Internal Medicine Subspecialties Research Articles

Frailty integration in medical specialties: Current evidence and suggested strategies from the Clin-STAR frailty interest group.

Frailty is a syndrome that can inform clinical treatments and interventions for older adults. Although implementation of frailty across medical subspecialties has the potential to improve care for the aging population, its uptake has been heterogenous. While frailty assessment is highly integrated into certain medical subspecialties, other subspecialties have only recently begun to consider frailty in the context of patient care. In order to advance the field of frailty-informed care, we aim to detail what is known about frailty within the subspecialties of internal medicine. In doing so, we highlight cross-disciplinary approaches that can enhance our understanding of frailty, focusing on ways to improve the implementation of frailty measures, as well as develop potential interventional strategies to mitigate frailty within these subspecialties. This has important implications for the clinical care of the aging population and can help guide future research.

Sticky Floor, Broken Ladder, and Glass Ceiling in Internal Medicine Academic Ranking, Leadership, and Research Productivity.

Despite more women entering medicine, substantial gender disparities remain in various medical disciplines. This study explores the extent of these disparities in Canadian academic internal medicine, particularly in academic ranks, leadership positions, and research productivity. Cross-sectional. Faculty physicians within internal medicine and subspecialties. Data on faculty physicians with Medical Doctorate (MD), Doctor of Osteopathic Medicine (DO), or Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees were compiled from 17 internal medicine programs listed in the Canadian Resident Matching Service (CaRMS). Research metrics were obtained using Elsevier's Scopus, and analyses were performed with Stata v14.2. Among 5099 physician faculty members in internal medicine, 34% were women, and 66% were men. Among the faculty members holding leadership positions, 68% were men, and 32% were women. There was a significant difference in h-index between men and women physician faculty members (p ≤ 0.001), with men having a higher research output. Across all academic ranks, men faculty had higher median h-index values: Assistant Professor (12 vs. 9), Associate Professor (20 vs. 16), and Professor (40 vs. 30). Women were underrepresented in the procedural specialties, while only a few internal medicine subspecialties, such as palliative medicine and geriatrics, had a women predominance. Our study underscores existing gender disparity within academic internal medicine in Canada, aligning with global trends. Women remain disproportionately underrepresented in academic ranks, leadership positions, and research productivity. Addressing these disparities necessitates a systemic and multifaceted approach, encompassing policy reforms, mentorship, and fostering an inclusive work environment.

Learning from our patients: An exploratory study to inform the development of a case tracking dashboard for internal medicine subspecialty fellows

Background Case tracking (following-up prior patient encounters) can help inform future clinical decisions and supplement experiential learning. Internal medicine subspecialty fellows see a high volume of patients and need to become subject matter experts within a short time frame, yet little is known about their specific needs and motivations around case tracking. Objective The objective of this study was to explore internal medicine subspecialty fellows’ motivations, preferences, and practices around case tracking. Methods We conducted interviews with internal medicine subspecialty fellows at a single academic medical center during the 2022–2023 academic year. Interviews were analyzed using qualitative content analysis. Results 22 fellows were interviewed for our study. We found that most fellows engaged in case tracking with lists in the electronic health record (EHR). Fellows primarily tracked cases of clinical uncertainty and patients with specific diseases or conditions of interest. Fellows sought information on patients’ health outcomes, results, and clinical notes. Motivations for tracking were predominantly related to curiosity, professional growth, and development of practice patterns. Barriers to case tracking included time, challenges maintaining patient lists, losing track of patients, and lack of motivation to develop and maintain an organized system. Conclusions Internal medicine subspecialty fellows engaged in and valued case tracking as a way to supplement their experiential learning. Our study highlighted their current practices, motivations, preferences, and challenges related to case tracking. We plan to use these findings to help develop an EHR-embedded dashboard to facilitate case tracking among subspecialty fellows.

Patched but Still Leaky: An Update on the Pipeline for Women in Gastroenterology.

