General Internists Research Articles

ANTIPLATELET AND ANTICOAGULATION THERAPY IN PATIENTS WITH ATRIAL FIBRILLATION AND CORONARY ARTERY DISEASE: A SURVEY OF CANADIAN PHYSICIANS

Patients with atrial fibrillation (AF) and coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) represent a population at increased risk of thromboembolism and bleeding. Such patients may receive antithrombotic therapy based on low-quality evidence. The purpose of this study is to understand the care gaps between consensus guideline recommendations and current practice for optimal antiplatelet therapy and oral anticoagulation (OAC) in this patient population. A national, multi-centre anonymous survey was conducted with physicians involved in the care of patients with non-valvular AF and CAD, undergoing PCI. Surveys were completed both in continuing medical education seminars and web-based online. A total of 66 physicians completed the survey. The majority were interventional cardiologists/fellows (68%), followed by general cardiologists/residents (17%) and general internists (11%). 80% of the participants indicated the 2016 Focused Update of the Canadian Cardiovascular Society (CCS) guidelines as their most common resource; however, 39% disagreed and 6% strongly disagreed that CCS guidelines provided clear recommendations. Stroke and bleeding risk scores such as CHADS2 (67%) and HASBLED (73%) were most commonly used. Most participants preferred a direct oral anticoagulant with concomitant antiplatelet therapy (59%), and a small number preferred warfarin (8%). CCS guidelines continue to be the main resource for appropriate antiplatelet and OAC therapy for Canadian physicians. However, translation of CCS guidelines into clinical practice is a challenge as this survey indicates that treatment decisions widely vary.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

2018: No Better Time to be a General Internist in Canada

2018: No Better Time to be a General Internist in Canada

A method for achieving high response rates in national surveys of U.S. primary care physicians.

Physician questionnaires are commonly used in health services research; however, many survey studies are limited by low response rate. We describe the effectiveness of a method to maximize survey response without using incentives, the effectiveness of survey reminders over time, and differences in response rates based on survey mode and primary care specialty. As part of a study to assess vaccine policy issues, 13 separate surveys were conducted by internet and mail over the period of 2008 to 2013. Surveys were conducted among pre-recruited networks of pediatricians, family physicians and general internists. Each network was active for 2 years and responded to 3–6 surveys. Physicians who indicated preference to respond through an online survey received up to 9 e-mailed requests to complete the questionnaire and up to 2 mailed questionnaires. Physicians who chose to respond by mail received up to 3 mailed questionnaires and a reminder postcard. For 6 of the 13 surveys conducted over the 6 year period, an additional mailing using a hand-addressed envelope was mailed to non-responders at the end of the usual protocol. Effectiveness of survey methods was measured by response rates. The overall response rates varied from 66‒83%. Response rates declined 17 percentage-points on average between the first and last surveys administered within each physician network. The internet group consistently had higher response rates than the mail group (74% vs. 62% on average). An additional mailing in a hand-written envelope boosted the final response rate by 11 percentage-points. Self-selection of survey mode, multiple reminders, and hand-written envelopes are effective methods for maximizing response rates in physician surveys.

Physician Nonprofessional Cancer Experience and Ovarian Cancer Screening Practices: Results from a National Survey of Primary Care Physicians.

Routine ovarian cancer screening is ineffective; therefore, no professional organization recommends this screening in asymptomatic patients. However, many physicians have recommended screening, exposing patients to unnecessary risk. Little research exists on how nonprofessional experience with cancer influences physicians' screening practices. This study examines the association between physicians' nonprofessional experience with cancer and reported adherence to ovarian cancer screening guidelines. A mail questionnaire with an annual examination vignette and questions about cancer screening recommendations was sent to a random sample of 3,200 U.S. family physicians, general internists, and obstetrician-gynecologists. This analysis included 497 physicians who received a vignette of a woman at average ovarian cancer risk and weighted results to represent these physician groups nationally. The outcome measure was adherence to ovarian cancer screening guidelines. Stepwise multivariate logistic regression estimated adjusted risk ratios for guideline adherence. In unadjusted analyses, 86.0% of physicians without nonprofessional cancer experience reported adherence to ovarian cancer screening guidelines compared with 69.2% of physicians with their own history of cancer, or a family member or close friend/coworker with cancer (p = 0.0045). In adjusted analyses, physicians with cancer themselves or in a family member or close friend/coworker were 0.82 times less likely (CI: 0.73-0.92) to report adhering to ovarian cancer screening recommendations than those without nonprofessional cancer experience. Despite recommendations to the contrary, many physicians reported recommending ovarian cancer screening in low-risk women. Physicians with nonprofessional cancer experience were more likely to report offering or ordering nonrecommended screening than physicians without this experience.

