Primary Care Internal Medicine Practice Research Articles

Under Documentation of Anemia in Older Adults in Primary Care Practices

Introduction: Anemia is prevalent in adults over the age 65 years, and its occurrence increases with age. The common causes of anemia in this population include nutrient deficiencies, acute or chronic inflammation and unexplained anemia of aging. Anemia in older adults is associated with poorer quality of life, decreased function, falls, fractures, hospitalization, long-term care placement and higher mortality. It was our hypothesis that despite these well documented adverse consequences anemia is under recognized in the primary care setting. Methods: This retrospective study evaluated patients aged 65 and older who were followed at internal medicine primary care clinics throughout northern Virginia over a one-year period from January to December 2023. The study population was identified using a slicer dicer program from the electronic health record, filtering for patients aged 65 and older who had a Medicare annual wellness exam in 2023. For this analysis, the study population was limited to approximately 1,500 patients, and chart reviews were performed on these patients. The World Health Organization's (WHO) definition of anemia, which specifies hemoglobin levels below 12 g/dL in women and below 13 g/dL in men, was used as the study definition for anemia. Any hemoglobin levels from 2022 to 2024 that met this definition was identified to have anemia. The primary objective was to identify the percentage of anemia cases correctly recognized and documented as a problem on the patients' problem list. Results: Out of the 1525 randomly-selected from a broad network of primary care internal medicine practices, there were 643 males and 882 females, and the age group breakdown was 724 patients aged 65 to 74, 629 patients aged 75 to 84, and 172 patients aged 85 and older. From this study population, 310 patients were identified to have anemia. The breakdown of the anemia patients were 154 males and 156 females, and the age group was 113 patients aged 65 to 74, 127 patients aged 75 to 84, and 70 patients aged 85 and older. The prevalence of anemia was 24% for males and 18% for females. For the age groups, the prevalence was 16% for aged 65 to 74, 20% for aged 75 to 84, and 40% for aged 85 and older. Out of the 310 patients with anemia, only 103 patients had anemia listed on the problem list. This indicates that only 33% of anemic patients had anemia correctly documented, while 67% did not. There were no significant differences in the recognition of anemia between sex and age groups. Anemia was correctly noted as a problem in 48 males (31%) and 55 females (35%). Additionally, anemia was correctly identified in 35 patients (31%) aged 65 to 74, 43 patients (34%) aged 75 to 84, and 25 patients (36%) aged 85 and older. Conclusions: There is a significant under-recognition of anemia in the geriatric population at the primary care setting. The rates of under-recognition are comparable between sexes and across different age groups. However, anemia has been found to be more prevalent in females and with increased age. This unaddressed anemia likely contributes to a chronic decline in function and quality of life, particularly in the frailer and more vulnerable population. Increased awareness and appropriate management of anemia in primary care settings can help prevent its associated negative effects.

Nursing Students' and Nurse Preceptors' Perspectives of an Ambulatory Dedicated Education Unit in Primary Care and General Internal Medicine.

The sustainability of prelicensure nursing clinical learning models within ambulatory care is dependent on strong partnership and the availability of ambulatory nurse preceptors. Evaluation of preceptor and student satisfaction with ambulatory clinical experiences is necessary to identify program strengths and opportunities. Nursing students' and nurse preceptors' perceptions of an ambulatory dedicated education unit (DEU) in primary care and general internal medicine practices were measured from 2021 to 2023. Students' survey responses indicated a high level of agreement for 20 (90.9%) of 22 items in 2021, 35 (100%) of 35 items in 2022, and 32 (91.4%) of 35 items in 2023. Preceptor responses demonstrated favorable agreement with all of the work-life satisfaction across the 3 years of the survey, with the exception of one question on the 2021 survey. Nursing students and staff nurse preceptors found the ambulatory DEU teaching and learning experience to be positive and satisfying. [J Nurs Educ. 2024;63(3):171-177.].

Integrating long-acting reversible contraceptives into primary care internal medicine practices: A clinical innovation to reduce wait time.