Women remain underrepresented in gastroenterology (GI). Studies have identified that a lack of formal mentorship for women contributes to this underrepresentation. While many GI divisions have adopted models for supporting GI fellows and faculty, there is a gap in our knowledge regarding mentorship options for internal medicine (IM) residents interested in GI. To evaluate representation of women at each level of their career (resident, fellow, and attending) and examine trends in representation of women in GI compared to other IM subspecialties. We analyzed AAMC Physician Specialty Data Reports to compare gender representation and growth of women representation across all IM subspecialties and residencies from 2007 to 2021. In 2021, 44.3% of IM residents, 37.8% of GI fellows, and 19.7% of actively practicing attending gastroenterologists were women. Since 2007, GI comprised significantly lower proportions of women attendings except for cardiology, and lower representation in fellows, except for cardiology and nephrology, than other IM subspecialties (p < 0.001). There was a consistently higher proportion of women GI fellows than attendings over the past 14years (p < 0.01). GI has among the lowest representation of women at each career level compared to other IM subspecialties. Given the previously reported preference of gender congruent mentoring, the underrepresentation of senior academic gastroenterologists who are women may be a contributing factor to lower proportions of women trainees choosing to pursue GI.

Current Communication Practices Between Internal Medicine Subspecialty Fellowship Applicants and Program Directors: A National Survey

PurposeAs fellowship applications increasingly transition to virtual interviews, the role of social media in this process remains uncertain. This study explores internal medicine subspecialty program directors' (PDs) perspectives on current communication practices, including the use of social media and email, between applicants and programs. MethodA national survey was conducted among U.S. internal medicine subspecialty fellowship PDs from November to December 2023. The survey collected demographic information about PDs, program-level information, and their views on using social media platforms (Twitter/X and Instagram) and email for program promotion and application review. ResultsOut of 297 PDs who responded (18.5% response rate), 52% were male, 69% identified as White/Caucasian, majority from age group 46-50 years. The subspecialties with the highest representation were infectious disease (15%), pulmonology and critical care (14%), and cardiology (12%). Among respondents, 41% used Twitter/X and 24% used Instagram for program promotion. A smaller fraction reviewed applicants through these platforms for interview invitations (14% via Twitter/X and 7% via Instagram). PDs reported receiving an average of 35 letters of intent emails and calling 36% of applicants for interviews. ConclusionsThis study is the first to assess the value PDs place on social media and email in the fellowship application review process across various internal medicine subspecialties. While social media is a valuable tool for program promotion and engagement, traditional email outreach remains crucial in the interview selection process.

Mentoring as a complex adaptive system – a systematic scoping review of prevailing mentoring theories in medical education

BackgroundEffective mentorship is an important component of medical education with benefits to all stakeholders. In recent years, conceptualization of mentorship has gone beyond the traditional dyadic experienced mentor-novice mentee relationship to include group and peer mentoring. Existing theories of mentorship do not recognize mentoring’s personalized, evolving, goal-driven, and context-specific nature. Evidencing the limitations of traditional cause-and-effect concepts, the purpose of this review was to systematically search the literature to determine if mentoring can be viewed as a complex adaptive system (CAS).MethodsA systematic scoping review using Krishna’s Systematic Evidence-Based Approach was employed to study medical student and resident accounts of mentoring and CAS in general internal medicine and related subspecialties in articles published between 1 January 2000 and 31 December 2023 in PubMed, Embase, PsycINFO, ERIC, Google Scholar, and Scopus databases. The included articles underwent thematic and content analysis, with the themes identified and combined to create domains, which framed the discussion.ResultsOf 5,704 abstracts reviewed, 134 full-text articles were evaluated, and 216 articles were included. The domains described how mentoring relationships and mentoring approaches embody characteristics of CAS and that mentorship often behaves as a community of practice (CoP). Mentoring’s CAS-like features are displayed through CoPs, with distinct boundaries, a spiral mentoring trajectory, and longitudinal mentoring support and assessment processes.ConclusionRecognizing mentorship as a CAS demands the rethinking of the design, support, assessment, and oversight of mentorship and the role of mentors. Further study is required to better assess the mentoring process and to provide optimal training and support to mentors.