Physicians speak: Medicine’s point of view on working with pharmacy

Physicians speak: Medicine’s point of view on working with pharmacy

Approach to the Geriatric Patient

As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in theDiagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults. This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

A tough pill to swallow: Medicolegal liability and dysphagia

Level of evidenceLevel 4 (Case Series). ObjectiveDysphagia is a debilitating condition that is associated with many etiologies. It can have a devastating effect on a patient's quality of life with long-term sequelae that make it a source of medical malpractice litigation. This study analyzed medical malpractice cases involving dysphagia and looked for factors determining legal liability. MethodsThe Westlaw Next legal database (Thomson Reuters, New York, NY) was searched for relevant malpractice cases and assessed for several factors including if the dysphagia was iatrogenic, the amount paid by the defendant, and the medical specialty of the defendants. ResultsA total of 45 cases of dysphagia were included. The majority of these cases were jury verdicts for the defendant (73.3%). Iatrogenic dysphagia was alleged in 55.5% of cases. Settlements and verdicts favoring the plaintiff resulted in awards ranging between $25,000 and $5,003,000 with a mean of $1,014,015. The most frequent physician specialists named were general surgeons (24.1), internists (11.1%), anesthesiologists (9.3%), gastroenterologists (7.4%), and otolaryngologists (5.6%). Iatrogenic dysphagia (OR 8.89 CI 1.02–77.32), medication-related iatrogenesis (OR 18.86 CI 1.82–195.41), and cases naming multiple specialties as a defendant (OR 5.90, CI 1.07–32.55) were factors associated with a verdict for the plaintiff or a settlement. ConclusionDysphagia is a condition with medicolegal consequences for many specialties. While the majority of these cases are decided in favor of the defendant the cost of a negative outcome is considerable. Iatrogenic dysphagia and naming more than one defendant specialty were associated with increased odds of a plaintiff verdict or settlement.

Antibiotic-Resistant E. coli in Uncomplicated Community-Acquired Urinary Tract Infection.

Routine urine culture testing is not recommended for uncomplicated urinary tract infections (UTIs). As a result, the antibiotic resistance patterns or the organisms causing UTIs are not adequately reflected in routine data. We studied the sensitivity of Escherichia coli (E. coli) to trimethoprim (TMP) and to cotrimoxazole (i.e., trimethoprim/sulfamethoxazole, TMP/SMX) in community-acquired UTI and compared the findings with the resistance data of the Antimicrobial Resistance Surveillance System (ARS). General practitioners and internists in private practice prospectively recruited all of their adult patients with symptoms of a urinary tract infection from May 2015 to February 2016. Urine specimens from all patients were tested (including urine culture testing and antibiotic susceptibility) and infections were defined as uncomplicated or complicated UTIs. 1245 participants from 58 medical practices were enrolled in the study. Pathogenic organisms were found in the urine of 877 patients, of whom 74.5% had E. coli infections. Among the E.-coli-positive UTIs, 52.4% were classified as uncomplicated and 47.6% as complicated. The prevalence of E. coli that was resistant to TMP and to TMP/SMX in uncomplicated UTIs was 15.2% and 13.0%, respectively, compared to 25.3% and 24.4%, respectively, from all UTIs in ARS in 2015. Study participants who had previously taken antibiotics had the highest prevalence of E. coli resistance (30.9%), followed by those who had two or more UTIs within the past six months (28.9%). E. coli with resistance to TMP was significantly less prevalent among the study patients with uncomplicated UTIs than in the routine data of the ARS. Accordingly, TMP should still be considered as an option for the treatment of uncomplicated UTIs. TMP/SMX is considered the agent of second choice because of its side effects. Surveillance systems based on routine data do not yield a representative sample for the evaluation of the resistance situation in patients with uncomplicated UTIs.