Long-acting reversible contraception (LARC) has long been regarded as highly effective and safe. However, access is limited and lengthy when specialty referrals are required. To integrate LARC services into an urban internal medicine primary care practice to decrease wait time for LARC procedures. This pre-post with control group study took place at two large urban academic primary care practices (Practices A and B) and included patients ages 18 to 45 years assigned female sex at birth. Pre-implementation baseline data were collected retrospectively from 2019 to 2020 by identifying subjects who requested LARC insertion or removal via their primary care practice and were referred to Obstetrics and Gynecology (Ob/Gyn) for the procedure. Wait time was noted from time of initial request in the medical record to time of procedure. Practice A developed an integrated primary care LARC program in which one of their LARC-trained providers began offering these procedures within their own practice. All other providers within the practice were educated on how to counsel patients about the devices and procedures. Practice B did not have an in-house LARC provider and continued referring patients to Ob/Gyn. Post-implementation data were collected prospectively 2021-2022. Ninety-one patients in Practice A experienced a significant decrease in wait time (87 vs 21 days, p < 0.001) over the observation period, with a majority undergoing procedures on their first visit with the in-house LARC provider. Wait time for the 54 patients in Practice B remained unchanged (57 vs 47 days, p = .59), often requiring multiple specialty visits. Integrating LARC services into a primary care internal medicine practice can significantly reduce wait times for these procedures with the potential to contribute to increased reproductive and menstrual autonomy.

Disease Modifying Treatment of Osteoarthritis with Triple Combination Anti-Microbial Therapy

Background: The study author, while still a medical student, observed microscopic evidence of chronic inflammation in joint tissue of patients suffering with osteoarthritis and hypothesized that osteoarthritis was caused by an infectious process. After graduating from medical school and entering into private practice, the study author had several patients who informed him that when they were on tetracycline therapy, for reasons other than arthritis, their arthritis symptoms diminished to some extent. After reporting improvement of arthritic symptoms with tetracycline, one of these patients subsequently received metronidazole and while taking both tetracycline and metronidazole reported that his arthritic symptoms improved to an even greater extent, as his joint pain further diminished but did not resolve. Subsequent treatment of osteoarthritis in other patients included the combination of tetracycline, metronidazole, other antibiotics and some natural products but only when L-lysine was added to the tetracycline and metronidazole combination therapy did the author observe yet further improvement in arthritic pain. Since L-lysine was reported to inhibit the growth of herpes simplex virus, the author and another colleague concluded that acyclovir might be a beneficial addition to the tetracycline, metronidazole, L-lysine combination. This four-component combination treatment resulted in total resolution or a marked diminution of osteoarthritis joint pain, joint tenderness and joint stiffness in most patients treated. It was further determined that L-lysine could be eliminated; that acyclovir could be replaced with valicyclovir; and that tetracycline could be replaced with minocycline or doxycycline.&#x0D; Preliminary studies of patients diagnosed with osteoarthritis and treated with tetracycline alone or the combination of tetracycline and metronidazole demonstrated improvement in their osteoarthritic symptoms. However the triple combination of doxycycline (broad spectrum antibiotic), metronidazole (antiprotozoal and antibacterial imidazole) and acyclovir (antiviral purine nucleoside) administered orally twice daily for eight weeks showed marked success in a group of patients suffering with osteoarthritis by substantially eliminating their joint pain, joint tenderness and joint stiffness while overcoming their fatigue and increasing their energy level. The data in this report substantiate that this triple combination is a disease modifying therapy that eliminates or markedly diminishes the symptomatology of osteoarthritis and further supports the hypothesis that osteoarthritis is an infectious disease. Objective: To evaluate the effect of the triple combination therapy of doxycycline, metronidazole, and acyclovir on the joint pain, joint stiffness and functionality in patients suffering with osteoarthritis. Design: Non-blinded study of treatment of patients suffering with osteoarthritis Setting: Primary care internal medicine practice in Alameda County, California. Sample: Six adult individuals suffering with osteoarthritis. Patients: Six patients, ages 53 through 82 years. Patient 1 was treated for 28 days and Patients 2 through 6 were treated for 56 days. Method: After obtaining informed consent, six patients suffering with osteoarthritis were prescribed a 56 day course of treatment with the triple combination of doxycycline, metronidazole, and acyclovir for treatment of their osteoarthritis. Utilizing the WOMAC index for assessment of the effectiveness of treatment of osteoarthritis, pre-treatment pain, stiffness and functional limitation, were compared to post-treatment pain, stiffness and functional limitations. Results: Three patients demonstrated total resolution of pain and stiffness and greater than 95% improvement in functional limitations. One of the remaining three patients demonstrated a 70% improvement in pain, total resolution of stiffness, and an 85% improvement in functional limitations; another one of the three remaining patients demonstrated an 86% improvement in pain, total resolution of stiffness, and a 79% improvement in functional limitations; while the last of the three remaining patients demonstrated at least an 85% improvement in pain, 67% improvement in stiffness, and a 63% improvement in functional limitations.&#x0D; Limitations: No randomization. No placebo. No control group. Small sample size. Conclusion: The results of treatment of these patients suffering the osteoarthritis support the hypothesis that osteoarthritis is an infectious disease. These results further suggest that osteoarthritis is, at a minimum, modifiable with the triple combination therapy of doxycycline, metronidazole, and acyclovir and is even curative of with this breakthrough treatment in many cases. The medical treatment reported in this article represents the first truly Disease Modifying medication therapy developed for osteoarthritis. &#x0D; Keywords: WOMAC index