Studying Provider’s Satisfaction on Video Consultation by Ain Shams University Virtual Hospital

Abstract Background Video consultations were developed to allow long-distance patient and clinician contact, care, advice and monitoring which has been shown to improve patient health status. When rural settings, lack of transport, a lack of mobility, decreased funding, or a lack of staff restrict access to care, video consultation may bridge the gap. Objective To measure satisfaction of physicians involved in video consultations services provided at Ain Shams Virtual Hospitals (AVH). To identify the main factors affecting satisfaction of physicians involved in such video consultations services provided at AVH. Methods A descriptive cross-sectional study was conducted to measure satisfaction of a sample of providers of video consultations at AVH from December 2020 to March 2021. Results Total 37 physicians were included in the study, 29 physicians responded (78.3%). The mean age ±SD is 37.97 ±6.3 and their main specialties were neuropsychiatry (40.7%), internal medicine subspecialties (40.7%), and surgical specialties (18.5%). About 83% were confident with their diagnoses in video consultations and (13.8%, 75.9%) of the physicians reported that they always/sometimes suffered from bad quality of image/sound respectively. More than half of the physicians (53.5%) thought that lack of physical examination would affect the accuracy of the diagnoses and 53.5% of the physicians thought that video consultation would be suitable for follow-up patients post operatively. Conclusion Two thirds of the physicians had a positive experience and were satisfied with using video consultations in their clinical practices. Recommendations It is recommended to use video consultations in following-up of patients. It is also recommended to monitor provider`s satisfaction over time.

A Qualitative Study of Internal Medicine Subspecialty Fellowship Program Directors' Perspectives on Short-Term Hospitalist Employment Prior to Fellowship.

Background Some internal medicine (IM) residents pursuing subspecialty training choose short-term hospitalist employment prior to fellowship, or "pre-fellowship hospitalist years." Residency and fellowship program directors (PDs) advise residents on this decision, but PD experience with fellows pursuing pre-fellowship hospitalist years and the impact on fellowship applications is unknown. Objective We aimed to explore perceptions of fellowship PDs regarding experience with fellows who pursued pre-fellowship hospitalist years, including perceived effects on how such years affect fellowship application candidacy. Methods A purposive sample of 20 fellowship PDs in the most highly competitive and commonly selected IM fellowships (cardiology, pulmonology/critical care medicine, hematology/oncology, gastroenterology) from 5 academic institutions were approached for participation in fall 2021. Interviews included semi-structured questions about pre-fellowship hospitalist employment. Utilizing rapid qualitative analysis, interview transcripts were summarized and reviewed to identify themes and subthemes describing fellowship PDs' perspectives of pre-fellowship hospitalist years. Results Sixteen fellowship PDs (80%) participated. PDs identified 4 major themes as important for trainees considering pre-fellowship hospitalist years: (1) Explain the "Why"-why the year was pursued; (2) Characteristics of the Hospitalist Position-what type of employment; (3) The Challenges-potential concerns faced with pre-fellowship hospitalist years; and (4) Describe the "What"-the experience's contribution to resident professional development. Conclusions Fellowship PDs in 4 competitive IM subspecialities placed a strong emphasis on explaining a clear, logical reason for seeking short-term hospitalist employment prior to fellowship, describing how it fits into the overall career trajectory, and selecting activities that demonstrate continued commitment to the subspecialty.

Fellowship-trained physicians who let their geriatric medicine certification lapse: A national survey.

