Outpatient General Internal Medicine Research Articles

New developments and perspectives in outpatient general internal medicine

Several studies have been published in 2023, in the field of general internal medicine, addressing various aspects of health and covering topics ranging from hormonal treatment of menopause to the management of chronic and acute diseases. A selection of articles was chosen for this update in outpatient general internal medicine, showing recent studies on outpatient care of patients (treatment, follow-up). The summary of articles is supplemented this year by a table of medical recommendations published in 2023, modestly proposed, and covering various areas. These guidelines, most of them from North America, show advances in the care and monitoring of outpatients, and should be interpreted in light of the various recommendations in Switzerland.

The Evaluation of a Pharmacist-Led Multidisciplinary Quality Committee in a General Internal Medicine Outpatient Clinic

The Evaluation of a Pharmacist-Led Multidisciplinary Quality Committee in a General Internal Medicine Outpatient Clinic

Development of a Visit Facilitator Role to Assist Physicians in an Ambulatory Consultative Medical Practice.

To decrease the electronic health record (EHR) clerical burden and improve patient/clinician satisfaction, allied health staff were trained as visit facilitators (VFs) to assist the physician in clinical and administrative tasks. From December 7, 2020, to October 11, 2021, patients with complex medical conditions were evaluated by an internal medicine physician in an outpatient general internal medicine (GIM) consultative practice at a tertiary care institution. A VF assisted with specific tasks before, during, and after the clinical visit. Presurvey and postsurvey assessments were performed to understand the effect of the VF on clinical tasks as perceived by the physician. A total of 57 GIM physicians used a VF, and 41 (82%) physicians and 39 (79%) physicians completed the pre-VF and post-VF surveys, respectively. Physicians reported a significant reduction in time reviewing outside materials, updating pertinent information, and creating/modifying EHR orders (P<.05). Clinicians reported improved interactions with patients and on-time completion of clinical documentation. In the pre-VF survey, "too much time spent" was the most common response for reviewing outside material, placing/modifying orders, completing documentation/clinical notes, resolving in-baskets, completing dismissal letters, and completing tasks outside of work hours. In the post-VF survey, "too much time spent" was not the most common answer to any question. Satisfaction improved in all areas (P<.05). VFs significantly reduced the EHR clinical burden and improved GIM physician practice satisfaction. This model can potentially be used in a wide range of medical practices.

Implementing a collaborative practice agreement for HIV pre-exposure prophylaxis in the primary care setting

BackgroundHuman immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) medications are highly effective at reducing HIV transmission despite their underutilization. Pharmacists can be involved in HIV PrEP management through collaborative practice agreements (CPAs). ObjectivesThis study aimed to (1) describe the development of a CPA for a pharmacist-led HIV PrEP service within an outpatient primary care clinic and (2) describe the growth of the HIV PrEP CPA service after implementation. Practice descriptionThe service was developed and implemented within a network of 7 outpatient general internal medicine (GIM) clinics associated with a large academic medical center. Pharmacists are embedded in the clinics and provide care alongside an interprofessional team. Practice innovationAn HIV PrEP CPA was developed and implemented by primary care pharmacists to increase access to HIV PrEP therapy through pharmacist-led visits. The pharmacist-led visits were piloted at one site before expanding to the other primary care clinics. Evaluation methodsData were analyzed using an electronic health record-generated report that included all patients prescribed HIV PrEP medications by a GIM primary care provider (PCP) within the last year. The report was generated before the start of the intervention in October 2021 and again in May 2022. Retrospective chart review was then used to identify prescribing patterns and referrals to the pharmacy HIV PrEP CPA. ResultsSeven months after the start of the HIV PrEP CPA, 122 patients were prescribed HIV PrEP by a GIM PCP. Thirty-four patients (27.9%) were newly started on HIV PrEP by a GIM PCP since the beginning of the initiative. A total of 53 patient referrals (43.4%) were placed to the pharmacy team. Five of the 7 GIM clinics have established pharmacist-led HIV PrEP services. ConclusionThis report describes the successful development and implementation of a pharmacist-led HIV PrEP CPA in Ohio.

