Internal Medicine Clinicians Research Articles

A rapid manual technique does not have adequate sensitivity and specificity to reliably discriminate between neutropenic and non-neutropenic dogs prior to administration of chemotherapy.

To develop and determine the accuracy of a rapid manual technique for the detection of pre-treatment neutropenia (<1.50 × 109/L) in dogs receiving chemotherapy. Twenty canine blood smears with known neutrophil counts between 1.00 × 109/L and 3.00 × 109/L were reviewed by two internal medicine clinicians and linear regressions performed to determine a cut-off value for a manual neutrophil count equating to >1.50 × 109/L. Consecutive blood samples from dogs undergoing chemotherapy were processed through an automated haematology analyser (VetScan HM5, Abaxis), and prospective blinded manual review by the same two observers assessed whether the manual technique could accurately detect dogs with neutropenia. Linear regression analysis found a cut-off of >26 neutrophils per 10 low power fields at the monolayer to be equivalent to a neutrophil count of >1.5 × 109/L. A total of 183 blood samples from 43 dogs were reviewed. Automated techniques detected neutropenia in 16 of 183 (9%) blood samples. Using the manual cut-off technique, 13 of 16 (81%) and 11 of 16 (69%) of neutropenic samples were correctly identified by observer 1 and observer 2, respectively. Twenty-three of 167 non-neutropenic dogs (14%) were incorrectly classified as neutropenic by observer 1, and 27 (16%) by observer 2. Inter-observer agreement was 92%. Sensitivity was 81% (95% confidence interval 54% to 96%) for observer 1 and 69% (95% confidence interval 41% to 89%) for observer 2. Specificity was 86% (95% confidence interval 80% to 91%) for observer 1 and 84% (95% confidence interval 77% to 89%) for observer 2. Manual estimation resulted in up to five of 16 (31%) neutropenic samples being incorrectly classified. A full automated differential cell count remains preferable.

Pragmatic Trial of Messaging to Providers About Treatment of Hyperlipidemia (PROMPT-LIPID): A Randomized Clinical Trial.

Lipid-lowering therapy (LLT) is underutilized for very high-risk atherosclerotic cardiovascular disease. PROMPT-LIPID (PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia) sought to determine whether electronic health record (EHR) alerts improve 90-day LLT intensification in patients with very high-risk atherosclerotic cardiovascular disease. PROMPT-LIPID was a pragmatic trial in which cardiovascular and internal medicine clinicians within Yale New Haven Health (New Haven, CT) were cluster-randomized to receive an EHR alert with individualized LLT recommendations or no alert for outpatients with very high-risk atherosclerotic cardiovascular disease and LDL-C (low-density lipoprotein cholesterol), ≥70 mg/dL. The primary outcome was 90-day LLT intensification (change to high-intensity statin and addition of ezetimibe or PCSK9i [proprotein subtilisin/kexin type 9 inhibitors]). Secondary outcomes included LDL-C level, proportion of patients with LDL-C of <70 or < 55 mg/dL, rate of major adverse cardiovascular events, ED visit incidence, and 6-month mortality. Results were analyzed using logistic and linear regression clustered at the provider level. The no-alert group included 47 clinicians and 1370 patients (median age, 71 years; 50.1% female, median LDL-C, 93 mg/dL); the alert group included 49 clinicians and 1130 patients (median age, 72 years; 47% female, median LDL-C 91, mg/dL). The primary outcome was observed in 14.1% of patients in the alert group as compared with 10.4% in the no-alert group. There were no differences in any secondary outcomes at 6 months. Among 542 patients whose clinicians (n=46) did not dismiss the EHR alert recommendations, LLT intensification was significantly greater (21.2% versus 10.4%, odds ratio, 2.33 [95% CI, 1.48-3.66]). With a real-time, targeted, individualized EHR alert as compared with usual care, the proportion of patients with atherosclerotic cardiovascular disease with LLT intensification was numerically higher but not statistically significant. Among clinicians who did not dismiss the alert, there was a > 2-fold increase in LLT intensification. EHR alerts, coupled with strategies to reduce clinician dismissal, may help address persistent gaps in LDL-C management. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04394715, https://www.clinicaltrials.gov/ct2/show/study/NCT04394715.