Only 62.6% of fellowship-trained and American Board of Internal Medicine (ABIM)-certified geriatricians maintain their specialty certification in geriatric medicine, the lowest rate among all internal medicine subspecialties and the only subspecialty in which physicians maintain their internal medicine certification at higher rates than their specialty certification. This study aims to better understand underlying issues related to the low rate of maintaining geriatric medicine certification in order to inform geriatric workforce development strategies. Eighteen-item online survey of internists who completed a geriatric medicine fellowship, earned initial ABIM certification in geriatric medicine between 1999 and 2009, and maintained certification in internal medicine (and/or another specialty but not geriatric medicine). Survey domains: demographics, issues related to maintaining geriatric medicine certification, professional identity, and current professional duties. 153/723 eligible completed surveys (21.5% response). Top reasons for not maintaining geriatric medicine certification were time (56%), cost of maintenance of certification (MOC) (45%), low Medicare reimbursement for geriatricians' work (32%), and no employer requirement to maintain geriatric medicine certification (31%). Though not maintaining geriatric medicine certification, 68% reported engaging in professional activities related to geriatric medicine. Reflecting on career decisions, 56% would again complete geriatric medicine fellowship, 21% would not, and 23% were unsure. 54% considered recertifying in geriatric medicine. 49% reported flexible MOC assessment options would increase likelihood of maintaining certification. The value proposition of geriatric medicine certification needs strengthening. Geriatric medicine leaders must develop strategies and tactics to reduce attrition of geriatricians by enhancing the value of geriatric medicine expertise to key stakeholders.

Medical student motivation in specialised contexts.

During their clinical years, medical students rotate in diverse environments, each with unique factors motivating or demotivating learning. Student motivation to learn in specialised clinical settings has not been robustly described. One framework to understand motivation to learn is self-determination theory (SDT), which posits that intrinsic motivation requires fulfilment of three innate psychological needs: competence, relatedness and autonomy. Referencing SDT, the authors aimed to understand factors influencing student motivation to learn in the specialised context of internal medicine (IM) subspecialty consult services, with the goal of optimising teaching and learning during these experiences. Focus groups were conducted with 12 fourth-year medical students who had completed at least one inpatient IM subspecialty consult elective at the University of California, San Francisco, in 2020-2021. Students discussed factors that promoted and hindered their learning and motivation. The authors performed abductive thematic analysis using SDT as a sensitising framework. Three themes were identified and provided insight into how student motivation to learn can be supported: teaching at the appropriate level; integration into the team and workflow; and self-directed learning and career exploration. These themes were overlaid onto the needs of SDT, demonstrating that, in specialised clinical contexts, fulfilment of the needs is interconnected. This study provided insight into how students' innate needs can be satisfied in the learning environment of IM subspecialty consult electives, thereby promoting students' intrinsic motivation. Based on insights from the study, the authors offer recommendations for how educators can optimise student motivation to learn.

An analysis of medical malpractice claims against medical oncologists from a national database: Implications for safer practice.

Malpractice claims data include valuable information about patient safety. We used mixed methods to analyze claims against medical oncologists (MO) from 2008 to 2019 using a national database. MO claims were compared to a group of other internal medicine subspecialties (OIMS). Logistic regression was used to examine correlates of closing with an indemnity payment. A subset of claims against MO were thematically analyzed using a validated safety incident taxonomy as a framework. 456 claims against MO were compared with 5771 claims against OIMS. MO claims closed with indemnity payments 29.8% of the time versus OIMS 30.3% (p = 0.87). Median MO and OIMS indemnity payments were similar ($190,591 vs. $233,432; p = 0.20). Correlates of MO claims closing with payment included patient assessment, communication among providers, and safety and security as contributing factors. Thematic analysis identified provider cognitive error, adverse drug events and relational problems as the most common safety incidents. MO malpractice claims have similar outcomes to OIMS. We demonstrate the proof-of-concept of applying a safety incident taxonomy to medical malpractice. Finding ways to reduce patient exposure to provider cognitive errors, adverse drug reactions, and communication breakdowns should be strategic priorities for safer cancer care.

A comparison of career plans of gastroenterology fellows compared to fellows in other internal medicine subspecialties

Background The career trajectory of medical professionals, particularly in specialized fields like gastroenterology, can significantly impact healthcare and research. This study aimed to analyze career choices among gastroenterology fellows in the US and investigate the factors influencing these choices. Methods We utilized data from the American Medical Association on internal medicine subspecialty fellows. The study examined career plans of gastroenterology fellows and compared them with those of other subspecialties. A chi-square test was performed to assess differences in career choices and practice settings. Results Among gastroenterology fellows, 46% opted for private practice, 28% pursued further training, and 26% chose academia. Notably, gastroenterology fellows were more inclined toward private practice than their counterparts in other subspecialties (46.3% vs 38.4%) and were less likely to pursue academic careers (25.6% vs 30.7%). Conclusion This study highlights a concerning trend among recent gastroenterology fellowship graduates favoring private practice over academic careers or additional training. To sustain and strengthen academic medicine in gastroenterology, interventions such as scholarships, mentorship programs, and loan repayment initiatives tailored to academic pursuits could play a crucial role.