High-Dose vs Standard-Dose Amoxicillin Plus Clavulanate for Adults With Acute Sinusitis

Acute bacterial sinusitis is common, but currently recommended antibiotic treatment provides minimal benefit. To confirm the previous finding that high-dose amoxicillin plus clavulanate (with double the amount of amoxicillin) may be superior to standard-dose amoxicillin plus clavulanate in adults. This double-blind, comparative-effectiveness randomized clinical trial was conducted from February 26, 2018, through May 10, 2020, at the academic primary care internal medicine and pediatrics practice of Albany Medical Center, located in Cohoes, New York. Participants included adults aged 18 years or older who were prescribed amoxicillin plus clavulanate for acute bacterial sinusitis diagnosed in accordance with the Infectious Diseases Society of America guidelines. Amoxicillin 875 mg with clavulanate 125 mg plus either placebo (standard dose) or amoxicillin 875 mg (high dose) twice a day for 7 days. The primary efficacy outcome was a global rating of "a lot better" or "no symptoms" at the end of 3 days of treatment using a Global Rating of Improvement scale, with outcomes ranging from 1 (a lot worse) to 6 (no symptoms). The primary adverse effect outcome was severe diarrhea at 3 or 10 days after the start of treatment. At an unplanned interim analysis prompted by COVID-19 restrictions, 157 of a projected 240 participants had been enrolled (mean age, 48.5 [range, 18.7-84.0] years; 117 women [74.5%]), with 79 randomized to the standard dose and 78 to the high dose; 9 and 12, respectively, withdrew or were lost to follow-up before the assessment of the primary outcome. At day 3, 31 of 70 participants (44.3%) in the standard-dose group reported a global rating of "a lot better" or "no symptoms," as did 24 of 66 (36.4%) in the high-dose group, for a difference of -7.9% (95% CI, -24.4% to 8.5%; P = .35). The study was, therefore, stopped for futility. Diarrhea was common in both groups by day 3, with any diarrhea reported in 29 of 71 participants (40.8%) receiving the standard dose and 28 of 65 (43.1%) receiving the high dose and severe diarrhea reported in 5 of 71 (7.0%) and 5 of 65 (7.7%), respectively. The results of this randomized clinical trial suggest that adults treated for clinically diagnosed acute sinusitis did not appear to benefit from taking high-dose compared with standard-dose amoxicillin plus clavulanate. ClinicalTrials.gov Identifier: NCT03431337.

TCU and UNTHSC School of Medicine.

TCU and UNTHSC School of Medicine.

Multiyear Outcomes of a Population-Oriented Care Redesign in an Internal Medicine Residency Continuity Clinic.

The cornerstone of ambulatory care training for internal medicine residents is the continuity clinic, which often serves medically and psychosocially complex patients. We conducted and evaluated a population-oriented redesign to improve care for "high-needs" patients and the resident experience at a hospital-based safety net primary care internal medicine practice in the Southeastern U.S. A Define, Measure, Analyze, Implement, Control (DMAIC) framework was adapted to identify and develop three main interventions to address major unmet needs of patients and trainees: (1) a behavioral health-focused team care model; (2) a formalized hospital discharge transitions workflow; and (3) the creation of larger "firms" of smaller resident practice partnerships. We constructed a financial model to justify investments, with metrics to track progress. Over three years, sustained reductions in hospitalizations and ED visits (mean annual changes of -11.6% and -16.9%, respectively) were achieved. Resident primary care provider (PCP)-to-patient continuity and satisfaction also improved.

Patient-Reported Use of the After Visit Summary in a Primary Care Internal Medicine Practice.