Electronic health records analytics to identify cancer patients with metabolic syndrome.

e18649 Background: Metabolic syndrome, defined as the presence of at least 3 of 5 clinical factors including hypertension, elevated triglyceride levels, low high-density lipoprotein level, insulin resistance, and central obesity, increases the risk of heart disease, fatty liver, and multiple cancers. Metabolic syndrome in cancer patients has been associated with poor cancer-specific and overall survival. Lifestyle modification in patients with metabolic syndrome may reduce the risk of poor outcomes. In this quality improvement project, we aimed to determine the prevalence of metabolic syndrome among cancer patients and survivors seen in an outpatient general internal medicine (GIM) clinic and to determine the feasibility of using electronic health records (EHR) analytics to systematically identify such patients and refer them to lifestyle interventions and liver imaging. Methods: Study period was January-December 2021. During this period, an EHR algorithm was used to identify patients with metabolic syndrome based on the presence of ICD-10 diagnoses of metabolic conditions (diabetes, hypertension, lipid disease, and obesity). This algorithm was used to direct data from patient visits into an interactive dashboard to track metabolic syndrome prevalence and continuously monitor referrals to interventions. In September 2021, a best practice alert based on the EHR algorithm was created to identify patients with metabolic syndrome and prompt providers to refer them to nutrition counseling, liver ultrasound with elastography, and/or a community-based active-living support group for cancer survivors. GIM clinic nurses also reviewed medications and utilized an EPIC SmartPhrase that incorporated laboratory values (e.g., glucose, A1c, and lipids), blood pressure, and body mass index to confirm whether patients actually met the criteria for metabolic syndrome, and if so, they notified medical providers who then ordered the interventions. Patients confirmed to have metabolic syndrome received educational materials about lifestyle modifications. Data extracted from the dashboard were analyzed using Minitab 17 statistical software. Results: Among 1133 patients seen in the GIM clinic during 2021, 609 (54%) had metabolic syndrome. A total of 1045 patients (92%) had hypertension, 802 (71%) had hyperlipidemia, 571 (50%) had obesity, and 483 (43%) had diabetes. Among the 609 patients with metabolic syndrome, 148 (24%) were referred to liver ultrasound with elastography, 124 (20%) to nutrition counseling, and 21 (3%) to the support group. Beginning September 1, the best practice alert was triggered for 1131 clinical encounters meeting criteria for metabolic syndrome. Conclusions: The prevalence of metabolic syndrome among cancer patients seen in a GIM clinic was high. EHR analytics can lead to systematic identification and referral of patients with metabolic syndrome to lifestyle interventions and liver imaging.

Medication Errors and Potentially Inappropriate Medication Use in Elderly Patients Admitted to the General Internal Medicine Outpatient Clinic of a University Hospital

Background: The frequency of chronic diseases, number of drugs used, and number of medication errors have increased in the elderly. In this study, we aimed to determine the prevalence of potentially inappropriate medication (PIM) use and medication errors in elderly patients admitted to a university hospital and to identify the influencing factors.&#x0D; Material and Methods: In this prospective cross-sectional study, the patients’ characteristics, drug use patterns, and medication errors in the previous month were recorded in detail. Following this, PIM use was assessed according to the 2015 Beers Criteria.&#x0D; Results: A total of 721 elderlay patients (60.9% female and 39.1% male) were included in this study. The mean number of drugs used by the patients per day was 4.6±2.8 and the rate of polypharmacy was 49.4%. The rate of medication errors was 54.2%, that of PIM use was 30.1%, and that of adverse drug reactions was 22.5%; these rates were higher in patients with polypharmacy. The most common medication error, PIM use, and adverse drug reaction were the omission of a daily dose (36.5%), inappropriate use of proton pump inhibitors (10%), and gastrointestinal system-related symptoms (7.7%), respectively. Diabetes mellitus and depression were found to be independent factors associated with medication errors.&#x0D; Conclusions: In the present study, patient-related medication errors, PIM use, and adverse drug reactions were more frequently observed in elderly patients with polypharmacy. In addition, medication errors were more commonly observed in elderly with diabetes mellitus and depression.

The Telemedicine Takeover: Lessons Learned During an Emerging Pandemic.