Effect of a Multidisciplinary Review Panel on Daily Morphine Milligram Equivalents for Patients With Chronic Pain.

Physicians and other health care professionals are challenged regularly to balance managing pain for patients with chronic pain receiving chronic opioid therapy (COT) with following the national guidelines and standards regarding daily morphine milligram equivalents (MME). This quality improvement project aimed to determine the effect of referral to a multidisciplinary review panel on daily MME for patients receiving COT for chronic pain. This quality improvement project included patients who had an established relationship with a primary care or community internal medicine clinician at a large health care organization and were referred to a newly created multidisciplinary review panel for their recommendations regarding treatment of pain. Criteria for patient referral were diagnosis of a chronic, painful condition, and use of chronic opioid medications. These patients were selected and referred at the discretion of their primary care clinician from January 2, 2019, through December 31, 2020. Data for this project were collected at the time of initial referral to the panel and 6 months after recommendations. The daily MME were assessed at the 2 time points. Thirteen patients were referred to the review panel during the project period. The median daily MME at the time of referral was 180. Daily MME decreased by a median of 14 MME after 6 months. The MME did not increase during the project period for any participants. Referral of patients receiving COT to a multidisciplinary review panel may reduce their daily opioid dose.

Clinicians' self-reported Efficacy in Cardiovascular Prevention Practice in the Southeastern United States

Aim: We assessed self-reported efficacy in cardiovascular prevention practice among internal medicine, family medicine, endocrinology and cardiology clinicians. Patients &amp; methods: We emailed a 21-item questionnaire to 956 physicians, nurse practitioners, physician assistants and pharmacists. Results: 264 clinicians responded (median age: 39 years, 55% women, 47.9% specialists). Most expressed high self-efficacy in lifestyle counselling, prescribing statins, metformin, and aspirin in primary prevention, but low self-efficacy in managing specialized conditions like elevated lipoprotein(a). Compared with specialists, PCPs expressed lower self-efficacy in managing advanced lipid disorders and higher self-efficacy in prescribing sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists. Conclusion: Self-efficacy in cardiovascular prevention varied across specialties. Future research should explore relevant provider, clinic and system level factors to optimize cardiovascular prevention.

Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment.

The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed method study we explored perceived pandemic-related practice changes to cervical cancer screenings and colposcopies. In 2021, a national sample of 1251 clinicians completed surveys, including 675 clinicians who performed colposcopy; a subset (n=55) of clinicians completed qualitative interviews. Nearly half of all clinicians reported they were currently performing fewer cervical cancer screenings (47%) and colposcopies (44% of those who perform the procedure) than before the pandemic. About one-fifth (18.6%) of colposcopists reported performing fewer LEEPs than prior to the pandemic. Binomial regression analyses indicated that older, as well as internal medicine and family medicine clinicians (compared to OB-GYNs), and those practicing in community health centers (compared to private practice) had higher odds of reporting reduced screening. Among colposcopists, internal medicine physicians and those practicing in community health centers had higher odds of reporting reduced colposcopies. Qualitative interviews highlighted pandemic-related care disruptions and lack of tracking systems to identify overdue screenings. Reductions in cervical cancer screening and colposcopy among nearly half of clinicians more than 1 year into the pandemic raise concerns that inadequate screening and follow-up will lead to future increases in preventable cancers. This study was funded by the American Cancer Society, who had no role in the study's design, conduct, or reporting.