Participants completed a cross-sectional survey about their use of the after visit summary (AVS) at a previous primary care visit. Of 355 participants, 294 (82.8%) recalled receiving it, 67.4% consulted it, 45.9% consulted it more than once, and 31.6% shared the AVS. In multivariable analysis, higher education and older age were associated with AVS consultation. Among the subset of 133 patients recalling personalized free-text instructions, 96% found them easy to understand and 94.4% found them useful. Our findings suggest that the AVS is a useful communication tool and improvement efforts should emphasize clarity for those most vulnerable to communication errors.

Population health challenges in primary care: What are the unfinished tasks and who should do them?

Background:There are numerous recommendations from expert sources that help guide primary care providers in cancer screening, infectious disease screening, metabolic screening, monitoring of drug levels, and chronic disease management. Little is known about the potential effort needed for a healthcare system to address these recommendations, or the patient effort needed to complete the recommendations.Methods:For 73 recommended population healthcare items, we examined each of 28,742 patients in a primary care internal medicine practice to determine whether they were up-to-date on recommended screening, immunizations, counseling, and chronic disease management goals. We used a rule-based software tool that queries the medical record for diagnoses, dates, laboratory values, pathology reports, and other information used in creating the individualized recommendations. We counted the number of uncompleted recommendations by age groups and examined the healthcare staff needed to address the recommendations and the potential patient effort needed to complete the recommendations.Results:For the 28,742 patients, there were 127,273 uncompleted recommendations identified for population health management (mean recommendations per patient 4.36, standard deviation of 2.65, range of 0–17 recommendations per patient). The age group with the most incomplete recommendations was age of 50–65 years with 5.5 recommendations per patient. The 18–35 years age group had the fewest incomplete recommendations with 2.6 per patient. Across all age groups, initiation of these recommendations required high-level input (physician, nurse practitioner, or physician’s assistant) in 28%. To completely adhere to recommended services, a 1000-patient cross-section cohort would require a total of 464 procedures and 1956 lab tests.Conclusion:Providers and patients face a daunting number of tasks necessary to meet guideline-generated recommendations. We will need new approaches to address the burgeoning numbers of uncompleted recommendations.

Attitudes Toward Naloxone Prescribing in Clinical Settings: A Qualitative Study of Patients Prescribed High Dose Opioids for Chronic Non-Cancer Pain.

Over the last 2 decades, medical providers have increasingly prescribed pharmaceutical opioids for chronic non-cancer pain, while opioid overdose death rates have quadrupled. Naloxone, an opioid antagonist, can be prescribed to patients with chronic pain to reverse an opioid overdose, yet little is known about how patients perceive this emerging practice. This study assessed the knowledge and attitudes toward naloxone prescribing among non-cancer patients prescribed opioids in primary care. Qualitative study design using semi-structured interviews. Adults (N = 24) prescribed high-dose (≥100 morphine mg equivalent daily dose) chronic opioid therapy in eight primary care internal medicine, family medicine and HIV practices in three large Colorado health systems. Inductive and deductive methods were used to analyze interview transcripts. Themes emerged related to knowledge of and benefits, barriers and facilitators to naloxone in primary care. Patients reported receiving limited education about opioid medication risks from providers and limited knowledge of naloxone. When provided with a description of naloxone, patients recognized its ability to reverse overdoses. In addition to pragmatic barriers, such as medication cost, barriers to naloxone acceptance included the perception that overdose risk stems from medication misuse and that providers might infer that they were misusing their opioid medication if they accepted a naloxone prescription, prompting an opioid taper. Facilitators to the acceptance of naloxone included medical providers' using empowering, non-judgmental communication practices, framing naloxone for use in "worst case scenarios" and providing education and training about opioids and naloxone. While patients recognized the utility of naloxone prescribing, we identified important barriers to patient acceptance of naloxone prescribing. To improve the naloxone prescribing acceptability in primary care practice, medical providers and health systems may need to enhance patient education, employ empowering, non-judgmental communication styles and adequately frame discussions about naloxone to address patients' fears.

