American Internal Medicine Research Articles

Idiosyncrasy in Assessment Comments: Do Faculty Have Distinct Writing Styles When Completing In-Training Evaluation Reports?

Written comments are gaining traction as robust sources of assessment data. Compared with the structure of numeric scales, what faculty choose to write is ad hoc, leading to idiosyncratic differences in what is recorded. This study offers exploration of what aspects of writing styles are determined by the faculty offering comment and what aspects are determined by the trainee being commented upon. The authors compiled in-training evaluation report comment data, generated from 2012 to 2015 by 4 large North American Internal Medicine training programs. The Linguistic Index and Word Count (LIWC) was used to categorize and quantify the language contained. Generalizability theory was used to determine whether faculty could be reliably discriminated from one another based on writing style. Correlations and ANOVAs were used to determine what styles were related to faculty or trainee demographics. Datasets contained 23-142 faculty who provided 549-2,666 assessments on 161-989 trainees. Faculty could easily be discriminated from one another using a variety of LIWC metrics including word count, words per sentence, and the use of "clout" words. These patterns appeared person specific and did not reflect demographic factors such as gender or rank. These metrics were similarly not consistently associated with trainee factors such as postgraduate year or gender. Faculty seem to have detectable writing styles that are relatively stable across the trainees they assess, which may represent an under-recognized source of construct irrelevance. If written comments are to meaningfully contribute to decision making, we need to understand and account for idiosyncratic writing styles.

Here Comes the Sun: Medical Professionalism and the Implications of the Sunshine Act for Gastroenterology Practice

The Affordable Care Act, passed in 2010, contained a number of regulations that directly affect physician practices, behavior, and relationships with others in the health care industry. One such provision is the “Physician Payment Sunshine Act,” which is the subject of this month’s Practice Management: The Road Ahead column. The authors have provided us with a detailed and enlightening review of how our relationships with pharmaceutical and medical device companies have become transparent and public. It will be important for you to understand this law and take the time to review your own data through CMS’s Enterprise Portal (http://www.cms.gov/Regulations-andGuidance/Legislation/National-Physician-Payment-Transp arency-Program/Physicians.html).

Hospitalist Career Decisions Among Internal Medicine Residents

Hospital medicine is a rapidly growing field of internal medicine. However, little is known about internal medicine residents' decisions to pursue careers in hospital medicine (HM). To identify which internal medicine residents choose a career in HM, and describe changes in this career choice over the course of their residency education. Observational cohort using data collected from the annual Internal Medicine In-Training Examination (IM-ITE) survey. 16,781 postgraduate year 3 (PGY-3) North American internal medicine residents who completed the annual IM-ITE survey in 2009-2011, 9,501 of whom completed the survey in all 3 years of residency. Self-reported career plans for individual residents during their postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2) and PGY-3. Of the 16,781 graduating PGY-3 residents, 1,552 (9.3 %) reported HM as their ultimate career choice. Of the 951 PGY-3 residents planning a HM career among the 9,501 residents responding in all 3 years, 128 (13.5 %) originally made this decision in PGY-1, 192 (20.2 %) in PGY-2, and 631 (66.4 %) in PGY-3. Only 87 (9.1 %) of these 951 residents maintained a career decision of HM during all three years of residency education. Hospital medicine is a reported career choice for an important proportion of graduating internal medicine residents. However, the majority of residents do not finalize this decision until their final year.

Prevalence of Resident Burnout at the Start of Training

Background: Job burnout is characterized by emotional exhaustion, depersonalization, and feelings of decreased personal accomplishment, and it may be linked to depression and suboptimal patient care. Burnout among American internal medicine residents ranges between 55% and 76%. Purpose: We aim to further characterize burnout prevalence at the start of residency. Methods: Between 2006 and 2007, all incoming internal medicine interns at Mount Sinai Hospital and Elmhurst Hospital Center were asked to complete a survey at orientation. The survey included an instrument to measure burnout, a sleep deprivation screen, a personality inventory and demographic information. Comparison tests were conducted to identify statistically significant differences. Results: The response rate was 94% (145/154). Overall burnout prevalence was 34% (50/145). Interns self-identifying as anxious (51% vs. 28%, p= .01) or disorganized (60% vs. 31%, p= .03) were more likely to have burnout. Conclusions: Our study found higher levels of burnout among beginning medical interns than reported in the literature. Burnout correlated with some self-reported personality features.