Association of Primary Care Risk Mitigation Visits and Nonelective Emergency Department Visits in Patients Using Long-term Opioid Therapy

ObjectiveTo determine risk factors for nonelective emergency department visits (NEDVs) and whether primary care visits incorporating risk mitigation tools prevented NEDVs among patients using long-term opioid therapy (LOT). Patients and MethodsWe retrospectively searched the electronic health records at Mayo Clinic primary care outpatient practices in Arizona and Florida in all of 2018 and 2019 for the records of individual adult patients using LOT. Patient and clinician demographic characteristics and patient risk factors were compared between patients with and without risk mitigation visits. Univariate and multivariable logistic regression was used to determine risk factors for NEDVs. ResultsAmong 457 patients using LOT identified during the study period, most were women (n=266, 58.2%), and the median age was 69 years. Long-term opioid therapy risk mitigation visits were performed equally by family medicine and internal medicine clinicians and by a significantly higher proportion of Florida clinicians than Arizona clinicians (87.0% vs 70.5%; P<.001). Older age, falls, and mental health care utilization all increased the risk of NEDVs. Risk mitigation visits were protective against NEDVs (odds ratio, 0.56; 95% CI, 0.35-0.89; P=.01) after adjustment for older age, falls, and mental health care utilization. ConclusionRisk mitigation visits are effective in preventing NEDVs, and all patients using LOT should have such visits when possible.

Web Exclusive. Annals Graphic Medicine - Why Bedside Rounds Need Bedside Language.

Web Exclusives23 May 2023Annals Graphic Medicine - Why Bedside Rounds Need Bedside LanguageFREERebekah L. Gardner, MD, Vinald W. Francis, BFA, Daniel Baxter, BFA, and Kate Cahill, MDRebekah L. Gardner, MDAlpert Medical School of Brown University, Providence, Rhode Island (R.L.G., K.C., V.W.F.)Search for more papers by this author, Vinald W. Francis, BFAAlpert Medical School of Brown University, Providence, Rhode Island (R.L.G., K.C., V.W.F.)Search for more papers by this author, Daniel Baxter, BFAGlenshaw, Pennsylvania (D.B.)Search for more papers by this author, and Kate Cahill, MDAlpert Medical School of Brown University, Providence, Rhode Island (R.L.G., K.C., V.W.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/G22-0044 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Download figure Download PowerPoint Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Rebekah L. Gardner, MD; Vinald W. Francis, BFA; Daniel Baxter, BFA; Kate Cahill, MDAffiliations: Alpert Medical School of Brown University, Providence, Rhode Island (R.L.G., K.C., V.W.F.)Glenshaw, Pennsylvania (D.B.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=G22-0044.Author/Illustrator Information: Rebekah L. Gardner, MD, is an academic general internal medicine physician and graphic medicine enthusiast (e-mail, [email protected]edu). Vinald W. Francis, BFA, is a medical illustrator and visual design specialist (e-mail, [email protected]edu). Daniel Baxter, BFA, is an artist and musician (e-mail, [email protected]com). Kate Cahill, MD, is a general internal medicine physician and clinician–educator (e-mail, [email protected]edu).This article was published at Annals.org on 23 May 2023. Nextarticle Advertisement FiguresReferencesRelatedDetails Metrics Latest ePublished: 23 May 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia: CARE-FH Protocol.

The Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia (CARE-FH) study aims to improve diagnostic evaluation rates for FH at Geisinger, an integrated health delivery system. This clinical trial relies upon implementation science to transition the initial evaluation for FH into primary care, attempting to identify individuals prior to the onset of atherosclerotic cardiovascular disease events. The protocol for the CARE-FH study of this paper is available online. The first phase of the project focuses on trial design, including the development of implementation strategies to deploy evidence-based guidelines. The second phase will study the intervention, rolled out regionally to internal medicine, community medicine, and pediatric care clinicians using a stepped-wedge design, and analyzing data on diagnostic evaluation rates, and implementation, service, and health outcomes.