The relationship between Elder Risk Assessment (ERA) scores and cardiac revascularization: a cohort study in Olmsted County, Minnesota, USA

PurposeThe aging population is predisposed to cardiovascular disease. Our goal was to determine the relationship between a higher Elder Risk Assessment (ERA) score and coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), in adults over 60 years.MethodsThis was a retrospective cohort study in a primary care internal medicine practice. Patients included community-dwelling individuals aged 60 years or older on January 1, 2005. The primary outcome was a combined outcome of CABG and PCI in 2 years. The secondary outcome was mortality 5 years after CABG or PCI. The primary predictor variable was the score on the ERA Index, an instrument that predicts emergency room visits and hospitalization. The outcomes were obtained using administrative data from electronic medical records. The analysis included logistic regression, with odds ratios for the primary outcome and time-to-event analysis for mortality.ResultsThe records of 12,650 patients were studied. A total of 902 patients (7.1%) had either CABG or PCI, with an average age of 74.5 years (±8.3 years). There were 205 patients (23%) who experienced CABG or PCI in the highest-score group (top 10%) compared with 29 patients (3%) in the lowest score group, for an odds ratio of 15.4; 95% confidence interval, 10.1–23.5. There was a greater association of revascularization events by increasing score group. We noted increased mortality by increasing ERA score, in patients undergoing CABG or PCI. The patients in the highest-scoring group had a 50% 5-year survival rate compared with a 97% 5-year survival rate in the lowest-scoring group (P < 0.001).ConclusionOlder adults in the highest-ERA-scoring group had the highest utilization of CABG or PCI. Patients with high ERA scores undergoing coronary revascularization were also at the highest risk of mortality. Providers should be aware that higher ERA scores can potentially predict outcomes in high-risk patients.

The Relationship Between Elder Risk Assessment Index Score and 30-Day Readmission From the Nursing Home

Objective: Preventable early readmission to the hospital is expensive, and identification of patients at risk is an important task for health care providers. The objective of this study was to determine the relationship between a high score on the Elder Risk Assessment (ERA) Index and 30-day readmission to the hospital in older patients discharged to a nursing home. Patients: Patients aged > 60 years residing in the community on January 1, 2005 and subsequently admitted to a local nursing home following hospitalization were included. The cohort was selected from all patients in a primary care internal medicine practice in Rochester, MN. Methods: This was a retrospective cohort study that used an electronically archived administrative risk index, the ERA Index, which was derived from demographic and clinical factors. The primary outcome was hospital readmission within 30 days following initial admission to a nursing home. The predictor variable was the ERA Index score. Univariate association between the total ERA Index score and individual components of the ERA Index and 30-day rehospitalization were determined. The ERA Index score cutoff with optimal sensitivity and specificity for hospital readmission was also identified. Results: Of 12 650 patients in the population, 800 were admitted to a facility between 2005 and 2007. Thirty-day readmission was not higher in the group with the highest ERA Index score (top quartile), with a relative risk of 1.72 (95% confidence interval [CI], 0.93–3.56) compared with the lowest-scoring group. The second- and third-highest quartiles were significantly associated with higher 30-day readmission. The individual component of the ERA Index that had the strongest association with early readmission was dementia, with an odds ratio of 2.69 (95% CI, 1.71–4.23). A cutoff score of 5 on the ERA Index resulted in a sensitivity of 0.81 and a specificity of 0.34 with an area under the curve of 0.55. Discussion: Those with the highest ERA Index score, the top quartile, were not at risk for early hospital readmission. The ERA Index does not predict readmissions from the nursing home to the hospital. There is a need to develop a unique index to predict rehospitalizations in nursing home residents.

Impact of a Multifaceted Intervention on Cholesterol Management in Primary Care Practices

Physician adherence to National Cholesterol Education Program clinical practice guidelines has been poor. We recruited 68 primary care family and internal medicine practices; 66 were randomly allocated to a study arm; 5 practices withdrew, resulting in 29 receiving the Third Adult Treatment Panel (ATP III) intervention and 32 receiving an alternative intervention focused on the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7). The ATP III providers received a personal digital assistant providing the Framingham risk scores and ATP III-recommended treatment. All practices received copies of each clinical practice guideline, an introductory lecture, 1 performance feedback report, and 4 visits for intervention-specific academic detailing. Data were abstracted at 61 practices from random samples of medical records of patients treated from June 1, 2001, through May 31, 2003 (baseline), and from May 1, 2004, through April 30, 2006 (follow-up). The proportion screened with subsequent appropriate decision making (primary outcome) was calculated. Generalized estimating equations were used to compare results by arm, accounting for clustering of patients within practices. We examined 5057 baseline and 3821 follow-up medical records. The screening rate for lipid levels increased from 43.6% to 49.0% (ATP III practices) and from 40.1% to 50.8% (control practices) (net difference, -5.3% [P = .22]). Appropriate management of lipid levels decreased slightly (73.4% to 72.3%) in ATP III practices and more markedly (79.7% to 68.9%) in control practices. The net change in appropriate management favored the intervention (+9.7%; 95% confidence interval [CI], 2.8%-16.6% [P < .01]). Appropriate drug prescription within 4 months decreased in both arms (38.8% to 24.8% in ATP III practices and 45.3% to 24.1% in control practices; net change, +7.2% [P = .37]) Overtreatment declined from 6.6% to 3.9% in ATP III and rose from 4.2% to 6.4% in control practices (net change, -4.9% [P = .01]). A multifactor intervention including personal digital assistant-based decision support may improve primary care physician adherence to the ATP III guidelines. Trial Registration clinicaltrials.gov Identifier: NCT00224848.

