Legitimizing Continuous Quality Improvement (CQI): Navigating Rationality in Undergraduate Medical Education
AbstractIn July of 2015, the Liaison Committee on Medical Education (LCME) —the primary accrediting body for North American allopathic medical schools—formally advanced a model of “formative accreditation” by requiring that medical schools engage in “ongoing planning and continuous quality improvement processes that establish short and long-term programmatic goal s, result in the achievement of measurable outcomes that are used to improve programmatic quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards.”As these and pa...
Source: Journal of General Internal Medicine - February 20, 2019 Category: Internal Medicine Source Type: research

Patients ’ and Providers’ Views on Causes and Consequences of Healthcare Fragmentation in the Ambulatory Setting: a Qualitative Study
ConclusionsThe results of this study offer a granular roadmap for how to decrease healthcare fragmentation. The large number and severity of negative consequences (including medical errors, misdiagnosis, increased cost, and provider burnout) underscore the urgent need for interventions to address this problem directly. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 19, 2019 Category: Internal Medicine Source Type: research

Cigarette Smoking and Quitting-Related Factors Among US Adult Health Center Patients with Serious Mental Illness
ConclusionsSmokers with SMI seen in federally funded health centers were just as likely to have made a quit attempt and to have plans to quit as smokers without SMI. Despite a higher likelihood of receiving clinician advice to quit, the lower quit ratio in this population suggests that advice alone is unlikely to be sufficient. These results underscore the need for augmented strategies to promote smoking cessation and reduce the excess burden of tobacco-related disease in patients with SMI. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 19, 2019 Category: Internal Medicine Source Type: research

Developing a Professional Identity as a Change Agent Early in Medical School: the Students ’ Voice
AbstractAs health systems are adapting to increased accountability for quality outcomes, population health, and collaborative care, medical schools are adapting curricula to better prepare physicians to function in health systems. Two components of this educational transformation are (1) increasing physician competence in Health Systems Science, including quality, population health, social determinants of health, and interprofessional collaboration, and (2) providing roles for students to act as change agents while adding value to the health system. The authors, three medical students who served as patient navigators durin...
Source: Journal of General Internal Medicine - February 19, 2019 Category: Internal Medicine Source Type: research

Stiff Person Syndrome and Type 1 Diabetes Mellitus: a Case of the Chicken or the Egg?
We present the case of a 23-year-old non-diabetic, insulin-na ïve woman with known SPS who was hospitalized for SPS-related symptomatology. The patient quickly developed type 1 diabetes mellitus (T1DM) with unexpectedly large insulin requirements. To our knowledge, there are no other reports describing rapid T1DM development during an acute hospitalization fo r SPS and fewer than 5 case reports describing the association of SPS with extreme insulin resistance. Our case highlights the key clinical features, pathology, and pathogenesis of both SPS and T1DM and explores the relationship between the two disease processes....
Source: Journal of General Internal Medicine - February 19, 2019 Category: Internal Medicine Source Type: research

Feedback Redefined: Principles and Practice
AbstractFeedback is defined as a regulatory mechanism where the effect of an action is fed back to modify and improve future action. In medical education, newer conceptualizations of feedback place the learner at the center of the feedback loop and emphasize learner engagement in the entire process. But, learners reject feedback if they doubt its credibility or it conflicts with their self-assessment. Therefore, attention has turned to sociocultural factors that influence feedback-seeking, acceptance, and incorporation into performance. Understanding and application of specific aspects of psychosocial theories could help i...
Source: Journal of General Internal Medicine - February 19, 2019 Category: Internal Medicine Source Type: research

Association of Income Disparities with Patient-Reported Healthcare Experience
ConclusionLower income-earning patients have poorer healthcare experience in all aspects of access and quality of care. Targeted policies focusing on improving communication, engagement, and satisfaction are needed to enhance patient healthcare experience for this vulnerable population. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 19, 2019 Category: Internal Medicine Source Type: research

Patient-Reported Outcomes of an Integrative Pain Management Program Implemented in a Primary Care Safety Net Clinic: a Quasi-experimental Study
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 19, 2019 Category: Internal Medicine Source Type: research

“Told”: the Word Most Correlated to Negative Online Hospital Reviews
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 14, 2019 Category: Internal Medicine Source Type: research

Developing the Geriatric Injury Documentation Tool (Geri-IDT) to Improve Documentation of Physical Findings in Injured Older Adults
ConclusionA practical tool to improve medical documentation of geriatric injuries for potential forensic use would be valuable. Practical challenges to utilization must be overcome. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 13, 2019 Category: Internal Medicine Source Type: research

Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity
ConclusionsThird- and fourth-year medical students report engaging in both high- and low-value behaviors, which are related to regional HCI. This underscores the importance of the clinical learning environment and suggests imprinting is already underway during medical school. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 12, 2019 Category: Internal Medicine Source Type: research

Use of Mortality as an Endpoint in Noninferiority Trials May Lead to Ethically Problematic Conclusions
ConclusionsThe use of mortality as an outcome in noninferiority trials is not rare and scenarios where the new treatment is statistically worse, but a conclusion of noninferiority or inconclusive do occur. We highlight these issues and propose simple steps to reduce the risk of ethically dubious conclusions. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 12, 2019 Category: Internal Medicine Source Type: research

Health Coaching Has Differential Effects on Veterans with Limited Health Literacy and Numeracy: a Secondary Analysis of ACTIVATE
AbstractBackgroundHealth coaching is an effective behavior change strategy. Understanding if there is a differential impact of health coaching on patients with low health literacy has not been well investigated.ObjectiveTo determine whether a telephone coaching intervention would result in similar improvements in enrollment in prevention programs and patient activation among Veterans with low versus high health literacy (specifically, reading literacy and numeracy).DesignSecondary analysis of a randomized controlled trial.ParticipantsFour hundred seventeen Veterans with at least one modifiable risk factor: current smoker, ...
Source: Journal of General Internal Medicine - February 12, 2019 Category: Internal Medicine Source Type: research

The Association Between Insulin Initiation and Adverse Outcomes After Hospital Discharge in Older Adults: a Population-Based Cohort Study
ConclusionsInitiation of insulin therapy in older hospitalized patients is associated with a higher risk of death and ED visits/readmissions after discharge, highlighting a need for better transitional care of insulin-treated patients. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 12, 2019 Category: Internal Medicine Source Type: research

Lack of Association Between Age and Coronary Artery Calcification (CAC): a Cross-Sectional Study
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 12, 2019 Category: Internal Medicine Source Type: research

CMS Billing Guidelines and Student Documentation: a New Era or New Burden?
AbstractThe Centers for Medicare and Medicaid Services (CMS) recently revised their Medicare Claims Processing Manual with the addition of CR 10412, a provision that permits teaching providers to fully bill for medical student notes. This change will have significant implications on the documentation duties of teaching physicians and trainees. Potential benefits of this provision include reduced documentation burden on house officers, improved medical student empowerment, and the infusion of more original content into the electronic medical record. However, these benefits may be offset by shifting the burden of documentati...
Source: Journal of General Internal Medicine - February 12, 2019 Category: Internal Medicine Source Type: research

Ulnar Distribution Paresthesia, Weakness and Atrophy: a Characteristic Presentation of Cubital Tunnel Syndrome
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 12, 2019 Category: Internal Medicine Source Type: research

Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial
ConclusionsA “light touch” email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation.Trial RegistryNCT02375932 (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 11, 2019 Category: Internal Medicine Source Type: research

Relationship Between Patient-Reported Hospital Experience and 30-Day Mortality and Readmission Rates for Acute Myocardial Infarction, Heart Failure, and Pneumonia
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 11, 2019 Category: Internal Medicine Source Type: research

How Have 30-Day Readmission Penalties Affected Racial Disparities in Readmissions?: an Analysis from 2007 to 2014 in Five US States
AbstractBackgroundThirty-day readmission penalties implemented with the Hospital Readmission Reduction Program (HRRP) place a larger burden on safety-net hospitals which treat a disproportionate share of racial minorities, leading to concerns that already large racial disparities in readmissions could widen.ObjectiveTo examine whether there were changes in Black-White disparities in 30-day readmissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia following the passage and implementation of HRRP, and to compare disparities across safety-net and non-safety-net hospitals.DesignRepeated c...
Source: Journal of General Internal Medicine - February 8, 2019 Category: Internal Medicine Source Type: research

Differences in Medicare Beneficiary Risk Scores by Physician ’s International Medical Graduate Status
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 8, 2019 Category: Internal Medicine Source Type: research

The “Waze” of Inequity Reduction Frameworks for Organizations: a Scoping Review
ConclusionsExisting equity intervention frameworks often lack specific guidance for implementing organizational change. Future frameworks should assess inner organizational context to guide translation of programs across different organizational departments and levels and provide specific guidelines on institutionalization and sustainability of interventions. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 7, 2019 Category: Internal Medicine Source Type: research

Phone Interviews for Preoperative Medical Evaluation for Cataract Surgery
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 7, 2019 Category: Internal Medicine Source Type: research

Palliative Care Needs in Oncology, Cardiology, and Neurology Clinic Patients in the USA
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 7, 2019 Category: Internal Medicine Source Type: research