Guide to radiation therapy use in companion animals

Background: Radiation therapy (RT) is an important component of a multimodality approach to treating cancer in companion animals. Many owners that receive a cancer diagnosis for their pet never get to consult with a veterinary oncologist, and so it is important that clinicians involved in cancer diagnosis or treatment (whether a general practitioner, internal medicine clinician, surgical specialist or neurologist) have a basic understanding of the equipment used, the basic mechanism of action, the indications, as well as the expected side effects of RT.Aim of the article: This article provides an updated review of veterinary RT. This is particularly timely, given the current investment in RT facilities in the UK, which will revolutionise the incorporation of RT into veterinary medicine in the near future.

The Virginia primary care workforce: Final results of a novel method of analysis.

Background: In order to evaluate the capacity of primary care to provide comprehensive, coordinated, continuous care, a description of the primary care workforce is necessary. There have been prior efforts to describe the distribution of primary care, however, an accurate and timely description of which clinicians are in what location has been lacking. Further, the scope of care provided has not been fully explored. This research aimed to describe the primary care workforce distribution and specialty across the state of Virginia. Methods: The Virginia All-Payers Claims Database (APCD) and National Plan and Provider Enumeration System (NPPES) we queried. We identified all physicians (MD and DO) through NPPES and then cross referenced these clinicians with the APCD to identify those with an active claim in 2018. The NPPES was used to identify the physician specialty. Results: In 2018, there were 20,779 active physicians, of which 3,054 were family medicine, 1,794 were pediatricians, 1, 079 were OB/Gyns, and 5,247 were internal medicine or general medicine clinicians. The number of clinicians remained relatively stable between 2015-2018. Physicians were also categorized by ambulatory, inpatient, and mixed care. Discussion: This is the first evaluation that identifies clinician characteristics by using both active practice and NPPES taxonomy of type of clinicians. This will provide insight into the way care is provided across the state and establishes a foundation for evaluation of continuous care, comprehensive care and coordinated care in the future. As claims can be used to identify individuals over the course of time, it will be possible to identify scope, continuity and additional characteristics of clinicians. Additionally, we hope to identify advanced practice providers and their scope of care as well as clinicians migration and evolution during their career.

Knowledge and attitudes amongst internal medicine clinicians in referring valvular heart disease patients : a multi-centre survey study

Abstract Funding Acknowledgements Type of funding sources: None. Background With advancement in valvular interventions, outcomes of valvular heart disease (VHD) patients have improved dramatically. However, very little is known regarding levels of knowledge and attitudes amongst non-cardiology clinicians in managing VHD. Purpose To determine the knowledge and attitudes towards VHD management, pertaining specifically to referrals to cardiology services for consideration for intervention, amongst internal medicine clinicians in Malaysia. Methods We conducted a multi-centre survey study. A 20-item survey was distributed amongst internal medicine clinicians within three different institutions. Results A total of 75 responses was obtained (response rate of 35.7%). The mean age of responders was 36.6 years (S.D. 7.9). 57.3% were male. Respondents include medical officers (50.6%), internal medicine consultants (31.9%) and internal medicine specialist (i.e. pre-consultant) (17.5%). Majority had more than 10 years of experience working as medical doctors (46.7%). 69.3% admit to managing patients with VHD regularly (defined as at least one VHD patient per week). Respondents were comfortable using online resources, both formal (95.0%) and informal (75.0%) sources. A large proportion felt that they had ‘insufficient’ or ‘very insufficient’ knowledge and experience managing VHD patients on their own (28.0% and 8.0% respectively) and less than half felt that management of VHD patients within their institutions was ‘adequate’ or ‘very adequate’ (46.7% and 2.7% respectively). However, it is reassuring that most respondents felt comfortable discussing cases of VHD with their senior colleagues or their local cardiology services. Although many were felt to be over-zealous in wanting too frequent an echocardiography monitoring for cases of mild VHD (majority felt that the patient would require it every 1 year (25.3%) or 1-2 years (29.3%)), nevertheless attitudes in referrals to cardiology services for consult and intervention were felt appropriate (majority felt that cardiology consult would be indicated if valvular lesion was at least moderate in severity (56.0%), when there were changes to the heart function or structure (52.0%), when patients became symptomatic (45.3%) or when there were two or more valvular lesions simultaneously (45.3%). However, within a Malaysian context, there may be a need to shift attitudes towards referring much earlier, consistent with changes in recent international guidelines on managing VHD, as valvular surgery waiting times are extremely long. Conclusion The survey highlights the need for education amongst internal medicine clinician to tackle both the over-zealous attitude in monitoring patients with mild valvular disease on one extreme, and in improving early referrals for VHD indicated for intervention in the other. Abstract Figure. Survey items on echocardiography Abstract Figure. Survey items on cardiology referrals