Closing the gap between internal medicine training and practice: Recommendations from recent graduates

Closing the gap between internal medicine training and practice: Recommendations from recent graduates

American internal medicine in the 21st century: can an Oslerian generalism survive?

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.

The current status of sports medicine training in United States internal medicine residency programmes

Objective: To determine the general status of sports medicine training in internal medicine residency programmes in the United States. Methods: A cross sectional survey of the programme directors and chief...

A Charter on Medical Professionalism

The changing healthcare system has led to frustration among physicians as their doctor-patient relationships and their medical treatment options are increasingly affected by external forces. To address these assaults on medical professionalism, leaders of European and American internal medicine groups formed the Medical Professionalism Project …

Cardiac auscultation. A glorious past--but does it have a future?

For most of this century, the stethoscope has served as a critical diagnostic tool in cardiovascular evaluation. With the advent of numerous new diagnostic modalities, however, especially ultrasonic imaging and Doppler techniques, cardiac auscultation is receiving less emphasis in teaching and practice.1 To compound this problem further, phonocardiography, ie, the graphic recording of heart sounds, which had served as a valuable means for teaching and documenting auscultation, has been largely discarded in this country. Although medical training directors and their students generally believe that cardiac auscultation is a skill that physicians should master,1 there appears to be a widespread belief that this skill is of secondary importance because the same information is readily obtainable through newer technological means. Possibly as a result of this attitude, there is no structured teaching of cardiac auscultation in three fourths of American internal medicine programs and two thirds of cardiology programs.1 This will inevitably lead to poor practice and teaching of this technique at all levels of training. Although not as well documented, the same process of attrition is probably affecting the other cognitive skills of history taking and bedside examination.2 3 4 Conventional wisdom dictates that auscultation not only provides important clinical information in itself but also is a cost-effective means to select additional tests.5 To support these assumptions, however, we must evaluate contemporary information concerning not only how auscultation can be used for additional test selection but also how it might, in comparison with other testing methods, provide a source of information of independent clinical value. For this reason, we shall examine a few specific examples in which auscultation can be used to achieve these ends. To maximize information gained through auscultation, however, we must attempt to identify sources of inaccuracy and suggest methods to correct these …

Innere Medizin in den deutschsprachigen Ländern und in den USA

Scientific relations in Internal Medicine between German-speaking countries and the United States were characterized by various stages during the last hundred and twenty years. From 1870 to the First World War German medical research and teaching as well as the competitive German university system were regarded as a model for US Medical Schools. After World War I, however, things changed as a result of American Medical Schools’ reforms which had been implemented. On the other hand, financial equipment of German universities was decreasing due to inflation and unemployment. Furthermore, between 1933 and 1945, many excellent scientists and clinicians were forced to emigrate from Germany and Austria to the US because of persecution by the Nazis for political or “racial” reasons. After the end of World War II, scientific and technical leadership of American Internal Me-dicine remained unchallenged; today many European physicians complete their training in the biomedical sciences in the United States. Beginning in the 1980s, German-speaking internists increasingly publish the results of their research in American scientific journals.

What Is the Oslerian Tradition?

Discussants of internal medicine often invoke but seldom define "the Oslerian tradition," which has many meanings. No definition provides clear insight into the issues now relevant to American internal medicine, primarily because, as William Osler knew, the field itself shows definitional ambivalence. The tradition might be best understood as a virtuous approach to medicine and to life as taught and modeled by Osler. If we understand his philosophy and methods, we will be better prepared to use and pass on (tradere, "to deliver") something of greater value: the ability to make wise choices that are in society's best interest.

Principles and Practice of Medical Intensive Care

Although Carlson and Geheb claim that this book is meant to be useful at the bedside and as a reference, with 1800 pages it is unlikely to fit into your white coat pocket. It is written from an American internal medicine perspective and covers its subject comprehensively in 149 chapters organised rationally into 13 sections, mostly based on physiological systems but also including organisation, resuscitation, monitoring, nutrition, and ethics. Its tone is authoritative but not didactic, and the systemic chapters flow from pathophysiology to therapy …

The invention and development of American internal medicine.