Introduction: Health care systems rose to the challenges of COVID-19 by creating or expanding telehealth programs to ensure that patients could access care without an in-person appointment. Traditionally, physicians receive limited formal telemedicine training, making preparedness for this transition uneven. To describe challenges to and attitudes toward providing virtual patient care, we distributed a survey to physicians within our system who largely had no formal prior training/experience with telemedicine, but transitioned to routine telemedicine use. Data collected are then used to offer actionable recommendations for health system leaders and medical educators. Materials and Methods: Surveys were distributed to all faculty outpatient general internal medicine physicians working at any New York University Langone Health, New York City Health + Hospitals/Bellevue and Gouverneur, and the VA NY Harbor Health System (n = 378) in mid-2020. Survey items consisted of Likert and open-ended questions related to experience with televisits (13 items) and attitudes toward care (24 items). Results: Telehealth-related challenges varied by site and modality. Primary challenges included establishing a connection from the patient's (98%) or physician's end (84%) and difficulty in the following domains: working with team members (39%), physical examinations (95%), establishing new patient relationships (70%), and taking history (40%), among others. In thematic analysis, significant themes with illustrative qualitative commentary emerged related to technological challenges, new systems issues, and new patient/physician communication experiences. Discussion: Experience differences were rooted in the type of technology employed. Safety-net practices conducted mostly telephonic visits, whereas private outpatient sites utilized video, despite both using identical electronic medical records. As we consider a "new normal" and prolonged community transmission of COVID-19 infection, it is essential to establish telemedicine training, tools, and protocols that meet the needs of both patients and physicians.

Polypharmacy and potential inappropriate drug use in the elderly admitted to the general internal medicine outpatient clinic

In this study, we aimed to investigate the rates of polypharmacy and potentially inappropriate drug (PID) use in elderly patients who admitted to General Internal Medicine Outpatient Clinic. In this prospective cross-sectional study, the frequency of chronic diseases, the number of drugs used and polypharmacy rates of elderly patients were determined. Then, PIDs rates were investigated according to the 2015 Beers criteria. 304 (58,9% female, 41,1% male) patients were included in the study. 95,8% had at least one concomitant chronic disease, the mean number of drugs used by the patients per day was 4,9 ± 3,3 and the rate of polypharmacy was 52,9%. A total of 124 PIDs were determined in 104 (34,2%) patients, and this rate was higher in patients with polypharmacy (p &lt; 0,05). The most common PIDs; the use of drugs that should be avoided in the elderly (Table 2-related PIDs; 28,3%), and the most common of these was the inappropriate use of proton pump inhibitors (PPIs).

Impact of a Commercial Artificial Intelligence-Driven Patient Self-Assessment Solution on Waiting Times at General Internal Medicine Outpatient Departments: Retrospective Study.

BackgroundPatient waiting time at outpatient departments is directly related to patient satisfaction and quality of care, particularly in patients visiting the general internal medicine outpatient departments for the first time. Moreover, reducing wait time from arrival in the clinic to the initiation of an examination is key to reducing patients’ anxiety. The use of automated medical history–taking systems in general internal medicine outpatient departments is a promising strategy to reduce waiting times. Recently, Ubie Inc in Japan developed AI Monshin, an artificial intelligence–based, automated medical history–taking system for general internal medicine outpatient departments.ObjectiveWe hypothesized that replacing the use of handwritten self-administered questionnaires with the use of AI Monshin would reduce waiting times in general internal medicine outpatient departments. Therefore, we conducted this study to examine whether the use of AI Monshin reduced patient waiting times.MethodsWe retrospectively analyzed the waiting times of patients visiting the general internal medicine outpatient department at a Japanese community hospital without an appointment from April 2017 to April 2020. AI Monshin was implemented in April 2019. We compared the median waiting time before and after implementation by conducting an interrupted time-series analysis of the median waiting time per month. We also conducted supplementary analyses to explain the main results.ResultsWe analyzed 21,615 visits. The median waiting time after AI Monshin implementation (74.4 minutes, IQR 57.1) was not significantly different from that before AI Monshin implementation (74.3 minutes, IQR 63.7) (P=.12). In the interrupted time-series analysis, the underlying linear time trend (–0.4 minutes per month; P=.06; 95% CI –0.9 to 0.02), level change (40.6 minutes; P=.09; 95% CI –5.8 to 87.0), and slope change (–1.1 minutes per month; P=.16; 95% CI –2.7 to 0.4) were not statistically significant. In a supplemental analysis of data from 9054 of 21,615 visits (41.9%), the median examination time after AI Monshin implementation (6.0 minutes, IQR 5.2) was slightly but significantly longer than that before AI Monshin implementation (5.7 minutes, IQR 5.0) (P=.003).ConclusionsThe implementation of an artificial intelligence–based, automated medical history–taking system did not reduce waiting time for patients visiting the general internal medicine outpatient department without an appointment, and there was a slight increase in the examination time after implementation; however, the system may have enhanced the quality of care by supporting the optimization of staff assignments.