Overview of Allopurinol Decisions in Primary Care: A Narrative Review

Background: Allopurinol is a type of drug called a xanthine oxidase inhibitor. It functions by lowering the production of uric acid in the body. It can be found in the kind of an oral tablet. Generalist physicians, specifically general internists and primary care physicians, are usually the first to see individuals with gout and for that reason play an essential role in the diagnosis and management of these patients. Gout is mostly managed in primary care and lasting treatment aims to reduce serum uric acid degrees with using allopurinol. Urate lowering therapy is indicated in patients who have had an acute gout attack and whose uric acid level remains high, increasing the risk of a subsequent attack. The effect of allopurinol on uric acid level is dose dependent and variable. Aim of the Study: In the present review, we aimed at discussing the indications of Allopurinol in primary care along with its benefits and side effects which should be considered by patients and physicians before prescribing it. Methods: Narrative review was conducted using electronic database such as; PubMed/Medline, Embase, Google scholar, for relevant articles related to our concerned topic which is about the usage of allopurinol in primary care and methods that family doctors use to make a decision about the usage, published up to 2018. Conclusion: The benefit-risk balance of allopurinol should be carefully assessed with respect to the patients’ condition and medical profile before prescription in the PCU.

Medical and psychological paradigm supervision somatic patients with comorbid mental disorders

The thesis is devoted to the research of medical and psychological paradigm Supervision of patients. Studies performed on clinical material of patients with a wide range of somatic disorders. This reveals the conceptual foundations of medical activities as a complex medical and psycho-pedagogical process, which not only improves the efficiency of the professional activities of doctors, but also the formation of individual image of the world of patients achieving this level of personal development where disease and related restrictions do not interfere with their self-development based on the existing system of values and meanings.
 The paper provides a detailed analysis of the interaction of the three components of medical and psychological care to patients and their families: psychodiagnosis psyhoeducation and correction (psychotherapy).
 Presents a program of psychological diagnosis of somatic patients, including a study of the characteristics of emotional state and distress intrapsychological and behavioral patterns, strategies for overcoming stress behavior and family functioning determine the influence of psychic correction targets formulated the task of medical and psychological assistance and the amount psyhoeducation classes.
 Concepts and practical application of medical and psychological training of general practitioners and medical internist at the stages of pre-tested and post-graduate training in preparation of interns, and the pre-cycles thematic improvement of doctors.
 Determined, medical, psychological and educational determinants doctor's practice, positive motivation of their activities; preparedness to common therapeutic activities; focus on subject-subject interaction; mastering the techniques of effective communication and more.

Military Internal Medicine Resident Decision to Apply to Fellowship and Extend Military Commitment

Nationally, the number of internal medicine physicians practicing in primary care has decreased amidst increasing interest in hospitalist medicine. Current priorities in the Military Health System include access to primary care and retention of trained personnel. Recently, we have conducted a study of military internal medicine residents' decision to enter infectious disease. As part of our larger effort, we saw an opportunity to characterize factors impacting decision making of internal medicine residents' desire to apply for subspecialty training and to extend active duty service obligations. Questions were developed after discussion with various military graduate medical education and internal medicine leaders, underwent external review, and were added to a larger question set. The survey link was distributed electronically to all U.S. military affiliated residencies' graduating internal medicine residents in December 2016-January 2017. Data were analyzed by decision to apply to fellowship and decision to extend military obligation using Fisher's exact test or Pearon's chi-square test. Sixty-eight residents from 10 of 11 military residency programs responded, for a response rate of 51%. The majority (62%) applied to fellowship to start after residency completion. Reasons cited for applying to fellowship included wanting to become a specialist as soon as possible (74%), wishing to avoid being a general internist (57%), and because they are unable to practice as a hospitalist in the military (52%). Fellowship applicants were more likely to plan to extend their military obligation than non-applicants, as did those with longer duration of military commitments. No other factors, including Uniformed Services University attendance or participation in undergraduate military experiences, were found to impact plan to extend active duty service commitment. The majority of graduating internal medicine residents apply for fellowship and report a desire to avoid being a general internist. Prospective fellows anticipate extending their active duty commitment, as do those with longer commitments.