Self-efficacy, depressive symptoms, and patients' expectations predict outcomes in asthma.

Certain psychosocial variables are relatively unexplored as possible predictors of asthma outcomes. To determine if asthma self-efficacy, depressive symptoms, and unrealistic expectations predict urgent care use and change in health-related quality of life measured by the Asthma Quality of Life Questionnaire and the SF-36 during 2 years. Prospective cohort study in a primary care internal medicine practice at a tertiary care center in New York City. Adults with moderate asthma who were fluent in either English or Spanish. At enrollment patients were interviewed in-person and completed a series of questionnaires including the Asthma Quality of Life Questionnaire (AQLQ), the SF-36, the Asthma Self-efficacy Scale, the Geriatric Depression Scale, and open-ended questions regarding their expectations of treatment. Patients also completed the AQLQ and SF-36 at various time intervals throughout the study and were interviewed by telephone every 3 months to record recent hospitalizations, emergency department visits and nonroutine office visits for asthma. A total of 224 patients were followed for a mean of 23.8 months. In hierarchical analysis, independent predictors of lower AQLQ scores were less self-efficacy, more depressive symptoms, expecting to be cured of asthma, requiring methylxanthines, being Hispanic or black, and having difficult or very difficult access to asthma care (all at P <0.05). Similar predictors were found for lower SF-36 scores. Another outcome, use of urgent care, was required by 60% of patients during the study period. Predictors of using urgent care were having more depressive symptoms, expecting a cure, being female, requiring oral beta-agonists, and having a history of prior hospitalizations for asthma (all at P <0.05). Less asthma self-efficacy, more depressive symptoms, and unrealistic expectations predict worse asthma outcomes. These relatively unexplored patient-centered variables in asthma are potentially modifiable and may offer new ways to intervene to improve asthma outcomes.

Contrast colon X-ray in the screening for colon polyps and cancer in a primary care internal medicine practice

Contrast colon X-ray in the screening for colon polyps and cancer in a primary care internal medicine practice

Orientation To Social Medicine and The Bronx: An Educational Experience For Adult Learners

Background: Little attention has been paid to the orientation process used to assist residents in their transition from student to physician. Description: The Residency Program in Social Medicine of the Montefiore Medical Center/Albert Einstein College of Medicine developed an innovative orientation for 1st-year residents in primary care internal medicine, pediatrics, and family practice, built on the principles of adult education. Evaluation: Formative evaluation questionnaires from four orientation cohorts, 1990-93, were analyzed (total residents = 77, respondents = 66, response rate = 86%), including both quantitative (Likert scale) and qualitative assessments of its goals and learning activities. Over the 4 years analyzed, 95%of the residents' median evaluation met or exceeded their expectations. More than 60%of the residents' median evaluations of all learning activities were rated very good to excellent. Qualitative evaluations highlighted both the special virtues and drawbacks of such an adult learning experience. Conclusions: This orientation conforms to the principles of adult education and has consistently achieved its goals in orienting residents to the history, organization, and culture of their clinical institutions and community.

Using computer-based medical records to predict mortality risk for inner-city patients with reactive airways disease.