Eosinopenia as a diagnostic marker of bloodstream infection in a general internal medicine setting: a cohort study

BackgroundLittle is known about the potential use of the eosinophil count as a predictive marker of bloodstream infection. In this study, we aimed to assess the reliability of eosinopenia as a predictive marker of bloodstream infection.MethodsThis retrospective cohort study was performed in the outpatient department and general internal medicine department of a tertiary university hospital in Japan. A total of 189 adult patients with at least 2 sets of blood cultures obtained during the period January 1–December 31, 2018, were included; those with the use of antibiotic therapy within 2 weeks prior to blood culture, steroid therapy, or a history of haematological cancer were excluded. The diagnostic accuracies of each univariate variable and the multivariable logistic regression models were assessed by calculating the areas under the receiver operating characteristic curves (AUROCs). The primary outcome was a positive blood culture indicating bloodstream infection.ResultsSevere eosinopenia (< 24.4 cells/mm3) alone yielded small but statistically significant overall predictive ability (AUROC: 0.648, 95% confidence interval (CI): 0.547–0.748, P < 0.05), and only moderate sensitivity (68, 95% CI: 46–85%) and specificity (62, 95% CI: 54–69%). The model comprising baseline variables (age, sex), the C-reactive protein level, and neutrophil count yielded an AUROC of 0.729, and further addition of eosinopenia yielded a slight improvement, with an AUROC of 0.758 (P < 0.05) and a statistically significant net reclassification improvement (NRI) (P = 0.003). However, the integrated discrimination index (IDI) (P = 0.284) remained non-significant.ConclusionsSevere eosinopenia can be considered an inexpensive marker of bloodstream infection, although of limited diagnostic accuracy, in a general internal medicine setting.

Physician Burnout and Timing of Electronic Health Record Use.

Rates of burnout among physicians have been high in recent years. The Electronic Health Record (EHR) is implicated as a major cause of burnout. To determine the association between physician burnout and timing of EHR use in an academic internal medicine primary care practice. We conducted an observational cohort study using cross-sectional and retrospective data. Participants included primary care physicians in an academic outpatient general internal medicine practice. Burnout was measured with a single-item question via self-reported survey. EHR time was measured using retrospective automated data routinely captured within the institution's EHR. EHR time was separated into four categories: weekday workhours in-clinic time, weekday workhours out-of-clinic time, weekday afterhours time, and weekend/holiday afterhours time. Ordinal regression was used to determine the relationship between burnout and EHR time categories. EHR use during in-clinic sessions was related to burnout in both bivariate (OR=1.04, 95% CI 1.01, 1.06; p=0.007) and adjusted (OR=1.07, 95% CI 1.03, 1.1; p=0.001) analyses. No significant relationships were found between burnout and afterhours EHR use. In this small single-institution study, physician burnout was associated with higher levels of in-clinic EHR use but not afterhours EHR use. Improved understanding of the variability of in-clinic EHR use, and the EHR tasks that are particularly burdensome to physicians, could help lead to interventions that better integrate EHR demands with clinical care and potentially reduce burnout. Further studies including more participants from diverse clinical settings are needed to further understand the relationship between burnout and afterhours EHR use.

Effect of A Brief Education On The Occupational History Taking In Hypertension Patients

Objective: This study is designed to measure the effect of 10-minutes training about occupational diseases, history taking and relation of occupation and hypertension on occupational history taking rates of physicians. &#x0D; Materials and Methods: This research is conducted between 01 April 2018 to 31 May 2018 at Hacettepe University Faculty of Medicine, Department of Internal Medicine, Division of General Internal Medicine Outpatient Clinic. The training including the importance and methods of taking occupational history, and the relation between occupation and diseases is given to the new assistant doctor group as an extra 10 minutes’ education session. At the end of May, researchers screened electronic medical files of patients who diagnosed with hypertension (ICD10 code I10) of outpatients in General Internal Medicine Division in April and May 2018.&#x0D; Results: We reviewed the data of 3619 adult patients administered to General Internal Medicine Outpatient Clinic of Hacettepe University Hospitals in between 01 April to 31 May 2018. A total of 395 (10.9%) patients had hypertension diagnosis code. The total number of patients whose occupational history taken were 151 (38.2%). There were statistically significant difference between physician groups not trained in April and trained 10 minutes in May, 62 (32%), and 89 (44.3%), respectively (p:0.012). Among the hypertensive patients whose occupational history were recorded, 36 (23.8%) had an occupation. &#x0D; Conclusion: This result emphasizes the importance of education in raising awareness of taking an occupational history. As occupational diseases are 100% preventable diseases, taking occupational history will enhance the diagnosis and effective treatment of the occupational or work-related diseases. Beginning from the medical faculty lectures, seminars and post-graduate education have to be added and increased regarding this important issue. &#x0D; Keywords: Occupational history, occupational disease, hypertension.