Point of Care Ultrasound for the General Internist: Pleural Effusions

Pleural effusions are a common finding in many clinical settings and have important diagnostic and therapeutic implications. They may be identified by physical exam, chest radiography, chest computerized tomography (CT) scans or point of care ultrasonography (POCUS). The use of POCUS for the diagnosis and management of pleural effusions offers several advantages relevant to the practice of the general internist. For the diagnosis of pleural effusion, POCUS has superior sensitivity and specificity when compared to chest radiography and physical exam. Abnormal sonographic features of the pleural fluid and the adjacent pleura may suggest the presence of an exudative or malignant effusion. POCUS can be used to quickly estimate the size of a pleural effusion. Lastly, the use of ultrasound guidance when performing a thoracentesis reduces the risk of pneumothorax and hemorrhage.

Approach to the Geriatric Patient

As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in theDiagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults. This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

Physician Knowledge of Human Genetic Variation, Beliefs About Race and Genetics, and Use of Race in Clinical Decision-making.

Race in the USA has an enduring connection to health and well-being. It is often used as a proxy for ancestry and genetic variation, although self-identified race does not establish genetic risk of disease for an individual patient. How physicians reconcile these seemingly paradoxical facts as they make clinical decisions is unknown. To examine physicians' genetic knowledge and beliefs about race with their use of race in clinical decision-making DESIGN: Cross-sectional survey of a national sample of clinically active general internists RESULTS: Seven hundred eighty-seven physicians completed the survey. Regression models indicate that genetic knowledge was not significantly associated with use of race. However, physicians who agreed with notions of race as a biological phenomenon and those who agreed that race has clinical importance were more likely to report using race in their decision-making. Genomic and precision medicine holds considerable promise for narrowing the gap in health among racial groups in the USA. For this promise to be realized, our findings suggest that future research and education efforts related to race, genomics, and health must go beyond educating health care providers about common genetic conditions to delving into assumptions about race and genetics.

Associations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set (HEDIS) Process Measures.

The value of the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program has been questioned as a marker of physician quality. To assess whether physician MOC status is associated with performance on selected Healthcare Effectiveness Data and Information Set (HEDIS) process measures. Annual comparisons of HEDIS process measures among physicians who did or did not maintain certification 20 years after initial certification. Fee-for-service Medicare. 1260 general internists who were initially certified in 1991 and provided care for 85 931 Medicare patients between 2009 and 2012. Annual percentage of a physician's Medicare patients meeting each of 5 HEDIS annual or biennial standards and a composite indicating meeting all 3 HEDIS diabetes standards. Among the 1260 physicians, 786 maintained their certification from 1991 to 2012 and 474 did not. The mean annual percentage of HEDIS-eligible diabetic patients who completed semiannual hemoglobin A1c testing was 58.4% among physicians who maintained certification and 54.4% among those who did not (regression-adjusted difference, 4.2 percentage points [95% CI, 2.0 to 6.5 percentage points]; P< 0.001). Diabetic patients of physicians who maintained certification more frequently met the annual standard for low-density lipoprotein (LDL) cholesterol measurement (83.1% vs. 80.5%; regression-adjusted difference, 2.3 percentage points [CI, 0.6 to 4.1 percentage points]; P= 0.008) and all 3 diabetic standards (46.0% vs. 41.6%; regression-adjusted difference, 3.1 percentage points [CI, 0.5 to 5.7 percentage points]; P= 0.019). The regression-adjusted difference in biennial eye examinations was statistically insignificant (P= 0.112). Measures for LDL cholesterol testing in patients with coronary heart disease and biennial mammography were also met more frequently among physicians who maintained certification (79.4% vs. 77.4% and 72.0% vs. 67.8%, respectively), with regression-adjusted differences of 1.7 percentage points (CI, 0.2 to 3.3 percentage points; P= 0.032) and 4.6 percentage points (CI, 2.9 to 6.3 percentage points; P< 0.001), respectively. Potential confounding by unobserved patient, physician, and practice characteristics; inability to determine clinical significance of observed differences. Maintaining certification was positively associated with physician performance scores on a set of HEDIS process measures. American Board of Internal Medicine.