Objective: To use routine data from a comprehensive electronic medical record system to predict death among patients with reactive airways disease. Design: Retrospective cohort study conducted in an academic primary care internal medicine practice. Subjects were 1,536 adults with reactive airways disease: 542 with asthma and 994 with chronic obstructive pulmonary disease (COPD). Measurements: The dependent variable was death from any cause within 3 years following patients' first primary care appointment in 1992. Multivariable logistic regression was used to identify independent predictors of 3-year mortality, with half of the patients used to derive the predictive model and the other half used to assess its predictability. Results: Of the 1,536 study patients, 191 (12%) died in the 3-year follow-up period. From information available on or before patients' first primary care visit in 1992, multivariable predictors of 3-year mortality were coincidental heart failure, male sex, presence of COPD, lower weight, low serum albumin concentration level, and a prior arterial PO2 of less than 60 mmHg; use of an inhaled corticosteroid was protective. The c-statistic (ROC curve area) in the validation cohort was 0.76, indicating good discrimination, and goodness of fit was excellent by Hosmer-Lemeshow chi-square (P > 0.5). Only 24% of the patients in the validation cohort were designated at high risk (estimated ≥15% 3-year mortality), but this group contained more than half of the deaths within 3 years for the entire cohort. Conclusions: Data generated during routine care and stored in a comprehensive electronic medical record can accurately predict mortality among patients with reactive airways disease. Such technology can be used by practices to control for severity of illness when assessing clinical practice and to identify high-risk patients for interventions to improve prognosis.

Clinical Characteristics of Women With a History of Childhood Abuse

To determine the prevalence of childhood physical or sexual abuse in women seen in primary care practices; to identify physical and psychologic problems associated with that abuse; and to compare the effects of childhood physical vs sexual abuse and childhood vs adult abuse. Cross-sectional, self-administered, anonymous survey. Four community-based, primary care internal medicine practices. A total of 1931 women of varied age and marital, educational, and economic status examined from February through July 1993. Prevalence of physical and sexual abuse, physical symptoms, psychological symptoms (Symptom Checklist-22), alcohol abuse (CAGE questions), and street drug use. Of the 1931 respondents, 424 (22.0%) reported childhood or adolescent physical or sexual abuse. Compared with women who reported never having experienced abuse (n=1257), women who reported abuse as children but not adults (n=204) had more physical symptoms (mean+/-SE, 6.2+/-0.2 vs 4.0+/-0.9; P<.001) and had higher scores for depression, anxiety, somatization, and interpersonal sensitivity (low self-esteem) (P<.001); were more likely to be abusing drugs (prevalence ratio [PR], 4.7; 95% confidence interval [CI], 2.9-7.6) or to have a history of alcohol abuse (PR, 2.2; 95% CI, 1.5-3.2); were more likely to have attempted suicide (PR, 3.7; 95% CI, 2.6-5.1); and were more likely to have had a psychiatric admission (PR, 3.2; 95% CI, 2.2-4.7). Women abused only as children did not differ from women who reported current, but not childhood, abuse in number of physical symptoms, emotional distress, substance abuse, or suicide attempts. Patients who reported both childhood and adult abuse had higher levels of psychological problems and physical symptoms than those who reported childhood or adult abuse alone. Childhood physical or sexual abuse is associated with adult health problems including physical symptoms, psychological problems, and substance abuse; for many variables, this association is as strong as for patients experiencing current abuse.

Childhood Abuse... Adult Health Problems

Over a million children are physically or sexually abused in the United States each year. These investigators surveyed female patients in four primary care internal medicine practices in Maryland to see how these children fare in adulthood. Of 2,392 eligible women asked to participate, 398 …

The Shifting Sands of Graduate Medical Education

Each year the American Medical Association (AMA) surveys all programs in graduate medical education (GME) accredited by the Accreditation Council for Graduate Medical Education. Because of the importance of GME in the national workforce policy debate, this year's survey report has been expanded to provide more detailed GME data. The authors describe the historical basis of the current GME workforce dilemma and the multiple forces that now tend to neutralize efforts to adapt to a changing marketplace. For example, as resident physicians find it increasingly difficult to locate suitable employment, one would expect a reduction in hospital-based programs and in the number of their resident physician appointments. Yet, while US medical graduates (USMGs) did not pursue certain programs in this year's National Resident Matching Program, AMA data show that during the past 2 years the reduced number of residents in hospital-based programs was almost exactly offset by the increased number in new and expanded programs. Also, more USMGs are leaving residency training to enter practice after 3 years of basic training in primary care (internal medicine, pediatrics, and family practice). At the same time, an increasing number of international medical graduates are remaining in subspecialty programs. Other examples are cited to show the ebb and flow of GME activities that behave like "shifting sands."