During the early twentieth century American physicians considered several different ways to identify medical specialists. The first autonomous specialty board was incorporated in 1924, and over the next few decades the board system became the accepted system for credentialing specialists. In 1936 the American Board of Internal Medicine (ABIM) became the twelfth specialty board. It was intended to recognize only a few outstanding internists, for the ABIM's founders believed that general practitioners should continue to deliver the vast majority of care. However, World War II greatly increased the importance of the ABIM and of the specialty boards system. The army medical services emphasized the importance of board certification, thus encouraging physicians to receive residency training and to sit for a specialty board. After the war, the expanding VA hospital system provided them a place to do so. Specialty training and board certification became the norm, not the exception. Also, the national exigencies of World War II forced Congress to devise a new system to distribute federal funds for biomedical research to universities. That system, continued as the National Institutes of Health, supported the subsequent growth of internal medicine in general, as well as its subspecialties. Both the ABIM and the other specialty boards were formed at a particular time and place in response to the specific interests of individuals and organizations, and their histories reflect both the ideals of their founders and the long-term structural effects of war.

The impending crisis in internal medicine training programs

Internal medicine, the specialty that has traditionally attracted the intellectual elite of the medical profession, seems to be headed for hard times. Although a recent survey forecasts an ever increasing number of internists per population in the United States during the coming decades [ 11, even to the point of surfeit, emerging warning signals can be detected. The failure of several outstanding medical internship programs to achieve their quota of interns in the national matching program this year has shaken many leaders of internal medicine out of their complacency [2], and may represent an early harbinger of an impending crisis. Israel, which usually lags behind the United States by several years, is already in the midst of a crisis of major magnitude in internal medicine. Although important differences exist between Israeli and American internal medicine, the Israeli situation may provide important lessons for American internal medicine, and it behooves the leadership of American medicine to examine its internal medicine scene in light of what has already transpired in Israel. Israel, for the past five to 10 years, has experienced an increasing shortage of residents in internal medicine, to the point where dozens of positions in university hospitals are unfilled, and the quality of the applicants has fallen. By attempting to analyze the pathophysiology of the problem, in the best tradition of internal medicine, perhaps solutions may be more readily apparent. Although some of the current observations have been discussed by perceptive observers [2-51, the pervasive magnitude of the problem has not been adequately reflected in the tone of most of the published articles, and a broad comprehensive analysis of the multiplicity of factors is timely. It is essential not to be diverted into focusing on only one or two of the etiologic factors in isolation, neglecting other perhaps more important ones. The classic internal medicine training paradigm represented the thinking man’s ideal, one in which meticulous history taking, detailed physical examination, and reasoned logical analysis were combined in a thoughtful, methodic, and deliberate process. This combination culminated in a diagnostic strategy and ultimately a treatment plan. Ample time was usually available to think, read, and discuss, and to relate to the individual patient and family. The correct diagnosis and treatment and ongoing care were the source of satisfaction derived by the internist who, with the training described by Barondess [6], aspired to be the kind of clinician epitomized by Tumulty [7]. In this classic model, the general internist was a virtuoso of sorts. In some ways, he might be considered the Renaissance man of medicine, familiar with the gamut of the subspecialities, as likely to diagnose an atrial myxoma as subacute thyroiditis, Whipple’s disease, or Felty’s syndrome, and the classic ultimate virtuouso performance was in ferreting out the difficult fever of unknown origin, the ultimate challenge. The ambience was contemplative and erudite. Time was available also by intellectual endeavors beyond immediate patient care. Library work and contributions to the medical literature were commonplace. What has happened to the field of internal medicine as

The literature of American internal medicine: a historical view.