The Hospitalist Movement 25 Years Later.

Hospitalists are generalists who specialize in the care of hospitalized patients. In the 25 years since the term hospitalist was coined, the field of hospital medicine has grown exponentially and established a substantial footprint in the medical community. There are now more hospitalists than practicing physicians in any other internal medicine subspecialty. Several key forces catalyzed the growth in the field of hospital medicine, including the quality, safety, and value movements; residency duty hour restrictions; the emergence of electronic health records; and the COVID-19 pandemic. Looking ahead, we see new opportunities in the realms of technology and telemedicine, and challenges persist in regard to balancing financial considerations with increasing workload and burnout. Hospitalists must remain nimble and seize emerging opportunities to continue supporting the field's prominence and growth.

THU001 Novel Interactive Text-messaging Curriculum For Endocrinology Board Review

Abstract Disclosure: P. Majety: None. A. Ajayi: None. A. Modest: None. M. Vamvini: Grant Recipient; Self; MV was supported by F32-DK126432, and Joslin Diabetes Center P&amp;F. J. Freed: None. Background: The ABIM certification exam is one of the measures to ensure that physicians have the clinical skills for good care delivery. The five-year average pass rate for the ABIM Endocrinology &amp; Metabolism subspecialty exam is 86%, relatively lower when compared to other subspecialties. The pass rate for first time test takers significantly decreased from a usual range of 84-91% over 2017-2020 to a nadir of 74% in 2021 compared to a mean of 84% for other medicine subspecialties. This represents the lowest pass rate in 2021 for any internal medicine subspecialty exam. Objectives: The primary purpose of our study was to assess the feasibility of a unique text messaging curriculum for endocrinology fellows and its utility in improving their knowledge. We also assessed their study habits and resources available to them for ABIM subspecialty exam preparation. Methods: In 2021, endocrinology fellows from 51 programs across the country were invited to participate in our curriculum. They completed a pre-test, joined a texting group via Remind application and received 1 multiple choice question daily (total n = 78). At the end of curriculum, fellows received a post-test questionnaire, and a feedback survey. After 15 weeks, they completed a post-test and survey. Paired results from pre- and post-test were compared. Results: A total of 89 fellows from 27 programs responded. Of these, 82 fellows, predominantly females (n=60; 73%), filled out the pre-test. On an average, 42 fellows (SD = 12) responded to the questions daily. Thirty fellows completed the post-test. The median number of correct responses on the pre-test was 5 (IQR 3-6), compared to 8 (IQR 6-9) in the post-test. There was a significant improvement (p-value &amp;lt;0.0001) in fellows’ performance in the post-test when compared with the pre-test following our intervention.Final feedback survey was filled out by 33 of them. Ninety-seven percent responded that they use question banks as a resource for exam preparation followed by PowerPoint presentations (52%), journals (48%), online videos (39%), textbooks (33%) and lecture notes (33%). 23 fellows (70%) preferred mobile friendly question bank applications; 5 fellows (15%) preferred online question banks available through company websites only. None of them preferred paper-based question banks.Nineteen of the 33 fellows (58%) found the curriculum very useful. 17 fellows (52%) said it served as a discussion tool sometimes, while 9 fellows (27%) said they used it as a discussion tool often. Thirty two out of 33 fellows (97%) responded that they would like to continue to receive a question daily for the rest of their fellowship. Conclusions: Text-messaging based curriculum for exam preparation is feasible and can improve test performance. Fellows find receiving a daily high yield multiple choice question via text-message as a useful tool for exam preparation. Presentation: Thursday, June 15, 2023