Knowledge and attitudes amongst internal medicine clinicians in referring valvular heart disease patients : a multi-centre survey study

Abstract Funding Acknowledgements Type of funding sources: None. Background With advancement in valvular interventions, outcomes of valvular heart disease (VHD) patients have improved dramatically. However, very little is known regarding levels of knowledge and attitudes amongst non-cardiology clinicians in managing VHD. Purpose To determine the knowledge and attitudes towards VHD management, pertaining specifically to referrals to cardiology services for consideration for intervention, amongst internal medicine clinicians in Malaysia. Methods We conducted a multi-centre survey study. A 20-item survey was distributed amongst internal medicine clinicians within three different institutions. Results A total of 75 responses was obtained (response rate of 35.7%). The mean age of responders was 36.6 years (S.D. 7.9). 57.3% were male. Respondents include medical officers (50.6%), internal medicine consultants (31.9%) and internal medicine specialist (i.e. pre-consultant) (17.5%). Majority had more than 10 years of experience working as medical doctors (46.7%). 69.3% admit to managing patients with VHD regularly (defined as at least one VHD patient per week). Respondents were comfortable using online resources, both formal (95.0%) and informal (75.0%) sources. A large proportion felt that they had ‘insufficient’ or ‘very insufficient’ knowledge and experience managing VHD patients on their own (28.0% and 8.0% respectively) and less than half felt that management of VHD patients within their institutions was ‘adequate’ or ‘very adequate’ (46.7% and 2.7% respectively). However, it is reassuring that most respondents felt comfortable discussing cases of VHD with their senior colleagues or their local cardiology services. Although many were felt to be over-zealous in wanting too frequent an echocardiography monitoring for cases of mild VHD (majority felt that the patient would require it every 1 year (25.3%) or 1-2 years (29.3%)), nevertheless attitudes in referrals to cardiology services for consult and intervention were felt appropriate (majority felt that cardiology consult would be indicated if valvular lesion was at least moderate in severity (56.0%), when there were changes to the heart function or structure (52.0%), when patients became symptomatic (45.3%) or when there were two or more valvular lesions simultaneously (45.3%). However, within a Malaysian context, there may be a need to shift attitudes towards referring much earlier, consistent with changes in recent international guidelines on managing VHD, as valvular surgery waiting times are extremely long. Conclusion The survey highlights the need for education amongst internal medicine clinician to tackle both the over-zealous attitude in monitoring patients with mild valvular disease on one extreme, and in improving early referrals for VHD indicated for intervention in the other. Abstract Figure. Survey item on echocardiography Abstract Figure. Survey item on cardiology referrals

Reduced Cognitive Burden and Increased Focus: A Mixed-methods Study Exploring How Implementing Scribes Impacted Physicians.