Systematic Handoffs to Improve Patient Outcomes and Resident Satisfaction: a Single-Center Observational Study
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 7, 2019 Category: Internal Medicine Source Type: research

Methadone Matters: What the United States Can Learn from the Global Effort to Treat Opioid Addiction
AbstractIn the midst of an opioid epidemic, mortality related to opioid overdose continues to rise in the US. Medications to treat opioid use disorder, including methadone and buprenorphine, are highly effective in reducing the morbidity and mortality related to illicit opioid use. Despite the efficacy of these life-saving medications, the majority of people with an opioid use disorder lack access to treatment. This paper briefly reviews the evidence to support the use of medications to treat opioid use disorder with a specific focus on methadone. We discuss the current state of methadone therapy for the treatment of opioi...
Source: Journal of General Internal Medicine - February 6, 2019 Category: Internal Medicine Source Type: research

Improving Longitudinal Survey Participation Among Internal Medicine Residents: Incorporating Behavioral Economic Techniques and Avoiding Friday or Saturday Invitations
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 6, 2019 Category: Internal Medicine Source Type: research

Interpreter Provision and Hospital-Associated Outcomes Within the Limited English Proficiency Population: Analysis of Administrative Data
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 6, 2019 Category: Internal Medicine Source Type: research

Associations Between Polypharmacy, Symptom Burden, and Quality of Life in Patients with Advanced, Life-Limiting Illness
AbstractBackgroundPolypharmacy may be particularly burdensome near the end of life, as patients “accumulate” medications to treat and prevent multiple diseases.ObjectiveTo evaluate associations between polypharmacy, symptom burden, and quality of life (QOL) in patients with advanced, life-limiting illness (clinician-estimated, 1  month–1 year).DesignSecondary analysis of baseline data from a trial of statin discontinuation.ParticipantsAdults with advanced, life-limiting illness.Main MeasuresPolypharmacy was assessed by summing the number of non-statin medications taken regularly or as needed. Sy...
Source: Journal of General Internal Medicine - February 4, 2019 Category: Internal Medicine Source Type: research

Access to HIV Pre-exposure Prophylaxis in Practice Settings: a Qualitative Study of Sexual and Gender Minority Adults ’ Perspectives
ConclusionsIn order to reduce HIV disparities, improving PrEP access will require additional efforts by providers and resources across health care settings to reduce barriers. Interventions to improve provider education about PrEP and provider communication skills for discussing sexual health are needed. Additionally, there should be system-level improvements to increase coordination between patients, providers, pharmacies, and payers to facilitate PrEP access and uptake. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 4, 2019 Category: Internal Medicine Source Type: research

Deprescribing in Advanced Illness: Aligning Patient, Clinician, and Health Plan Goals
In this report, we pr opose several actionable steps to address quality and reimbursement-based barriers such as facilitating the exclusion of those engaged in deprescribing efforts from quality measures and the development of deprescribing-based quality measures. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 4, 2019 Category: Internal Medicine Source Type: research

Primary Care Provides the Majority of Outpatient Care for Patients with Diabetes in the US: NAMCS 2009 –2015
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - February 4, 2019 Category: Internal Medicine Source Type: research

Practicing Medicine with Colleagues: Pitfalls from Social Psychology Science
AbstractThis perspective reviews three pitfalls from psychology science that can distort clinical assessments and contribute to interpersonal conflicts. One pitfall is the illusion that one ’s own subjective perceptions or judgments are objective observations or interpretations that reasonable colleagues would share. A second pitfall involves self-serving situational attributions rather than disposition attributions for explaining missteps after things go wrong. A third pitfall is co nfirmation bias that leads to a perseverance of erroneous beliefs, a tendency to mostly seek supportive colleagues, and a failure to ch...
Source: Journal of General Internal Medicine - January 31, 2019 Category: Internal Medicine Source Type: research

Changes in Outpatient Services and Medication Use Following a Non-fatal Opioid Overdose in the West Virginia Medicaid Program
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 28, 2019 Category: Internal Medicine Source Type: research

Association of Health Literacy and Numeracy with Interest in Research Participation
AbstractBackgroundThere is much attention to recruitment of diverse populations in research, but little is known about the influence of health literacy and numeracy skills.ObjectiveTo determine if health literacy and numeracy affect individuals ’ interest to participate in research studies.DesignCross-sectional survey data were pooled from 3 large studies conducted in the Mid-South Clinical Data Research Network.ParticipantsAdult patients enrolled in 1 of 3 Mid-South Clinical Data Research Network studies.Main MeasuresThe survey domains included demographic items, the 3-item Brief Health Literacy Screen (range 3 &nda...
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