Adapting International Asthma Management Guidelines to Regions of Turmoil: The Syrian Experience

Background: Adherence to international asthma management guidelines is suboptimal even in developed countries. In low resources settings, especially during periods of turmoil, asthma care becomes emergency-oriented, long-term Inhaled corticosteroids prescription is limited, and follow up is rare. The current conditions in Syria have weakened the health system. It is not multisectoral and asthma management is not routinely included in primary care centers. There is a weak referral system to secondary care and specialists. Frequently, internal medicine general hospital outpatient clinics are the first contact. To our knowledge, no studies have evaluated asthma knowledge and management skills of internal medicine physicians and residents in regions of turmoil like present-time Syria. Purpose: The purpose of this study was to assess asthma knowledge and management skills of general internists and residents, barriers to adherence to international management guidelines, and means to improve compliance and outcome. Methods: We developed and administered to general practitioners asthma management audit forms which were reviewed by a trainer pulmonologist for compliance with international management guidelines. When discrepancies were noted, onsite training was provided in weekly sessions. Follow up of care of asthma patients was done by mobile devices to track patients unable to return to the hospital clinic. Findings: Implementation of these strategies resulted in improved adherence to ICS dosing guidelines (P=0.002) and optimal technique for inhaler use by patients. Interpretation: We recommend that WHO programs for CRD include auditing of care by internists with onsite supervision and teaching and mobile follow up technology. We believe these recommendations will be useful and add value to existing programs and will improve asthma care. Funding Statement: We declare no funding. Conflict of Interest: We declare no conflict of interest. (We declare no conflict of interest, and no funding.) Ethics Approval Statement: Ethical approval was secured from hospital [Damascus General Hospital] institutional board, and patient consent forms were collected.

P.108 Case report: listeria rhombencephalitis in a healthy 64 year old woman

Background: Listeria rhombencephalitis is a rare and serious complication of Listeria monocytogenes infection. We present a case of presumed Listeria rhombencephalitis with dramatic recovery from a highly morbid state. Methods: A previously healthy 64 year old woman with a remote and stable history of a major depressive episode and no history to suggest immune compromise presented with nausea and vomiting followed by the acute onset of diplopia and gait disturbance 28 days after exposure to an identified infectious source of spring rolls and 21 days after a severe diarrheal illness from that exposure. Our patient was evaluated by emergency physicians and general internists over a period of 1 week after the onset of diplopia and gait disturbance and given a diagnosis of serotonin syndrome before receiving a consultation from Neurology. Her presentation featured a deep encephalopathy and an unusual hyperkinetic movement disorder with startle myoclonus, palatal myoclonus and diffuse tremor. Results: Her MRI scan showed FLAIR hyperintensities in the bilateral cerebellum and pons with adjacent pial enhancement, characteristic of Listeria rhombencephalitis. Her CSF showed a lymphocytic pleocytosis with normal chemistry. Conclusions: She recovered dramatically to treatment with IV ampicillin. This case report illustrates the importance of considering Listeria rhombencephalitis in immunocompetent patients with brainstem symptoms following a diarrheal illness.

Geographic variation in incidence and prevalence rates for rheumatoid arthritis in Saskatchewan, Canada 2001-2014.