Understanding how medical scribes impact care delivery can inform decision-makers who must balance the cost of hiring scribes with their contribution to alleviating clinician burden. The objective of this study was to understand how scribes impacted provider efficiency and satisfaction. This was mixed-methods study. Internal and family medicine clinicians were included. We administered structured surveys and conducted unstructured interviews with clinicians who adopted scribes. We collected average days to close charts and quantity of after-hours clinical work in the 6 months before and after implementation using electronic health record data. We conducted a difference in difference (DID) analysis using a multilevel Poisson regression. Three themes emerged from the interviews: (1) charting time is less after training; (2) clinicians wanted to continue working with scribes; and (3) scribes did not reduce the overall inbox burden. In the 6-month survey, 76% of clinicians endorsed that working with a scribe improved work satisfaction versus 50% at 1 month. After implementation, days to chart closure decreased [DID=0.38 fewer days; 95% confidence interval (CI): -0.61, -0.15] the average minutes worked after hours on clinic days decreased (DID=-11.5 min/d; 95% CI: -13.1, -9.9) as did minutes worked on nonclinical days (DID=-24.9 min/d; 95% CI: -28.1, -21.7). Working with scribes was associated with reduced time to close charts and reduced time using the electronic health record, markers of efficiency. Increased satisfaction accrued once scribes had experience.

Understanding and Application of Daptomycin-Susceptible Dose-Dependent Category for Enterococcus: A Mixed-Methods Study.

BackgroundIn 2018, the Clinical Microbiology Laboratory at our institution adopted updated daptomycin Enterococcus–susceptible dose-dependent breakpoints. While the introduction of susceptible dose-dependent (SDD) was intended to guide practice toward optimal dosing, the understanding and application of daptomycin SDD breakpoints for enterococci were unknown.MethodsThis mixed-methods study combined a clinician survey with a retrospective pre–post prescribing analysis. An 8-question survey was distributed to infectious diseases (ID) and internal medicine (IM) clinicians. A retrospective chart review of hospitalized adults with infections due to Enterococcus spp. was conducted before (pre-SDD) and after (post-SDD) adoption of SDD reporting for enterococci.ResultsSurvey response rates were 40 of 98 (41%) for IM and 22 of 34 (65%) for ID clinicians. ID clinicians scored significantly higher than IM clinicians in knowledge of SDD. Chart review of 474 patients (225 pre- vs 249 post-SDD) showed that daptomycin dosage following susceptibility testing was significantly higher post-SDD compared with pre-SDD (8.5 mg/kg vs 6.4 mg/kg; P < .001) with no difference in empiric dosing (6.3 mg/kg vs 6.2 mg/kg; P = .67). Definitive daptomycin use varied between the pre- and post-SDD periods (35.1% vs 16.9%; P < .001).ConclusionsThe survey revealed that ID clinicians placed more importance on and had more confidence in the SDD category over IM clinicians. SDD reporting was associated with a change in definitive daptomycin dosing. ID specialist involvement is recommended in the care of infections due to enterococci for which daptomycin is reported as SDD given their expertise.

Implementation of a "Cases and Conundrums" Conference Among Early Career Internal Medicine Clinicians.

Isolation among primary care clinicians impacts diagnostic accuracy, clinical confidence, and joy in work. In residency training programs, formal case conferences are foundational to the collaborative learning experience; however, in modern outpatient practice, informal discussions of challenging

Interspeciality Othering: A Qualitative Analysis of Physician Interpersonal Conflict at the Time of Admission From the Emergency Department.