The literature of medicine is shaped by social and intellectual forces as well as by scientific discoveries. In America, the literature of internal medicine evolved gradually in response to changes in the structure and philosophy of medical education and the growing emphasis on research during the past century. When careers in medical education and research became possible through philanthropic and government support, Americans became more productive in research. As academic advancement came to depend primarily on publication, the literature of American internal medicine expanded dramatically. The current scope and character of the medical literature also reflect the persistent trend toward specialization and subspecialization that began more than a century ago. Although medical journals have been the most important medium for the publication of new medical knowledge for nearly 200 years, recent dramatic advances in the technology of information storage and transfer promise to undermine their primacy.

Issues for American internal medicine through the last century.

The content, role, and purpose of internal medicine, organized as an American specialty 100 years ago, have been marked by ambivalence from the beginning. Nevertheless, molded to a large extent by external events, including the strategic and symbolic importance of surgery in American medicine, the rise of university medical schools, development of other specialties, and, more recently, the demand for primary care and the incentives built into reimbursement schemes and organized health care systems, internal medicine has become a powerful entity in American medicine. Its role in the future is likely to be more influential than in the past, both in policy and substantive areas. Continuing tensions in internal medicine include uncertainties about the relation between generalism and specialism, primary care and subspecialties, and internal medicine and general medicine.

The History of American Internal Medicine: A New Series of Articles

Editorials1 September 1986The History of American Internal Medicine: A New Series of ArticlesRUSSELL C. MAULITZ, M.D., Ph.D.RUSSELL C. MAULITZ, M.D., Ph.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-105-3-452_1 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe article by Paul Beeson (1) in the History of Medicine section of this issue inaugurates a new series. These papers will consider the evolution in the United States of this protean specialty from two points of view. Some authors are historians, others internists who were "participant-observers" in the development of 20th century internal medicine. Each has prepared an essay surveying key aspects of the subject. Topics include internal medicine's continued search for direction, redefinition, and purpose; its literature; and some of its subspecialties. The essays have grown out of a conference, "Grand Rounds: One Hundred Years of Internal Medicine,"...

One hundred years of American internal medicine. A view from the inside.

The term internal medicine began to be used by German writers in the late 19th century to designate a branch of practice incorporating the growing understanding of morbid anatomy, microbiology, physiology, and biochemistry. American practitioners of internal medicine began to take a respected place in world medicine toward the close of the 19th century. Noteworthy changes followed World War II, owing to allocation of large sums of money for biomedical research by governments, philanthropic organizations, and the pharmaceutical industry. Clinical problems in this period shifted in preponderance from acute infections to the chronic diseases that accompany aging. Complex diagnostic procedures, together with a diversity of therapeutic choices, created need for full-time teachers and clinical investigators in medical schools, as well as for subspecialists in practice. The pendulum may have swung too far toward specialization, and in the future a substantial proportion of practitioners of internal medicine will still continue to serve as generalist physicians.

Medical Oncology in Journals of Internal Medicine

The coverage of medical oncology in internal medicine journals was evaluated by reviewing the contents of the 1974 and 1975 issues of three leading American internal medicine journals. The percentage of articles relevant to medical oncology compared favorably with figures for the other subspecialties of internal medicine. The subject matter of the medical oncology articles in the three journals was found to be complementary to the content spectrum of the subspecialty journal, Cancer. This distribution may be useful to the medical oncologist but may present a skewed view of recent developments in medical oncology to the nononcologist internist who relies largely on internal medicine journals for information regarding new trends in medical oncology. The implications of these findings are discussed, particularly with regard to the possibility that a similar situation exists for the other subspecialties of internal medicine.

The Association of American Physicians—Its First Seventy-Five Years

Just before the 76th anniversary meeting of the Association of American Physicians rolled around in May, 1961, members were sent a copy of the history of the Association by James Howard Means. A good many of them may have had the feeling this was deja vu —they had heard it all before at the Association banquet the year before. There is truth in this notion, for the speech came near being measured by calendar, not clock, but it is not anywhere near the whole truth. Not just members of this exclusive medical club, but medical historians and physicians generally will be grateful that while there was yet time Means was able to collect material, memorabilia, letters, and other documents from which he has woven a detailed, sometimes dry, anecdotal, but fascinating chronicle of American internal medicine over the last 100 years. In our time, when the proliferation of satellite societies