To estimate and compare incidence/prevalence of rheumatoid arthritis (RA) in different geographic health regions and between urban/rural locations of residence within the province of Saskatchewan. Saskatchewan Provincial Administrative Health Databases (2001-2014) were utilized as data sources. Two RA case-definitions were employed: (1) three physician billing diagnoses, at least one of which was submitted by a specialist (rheumatologist, general internist, or orthopedic surgeon) within 2years; (2) one hospitalization diagnosis (ICD-9-CM code-714 and ICD-10-CA codes-M05, M06). Data from these definitions were combined to estimate annual RA incidence and prevalence. Annual incidence and prevalence rates across geographic regions and between rural and urban residences were examined. An increasing RA prevalence gradient was observed in a south to north direction within the province. In the 2014-2015 Fiscal Year, the southern region of Sun Country had a 0.57% RA prevalence and the Northern Health Regions a prevalence of 1.15%. Incidence rates fluctuated over time in all regions but tended to be higher in Northern Health Regions. A higher RA prevalence trend was observed in rural residents over the study period. Higher prevalence rates were observed for RA in Northern Health Regions than elsewhere in the province. Rural prevalence rates were higher than for urban residents. Healthcare delivery strategic planning will need to ensure appropriate access for RA patients throughout the province.

Feedback Credibility in a Formative Postgraduate Objective Structured Clinical Examination: Effects of Examiner Type.

Resident perspectives on feedback are key determinants of its acceptance and effectiveness, and provider credibility is a critical element in perspective formation. It is unclear what factors influence a resident's judgment of feedback credibility. We examined how residents perceive the credibility of feedback providers during a formative objective structured clinical examination (OSCE) in 2 ways: (1) ratings of faculty examiners compared with standardized patient (SP) examiners, and (2) ratings of faculty examiners based on alignment of expertise and station content. During a formative OSCE, internal medicine residents were randomized to receive immediate feedback from either faculty examiners or SP examiners on communication stations, and at least 1 specialty congruent and either 1 specialty incongruent or general internist faculty examiner for clinical stations. Residents rated perceived credibility of feedback providers on a 7-point scale. Results were analyzed with proportional odds models for ordinal credibility ratings. A total of 192 of 203 residents (95%), 72 faculty, and 10 SPs participated. For communication stations, odds of high credibility ratings were significantly lower for SP than for faculty examiners (odds ratio [OR] = 0.28, P < .001). For clinical stations, credibility odds were lower for specialty incongruent faculty (OR = 0.19, P < .001) and female faculty (OR = 0.45, P < .001). Faculty examiners were perceived as being more credible than SP examiners, despite standardizing feedback delivery. Specialty incongruency with station content and female sex were associated with lower credibility ratings for faculty examiners.

The American Board of Internal Medicine Maintenance of Certification Examination and State Medical Board Disciplinary Actions: a Population Cohort Study.

Some have questioned whether successful performance in the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program is meaningful. The association of the ABIM Internal Medicine (IM) MOC examination with state medical board disciplinary actions is unknown. To assess risk of disciplinary actions among general internists who did and did not pass the MOC examination within 10years of initial certification. Historical population cohort study. The population of internists certified in internal medicine, but not a subspecialty, from 1990 through 2003 (n = 47,971). ABIM IM MOC examination. General internal medicine in the USA. The primary outcome measure was time to disciplinary action assessed in association with whether the physician passed the ABIM IM MOC examination within 10years of initial certification, adjusted for training, certification, demographic, and regulatory variables including state medical board Continuing Medical Education (CME) requirements. The risk for discipline among physicians who did not pass the IM MOC examination within the 10year requirement window was more than double than that of those who did pass the examination (adjusted HR 2.09; 95% CI, 1.83 to 2.39). Disciplinary actions did not vary by state CME requirements (adjusted HR 1.02; 95% CI, 0.94 to 1.16), but declined with increasing MOC examination scores (Kendall's tau-b coefficient = - 0.98 for trend, p < 0.001). Among disciplined physicians, actions were less severe among those passing the IM MOC examination within the 10-year requirement window than among those who did not pass the examination. Passing a periodic assessment of medical knowledge is associated with decreased state medical board disciplinary actions, an important quality outcome of relevance to patients and the profession.