Purpose: Communication, teamwork, and conflict navigation among physician colleagues are core competencies for graduate medical trainees. 1 Yet, how these core elements of professional behavior are enacted in practice remains poorly characterized, and interpersonal interactions continue to be a central source of workplace conflict. 2,3 While this threat to an effective learning environment has been described in the nursing literature, 4 physicians’ experience of conflict with other physician colleagues remains poorly characterized. The goal of this study was to gain a more nuanced understanding of interphysician conflict to provide foundational guidance for how training communities can support best practices and curricular innovation regarding communication. Methods: Using a constructivist grounded theory approach, the authors explored the perceptions of interpersonal interactions of emergency medicine (EM) and internal medicine (IM) clinicians, using conversations regarding hospital admissions as a critical interface between members of these 2 disciplines. The authors used a purposive sampling approach to recruit participants and included EM residents and attending physicians and IM attending physicians who serve in the triage hospitalist role. Two authors conducted hour-long, semistructured interviews over Zoom. The 2 primary investigators then coded the transcripts according to Charmaz’s 5 3 stages of coding: initial, focused, and theoretical. Investigators used a constant comparative and integrative analysis to refine the interview guide, and interviews continued until thematic sufficiency was reached. Results: The authors interviewed 18 participants for this study, including 9 IM faculty and 9 EM providers (4 faculty, 5 residents). Participants identified primers, modifiers, consequences, and solutions to interphysican conflict. They described how preconceived perceptions of their colleagues’ specialty and misalignments in expectations around clinical care primed the learning environment for conflict. EM and IM providers also emphasized the role of word choices in creating mutual feelings of being undervalued, disempowered, and having their clinical judgment questioned. They described important personal and professional consequences that occurred secondary to this conflict, such as stress, burnout, job dissatisfaction, self-doubt, questioning their choice of medical specialty, and concerningly they expressed these encounters reinforced bias and stereotyping among specialties. Finally, providers suggested strategies to repair conflictual interactions and improve communication. They noted that focusing on honesty, empathy, teaching, and active team formation could be used to resolve or avoid conflict. Discussion: Our data suggest that interpersonal conflict between physicians is a pervasive issue. Participants describe that these encounters impact both their professional and personal wellness, which aligns with the broader workplace conflict literature. Interspecialty “othering” and preexisting biases and stereotypes prime the workplace for these conflictual interactions. They also serve as a lens to interpret misaligned expectations and difference of opinion as error, clinical incompetence, and work avoidance, which further propagate conflict. Trainees are exposed to interspeciality othering and expressions of other specialties’ relative inferiority early in training. These attitudes are often modeled by supervisors and play a role in specialty identity formation. Finally, propagation of bias and stereotyping is a concerning consequence of interphysican conflict and may serve to further the divide between EM and IM providers. Empathy, honesty, and mutual teaching are important strategies to combat stereotyping and othering and may help mitigate the deleterious consequences of interphysican conflict. Significance: Educators should specifically target interventions to foster improved interspecialty communication to promote conflict navigation and teamwork competencies. Learners need to not only understand how to give a structured handoff but also have strategies for both preventing conflict and navigating it once it does occur. Additionally, it is critical for educators to be mindful of the role that our words, actions, and attitudes play in influencing trainees’ perspectives of other specialties.

Cost awareness of radiological studies among doctors at Universitas Academic Hospital in Bloemfontein, South Africa.

BackgroundSouth Africa has high healthcare expenses. Improving cost-consciousness could decrease government expenditure on healthcare.ObjectivesTo determine cost awareness of radiological studies among doctors at a tertiary hospital. The objective was met by assessing the accuracy of cost estimation according to the level of training and speciality, whether participants had received prior education/training related to cost awareness and if they had a desire to learn more about the cost of radiological imaging.MethodA cross-sectional survey was conducted in six clinical departments at Universitas Academic Hospital using an anonymous questionnaire that determined doctors’ cost awareness of five radiological studies. Each radiological study was answered using six different cost ranges, with one correct option. Costs were based on the Department of Health’s 2019 Uniform Patients Fee Schedule (UPFS).ResultsIn total, 131 (67.2%) of 195 questionnaires distributed to registrars and consultants were returned. Overall, low accuracy of cost estimation was observed, with 45.2% of the participants choosing only incorrect options. No participant estimated all five costs correctly. Only the Internal Medicine clinicians demonstrated a significant difference between registrars and consultants for the number of correct answers (median 0 and 1, respectively) (p = 0.04). No significant differences were found between specialities stratified by registrars/consultants. Most participants (88.6%) would like to learn about imaging costs. Only 2.3% of the participants had received prior education/training related to cost awareness of radiological studies.ConclusionDoctors were consistently inaccurate in estimating the cost of radiological studies. Educating doctors about the cost of radiological imaging could have a positive effect on healthcare expenditure.