Outpatient general internal medicine practiced by a clinical neurologist: The diagnosis and clinical features of patients with neurologic findings in our hospital

Outpatient general internal medicine practiced by a clinical neurologist: The diagnosis and clinical features of patients with neurologic findings in our hospital

A teaching skills assessment tool inspired by the Calgary–Cambridge model and the patient-centered approach

ObjectiveThe aim of this study was to develop a descriptive tool for peer review of clinical teaching skills. Two analogies framed our research: (1) between the patient-centered and the learner-centered approach; (2) between the structures of clinical encounters (Calgary–Cambridge communication model) and teaching sessions. MethodDuring the course of one year, each step of the action research was carried out in collaboration with twelve clinical teachers from an outpatient general internal medicine clinic and with three experts in medical education. The content validation consisted of a literature review, expert opinion and the participatory research process. Interrater reliability was evaluated by three clinical teachers coding thirty audiotaped standardized learner-teacher interactions. ResultsThis tool contains sixteen items covering the process and content of clinical supervisions. Descriptors define the expected teaching behaviors for three levels of competence. Interrater reliability was significant for eleven items (Kendall’s coefficient p<0.05). ConclusionThis peer assessment tool has high reliability and can be used to facilitate the acquisition of teaching skills.

Increased Gardnerella vaginalis urogenital biofilm in inflammatory bowel disease

IntroductionInflammatory bowel disease (IBD) is a systemic inflammatory condition that affects the entire organism, not only the bowel. An impaired interaction with microbiota has been shown to be important. We looked for bacterial factors, which may contribute to the well-known higher incidence of poor reproductive outcome in IBD. MethodsUrine specimen of patients with Crohn's disease (N=42), ulcerative colitis (N=46), and randomly selected patients attending the General Internal Medicine Outpatient Clinic of the Charité for non-IBD related medical conditions (N=49) was analyzed for bacteria adherent to desquamated epithelial cells and diffusely distributed bacteria in the urine using fluorescence in situ hybridization. ResultsThe urine of IBD patients contained significantly more often Gardnerella vaginalis biofilms (CD 38%, UC 43%) than those of the control group (16%). There was no link between current disease activity, history of and present fistula and G. vaginalis biofilms, but the samples of patients with steroid refractory/dependent disease were significantly more often G. vaginalis biofilm positive. No significant differences in number of epithelial cells and leukocytes, and total bacterial counts were present. ConclusionsThere is a significant link between IBD and G. vaginalis biofilm. This observation suggests an epithelial barrier dysfunction of the genital tract. Since G. vaginalis is believed to be one of the reasons responsible for bacterial vaginosis, it may be an important factor in the well-known higher incidence of poor reproductive outcome in IBD. Excessive G. vaginalis biofilms in steroid refractory/dependent disease suggests a need to avoid long-term steroid therapy.

How to fulfill residents' training needs and public service missions in outpatient general internal medicine?

QUESTION UNDER STUDY/PRINCIPLES: Ambulatory care is a mandatory component of post-graduate training in general internal medicine. Academic outpatient clinics face challenges in training residents in terms of exposure to sufficient patient case-mix, diversity of clinical activities and continuity of care while fulfilling their mission to provide care to vulnerable populations. We report the development and evaluation of a new postgraduate curriculum in ambulatory care in Geneva, Switzerland, designed to overcome such challenges. The content of learning activities was adapted to core competencies and learning objectives. In the new 2-year curriculum, residents had their working week divided into 2½ days of continuity clinic over two years, and 2½ days of 6 to 12 months rotations (e.g., walk-in clinics). Team work was consolidated through the creation of subunits including an attending physician, 1-2 senior residents during one year and 6- to 8 residents, who met in bi-monthly meetings with other health professionals. In both local and national surveys, residents and senior residents expressed an overall global satisfaction with the new curriculum. Nursing and administrative staff were less satisfied, because of reduced residents' time in each unit. Interprofessional meetings were highly appreciated for both patient care and team building. Management of residents' absences became more complex. The new curriculum met its goals in gaining residents' satisfaction and in reinforcing interprofessional collaboration although management of human resources became more complex. It also gave insights into challenges to be addressed when disseminating a new curriculum, such as strong leadership, educational expertise and management skills and tools.

