for a mean of 4.3±3.0 SD hours weekly. Online-only sources were the most frequently utilized medical resource (mean Likert response 4.16±0.87). Respondents most commonly cited specific patients’ cases (4.38±0.65) and preparation for talks (4.08±0.89) as motivating factors, and family responsibilities (3.99±0.65) and lack of motivation (3.93±0.81) as inhibiting factors.CONCLUSIONS: To stimulate residents’ reading, residency programs should encourage patient- and case-based learning; require teaching assignments; and provide easy access to online curricula.

Impaired Fibrinolysis in Premenopausal Women and Age-matched Men with Type 2 Diabetes Mellitus: A Pilot Study

Background The presence of Type 2 diabetes mellitus (DM) is one of the strongest predictors of cardiovascular disease (CVD) in women. Although the specific mechanisms underlying this increased risk are unknown, one factor that may contribute to CVD in women with Type 2 DM is impaired fibrinolysis. Healthy premenopausal women have a low rate of CVD and excellent fibrinolytic potential. Impairment in fibrinolysis in people with DM has been demonstrated mainly in men, whereas the fibrinolytic potential of women with Type 2 DM has not been characterized well. This pilot study compared fibrinolytic measures in premenopausal women and men with DM with those of healthy age-matched control women and men to help determine whether fibrinolysis is abnormal in women with DM. Methods Fibrinolytic measurements included euglobulin clot lysis time (ELT), fibrinogen, plasminogen activator inhibitor 1, and tissue-type plasminogen activator. Results Poststasis ELT was significantly impaired in the women with DM as compared with the control women. The men with DM had a tendency toward slower poststasis ELT than did the control men, but the differences between the mens groups were not significant. In the womens groups only, we observed a trend toward increased plasminogen activator inhibitor 1 among the women with DM. Conclusions Women with DM have a more significant abnormality in poststasis ELT than do men with DM as compared with sex-specific counterparts without DM.

Exercise and Noninsulin-Dependent Diabetes Mellitus (NIDDM)

Exercise has long been recognized as a cornerstone in the management of patients with noninsulin dependent diabetes (NIDDM). Over 70 years ago, Allen and others reported that acute bouts of exercise lowered the blood glucose concentration of persons with diabetes and improved glucose tolerance temporarily (1). Since that time, numerous studies have confirmed beneficial effects of exercise for the person with NIDDM. The potential benefits of exercise or even an increased level of habitual physical activity for persons with NIDDM are multiple, ranging from the prevention of diabetes to the treatment and management of diabetes. In addition, these benefits occur both in terms of both metabolic and cardiovascular parameters.