Man vs. Machine: Comparing Physician vs. Electronic Health Record–Based Model Predictions for 30-Day Hospital Readmissions

Electronic health record (EHR)-based readmission risk prediction models can be automated in real-time but have modest discrimination and may be missing important readmission risk factors. Clinician predictions of readmissions may incorporate information unavailable in the EHR, but the comparative usefulness is unknown. We sought to compare clinicians versus a validated EHR-based prediction model in predicting 30-day hospital readmissions. We conducted a prospective survey of internal medicine clinicians in an urban safety-net hospital. Clinicians prospectively predicted patients' 30-day readmission risk on 5-point Likert scales, subsequently dichotomized into low- vs. high-risk. We compared human with machine predictions using discrimination, net reclassification, and diagnostic test characteristics. Observed readmissions were ascertained from a regional hospitalization database. We also developed and assessed a "human-plus-machine" logistic regression model incorporating both human and machine predictions. We included 1183 hospitalizations from 106 clinicians, with a readmission rate of 20.8%. Both clinicians and the EHR model had similar discrimination (C-statistic 0.66 vs. 0.66, p = 0.91). Clinicians had higher specificity (79.0% vs. 48.9%, p < 0.001) but lower sensitivity (43.9 vs. 75.2%, p < 0.001) than EHR model predictions. Compared with machine, human was better at reclassifying non-readmissions (non-event NRI + 30.1%) but worse at reclassifying readmissions (event NRI - 31.3%). A human-plus-machine approach best optimized discrimination (C-statistic 0.70, 95% CI 0.67-0.74), sensitivity (65.5%), and specificity (66.7%). Clinicians had similar discrimination but higher specificity and lower sensitivity than EHR model predictions. Human-plus-machine was better than either alone. Readmission risk prediction strategies should incorporate clinician assessments to optimize the accuracy of readmission predictions.

Knowledge and Attitudes Amongst Internal Medicine Clinicians in Referring Valvular Heart Disease Patients: A Survey Study

Knowledge and Attitudes Amongst Internal Medicine Clinicians in Referring Valvular Heart Disease Patients: A Survey Study

When Pediatric Hospitalists Took Care of Adults During the COVID-19 Pandemic.

In April 2020, the coronavirus disease 2019 (COVID-19) pandemic raged through our hospital system in Connecticut.1 Medical teams for adult patients mobilized their staff and units for the incessant surge. Patient volume and acuity on the adult units began to rise amid the uncertainty of personal protective equipment (PPE) supplies, fear of a formidable impact, and potential depletion of the clinical workforce. In preparation, the pediatrics department chair of our children’s hospital within a larger academic medical center asked for volunteers to help the adult teams. The pediatric wards were strangely quiet as patients and families stayed away from the hospital and elective surgeries were canceled. In comparison, admissions to adult units in our hospital continued to rise exponentially (3 cases of COVID-19 on March 15 and 354 on April 9), further displaying the disproportionate impact of the pandemic on adults. Because pediatric hospitalizations to COVID-19 remained low and the demand for beds for hospitalized adults continued to rise, we initially gave two of our pediatric units to internal medicine clinician teams for adult admissions. Along with more hospitalized patients, the need for more clinicians to care for patients became more apparent. We heard that our pediatric critical care and pediatric emergency department faculty were helping to staff with adult medical ICUs. We knew that would be us soon and began work to brush up on our internal medicine skills.2 Instead of waiting to be asked, we decided proactively to offer our services to the internal medicine department as a team of pediatric nurses, pediatric housestaff, and pediatric hospitalists under the guidance of medicine-pediatrics hospitalists and medicine-pediatrics housestaff. Shortly, we were deployed to open a new adult COVID-19 …