Factors Affecting Clinician Educator Encouragement of Routine HIV Testing Among Trainees

Adoption of CDC recommendations for routine, voluntary HIV screening of all Americans age 13–64 years has been slow. One method to increase adherence to clinical practice guidelines is through medical school and residency training. To explore the attitudes, barriers, and behaviors of clinician educators (CEs) regarding advocating routine HIV testing to their trainees. We analyzed CE responses to a 2009 survey of Society of General Internal Medicine members from community, VA, and university-affiliated clinics regarding HIV testing practices. Clinician educators were asked about their outpatient practices, knowledge and attitudes regarding the revised CDC recommendations and whether they encouraged trainees to perform routine HIV testing. Associations between HIV testing knowledge and attitudes and encouraging trainees to perform routine HIV testing were estimated using bivariate and multivariable logistic regression. Of 515 respondents, 367 (71.3%) indicated they supervised trainees in an outpatient general internal medicine clinic. These CEs demonstrated suboptimal knowledge of CDC guidelines and over a third reported continued risk-based testing. Among CEs, 196 (53.4%) reported that they encourage trainees to perform routine HIV testing. Higher knowledge scores (aOR 5.10 (2.16, 12.0)) and more positive attitudes toward testing (aOR 8.83 (4.21, 18.5)) were independently associated with encouraging trainees to screen for HIV. Reasons for not encouraging trainees to screen included perceived low local prevalence (37.2%), competing teaching priorities (34.6%), and a busy clinic environment (34.0%). Clinician educators have a special role in the dissemination of the CDC recommendations as they impact the knowledge and attitudes of newly practicing physicians. Despite awareness of CDC recommendations, many CEs do not recommend universal HIV testing to trainees. Interventions that improve faculty knowledge of HIV testing recommendations and address barriers in resident clinics may enhance adoption of routine HIV testing.

Automated Clinical Reminders for Primary Care Providers in the Care of CKD: A Small Cluster-Randomized Controlled Trial

Primary care physicians (PCPs) care for most non-dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs). Cluster-randomized controlled trial. 30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist. 2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates <45 mL/min/1.73 m(2) recommending renal referral and urine albumin quantification if not done within the prior year. Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, <130/80 mm Hg), and use of renoprotective medications. The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, -6.8%; 95% CI, -15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, -2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up (P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups. Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set. PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.

Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians.

The number of hospital-based physicians, or hospitalists, in the United States has grown rapidly, yet no published data have characterized hospitalists or their practices. A self-administered questionnaire was used to describe 1) the features of hospitalists, 2) the hospitals in which they practice, and 3) the practice of inpatient medicine. The questionnaire contained 48 questions that covered four domains: demographic information about the respondent, the clinical and nonclinical workload and responsibilities of the respondent, organizational and financial aspects of the respondent's practice, and the respondent's satisfaction and his or her perception of the reaction of other physicians and nurses to the hospitalist system. The overall response rate was 57%. Data are reported on 372 surveys. Respondents were young and most were men, and only 48% had practiced hospital-based medicine for more than 2 years. Eighty-nine percent of respondents were internists; of these, 51% were generalists and 38% were subspecialists. Most hospitalists limited their practices to the inpatient setting, but 37% practiced outpatient general internal medicine or subspecialty medicine in a limited capacity. In addition to providing care for inpatients, 90% of hospitalists were engaged in cohsultative medicine. Quality assurance and practice guideline development were the most frequently reported nonclinical activities (53% and 46%; respectively). Small group practices (31%) and staff-model health maintenance organizations (25%) were the most common practice settings, and 78% of participants were reimbursed through salary. Financial incentives were common (43%) but modest. Accurate information about hospitalists and their practices will be important to clinicians, educators, researchers, and policymakers as the hospitalist movement continues to grow.

Doing Attributions in Medical Interaction: Patients' Explanations for Illness and Doctors' Responses

This paper presents an analysis of the process of offering and responding to attributions in social interaction. Analyses of audio and video recordings of patients' visits to an outpatient general internal medicine clinic reveal the ways in which patients offer their own explanations for their health problems, and how doctors respond to these explanations. In these explanation-response sequences, patients and doctors collaboratively enact an asymmetrical social organization wherein patients are authorities about their experiences but not about why their health problems occur. Patients exhibit caution when they offer explanations; they downplay their knowledge and they avoid setting themselves up for disaffiliative responses. Patients do not compel doctors to interrupt information gathering to assess their explanations. Doctors take these opportunities to focus on patients' symptoms. Patients' authority is thus restricted to the empirical realm rather than encompassing the analysis of empirical facts.