Impact of Medical Marijuana Legalization on Opioid Use, Chronic Opioid Use, and High-risk Opioid Use
ConclusionsIn states where marijuana is available through medical channels, a modestly lower rate of opioid and high-risk opioid prescribing was observed. Policy makers could consider medical marijuana legalization as a tool that may modestly reduce chronic and high-risk opioid use. However, further research assessing risk versus benefits of medical marijuana legalization and head to head comparisons of marijuana versus opioids for pain management is required. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

Factors Affecting Adherence in a Pragmatic Trial of Annual Fecal Immunochemical Testing for Colorectal Cancer
AbstractBackgroundColorectal cancer screening by fecal immunochemical test (FIT) reduces the burden of colorectal cancer. However, effectiveness relies on annual adherence, which presents challenges for clinic staff and patients.ObjectiveDescribe FIT return rates and identify factors associated with FIT adherence over 2  years in a mailed FIT outreach program in federally qualified health centers.DesignObservational study nested in the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) trial. Five thousand one hundred ninety-five patients had an initial FIT order and were followed for...
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

A Qualitative Study of Primary Care Providers ’ Experiences with the Veterans Choice Program
ConclusionsThe VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

Factors Underlying Increased Incidence of Sudden Unexpected Death in Rural Counties in North Carolina
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

Strategies for Building Delivery Science in an Integrated Health Care System
We describe five key strategies we employed to address these barriers and develop a portfolio of delivery science programs in Kaiser Permanente Northern California. This portfolio now includes small and medium-sized grant programs, training programs for postdoctoral research fellows and experienced physician researchers, and a dedicated team that partners with clinicians to develop high-priority ideas and conduct small projects. Most of our approaches are consistent with frameworks used to develop delivery science by other health systems; some are innovative. Most of these strategies are adaptable by other health systems p...
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

Health Care Providers ’ Experiences with Implementing Medical Aid-in-Dying in Vermont: a Qualitative Study
ConclusionHealth care providers ’ participation in AID involves clinical tasks outside of responding to patients’ requests and writing prescriptions. Research to identify best practices should focus on all domains of clinical practice in order to best prepare providers. (Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

From the Editors ’ Desk: Why Does Not Improvement in Communication Lead to Improvement in “Hard” Outcomes?
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

The Art of Medicine: JGIM Introduces Sketchbook
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 25, 2019 Category: Internal Medicine Source Type: research

Access and Affordability in Low- to Middle-Income Individuals Insured Through Health Insurance Exchange Plans: Analysis of Statewide Data
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 24, 2019 Category: Internal Medicine Source Type: research

Patient Characteristics and General Practitioners ’ Advice to Stop Statins in Oldest-Old Patients: a Survey Study Across 30 Countries
AbstractBackgroundStatins are widely used to prevent cardiovascular disease (CVD). With advancing age, the risks of statins might outweigh the potential benefits. It is unclear which factors influence general practitioners ’ (GPs) advice to stop statins in oldest-old patients.ObjectiveTo investigate the influence of ahistory of CVD,statin-related side effects, frailty andshort life expectancy, on GPs ’ advice to stop statins in oldest-old patients.DesignWe invited GPs to participate in this case-based survey. GPs were presented with 8 case vignettes describing patients>  80 years using a statin, ...
Source: Journal of General Internal Medicine - January 16, 2019 Category: Internal Medicine Source Type: research

Making America Great
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 16, 2019 Category: Internal Medicine Source Type: research

Coding Bias in Respiratory Tract Infections May Obscure Inappropriate Antibiotic Use
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 16, 2019 Category: Internal Medicine Source Type: research

Spatial Clusters of Breast Cancer Mortality and Incidence in the Contiguous USA: 2000 –2014
AbstractBackgroundClusters of breast cancer with varied incidence or mortality are known to exist. No national scale of analysis of geographical variation in breast cancer incidence has been published before for the contiguous USA.MethodsThis was a spatial cluster analysis of incidence and mortality data on breast cancer in the contiguous USA at the county resolution. Data for the years 2000 –2014 were downloaded and analyzed with the software SaTScan with the goal to identify significant spatial clusters of breast cancer. Regression analysis was used to then adjust breast cancer incidence and mortality for several k...
Source: Journal of General Internal Medicine - January 16, 2019 Category: Internal Medicine Source Type: research

Against Medical Advice Discharges Are Increasing for Targeted Conditions of the Medicare Hospital Readmissions Reduction Program
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 16, 2019 Category: Internal Medicine Source Type: research

Hyperacute Gonococcal Keratoconjunctivitis
(Source: Journal of General Internal Medicine)
Source: Journal of General Internal Medicine - January 16, 2019 Category: Internal Medicine Source Type: research