S1733 Mapping Professional Trajectories: Comparing Career Plans of Gastroenterology Fellows and Other Internal Medicine Subspecialties

S1733 Mapping Professional Trajectories: Comparing Career Plans of Gastroenterology Fellows and Other Internal Medicine Subspecialties

Gastroenterology fellowship application and match trends in the United States over a 12-year period, 2010 to 2022

Introduction Gastroenterology has recently gained prominence as a competitive internal medicine subspecialty. The intense competition within the gastroenterology fellowship match (GFM) presents challenges for both applicants and programs, particularly in virtual interviews due to the COVID‐19 pandemic. We analyzed the variables impacting GFM competitiveness to provide insights for prospective gastroenterologists and programs to enhance the match process. Methods We used publicly available National Resident Matching Program (NRMP) data to examine applications and match data for internal medicine subspecialties from 2010 to 2022. We considered factors such as the number of positions, applicants, and programs, utilizing the specialty competitiveness ratio (SCR) to assess competitiveness. Annual growth rates for positions and applications and average annual growth rates were calculated. Correlation coefficients between annual salaries and SCR were computed using various compensation reports. Results GFM’s competitiveness has increased recently, evidenced by substantial growth in positions (4.61%) and applications (3.81%) since 2010. Gastroenterology ranked as the second-fastest growing specialty in positions and applications. In 2022, GFM ranked fourth in applications (974) and positions offered (616). Among internal medicine subspecialties, gastroenterology exhibited the highest SCR (1.58). Correlation analysis highlighted a positive link between SCR and compensation across specialties. Conclusion The escalating competition within GFM necessitates an expansion of positions to address potential shortages. Complex factors, such as academic interest and financial considerations, require multifaceted strategies to ensure an adequate supply of gastroenterologists. Further research is warranted to examine the long-term consequences of this trend.

Financial conflicts of interest between pharmaceutical companies and executive board members of internal medicine subspecialty societies in Japan between 2016 and 2020.

Pharmaceutical companies make payments to physicians such as compensations for lecturing or consulting. Of particular, financial relationships between pharmaceutical companies and leaders of professional medical societies are concern in medical community. However, little was known about them in Japan. This study aimed to evaluate the magnitude and prevalence of personal payments to executive board members (EBMs)of 15 medical associations representing different subspecialties within the Japanese Society of Internal Medicine. All EBMs of 15 medical associations representing internal medicine subspecialties were collected from each association webpage. Payments to the EBMs were extracted from the pharmaceutical companies belonging to the Japan Pharmaceutical Manufacturers Association between 2016 and 2020. We performed descriptive analysis on the payment data. Of the 353 different EBMs identified, 350 (99.2%) received one or more personal payments from the pharmaceutical companies over the 5 years. 99.2% (350) and 97.2% (343) of all EBMs received personal payments 3 years before and in the year of their board membership. A total of $70,796,014 were made to the EBMs over the 5 years. The median 5-year combined personal payments per EBM was $150,849 (interquartile range [IQR]:$73,412-$282,456). EBMs who were chairman or vice chairman of executive board received significantly larger median personal payments than those who were not ($225,685 vs. $143,885, p = 0.01 in the U test). Among the 15 societies, there were 12 (80.0%) societies with all (100%) EBMs receiving personal payments from the pharmaceutical companies. Although every society has their own conflicts of interest policy, none publicly discloses the financial relationships between pharmaceutical companies and their EBMs due to their privacy. This study demonstrated that nearly all EBMs of 15 medical associations representing internal medicine subspecialties had substantial financial relationships with the pharmaceutical companies in Japan over the past 5 years.

Cognitive biases in internal medicine: a scoping review.

Medical errors account for up to 440,000 deaths annually, and cognitive errors outpace knowledge deficits as causes of error. Cognitive biases are predispositions to respond in predictable ways, and they don't always result in error. We conducted a scoping review exploring which biases are most prevalent in Internal Medicine (IM), if and how they influence patient outcomes, and what, if any, debiasing strategies are effective. We searched PubMed, OVID, ERIC, SCOPUS, PsychINFO, and CINAHL. Search terms included variations of "bias", "clinical reasoning", and IM subspecialties. Inclusion criteria were: discussing bias, clinical reasoning, and physician participants. Fifteen of 334 identified papers were included. Two papers looked beyond general IM: one each in Infectious Diseases and Critical Care. Nine papers distinguished bias from error, whereas four referenced error in their definition of bias. The most commonly studied outcomes were diagnosis, treatment, and physician impact in 47 % (7), 33 % (5), and 27 % (4) of studies, respectively. Three studies directly assessed patient outcomes. The most commonly cited biases were availability bias (60 %, 9), confirmation bias (40 %, 6), anchoring (40 %, 6), and premature closure (33 %, 5). Proposed contributing features were years of practice, stressors, and practice setting. One study found that years of practice negatively correlated with susceptibility to bias. Ten studies discussed debiasing; all reported weak or equivocal efficacy. We found 41 biases in IM and 22 features that may predispose physicians to bias. We found little evidence directly linking biases to error, which could account for the weak evidence of bias countermeasure efficacy. Future study clearly delineating bias from error and directly assessing clinical outcomes would be insightful.

Telehealth as a Tool to Improve Access and Reduce No-Show Rates in a Large Safety-Net Population in the USA.

Low-income populations are at higher risk of missing appointments, resulting in fragmented care and worsening disparities. Compared to face-to-face encounters, telehealth visits are more convenient and could improve access for low-income populations. All outpatient encounters at the Parkland Health between March 2020 and June 2022 were included. No-show rates were compared across encounter types (face-to-face vs telehealth). Generalized estimating equations were used to evaluate the association of encounter type and no-show encounters, clustering by individual patient and adjusting for demographics, comorbidities, and social vulnerability. Interaction analyses were performed. There were 355,976 unique patients with 2,639,284 scheduled outpatient encounters included in this dataset. 59.9% of patients were of Hispanic ethnicity, while 27.0% were of Black race. In a fully adjusted model, telehealth visits were associated with a 29% reduction in odds of no-show (aOR 0.71, 95% CI: 0.70-0.72). Telehealth visits were associated with significantly greater reductions in probability of no-show among patients of Black race and among those who resided in the most socially vulnerable areas. Telehealth encounters were more effective in reducing no-shows in primary care and internal medicine subspecialties than surgical specialties or other non-surgical specialties. These data suggest that telehealth may serve as a tool to improve access to care in socially complex patient populations.

Factors related to Japanese internal medicine doctors’ retention or migration to rural areas: a nationwide retrospective cohort study

Internal medicine (IM) doctors in Japan play the role of primary care physicians; however, the shortage of rural physicians continues. This study aims to elucidate the association of age, sex, board certification, type of work, and main clinical work with the retention or migration of IM doctors to rural areas. This retrospective cohort study included 82,363 IM doctors in 2010, extracted from the national census data of medical doctors. The explanatory variables were age, sex, type of work, primary clinical work, and changes in board certification status. The outcome was retention or migration to rural areas. The first tertile of population density (PD) of municipalities defined as rural area. After stratifying the baseline ruralities as rural or non-rural areas, the odds ratios (ORs) of the explanatory variables were calculated using generalized estimation equations. The analyses were also performed after age stratification (<39, 40-59, ≥60 years old). Among the rural areas, women had a significantly higher OR for retention, but obtaining board certification of IM subspecialties had a significantly lower OR. Among the non-rural areas, physicians who answered that their main work was IM without specific subspecialty and general had a significantly higher OR, but obtaining and maintaining board certification for IM subspecialties had a significantly lower OR for migration to rural areas. After age stratification, the higher OR of women for rural retention was significant only among those aged 40-59 years. Those aged under 40 and 40-59 years in the non-rural areas, who answered that their main work was IM without specific subspecialty had a significantly higher OR for migration to rural areas, and those aged 40-59 years in the rural areas who answered the same had a higher OR for rural retention. Obtaining and maintaining board certification of IM subspecialties are possible inhibiting factors for rural work, and IM doctors whose main work involves subspecialties tend to work in non-rural areas. Once rural work begins, more middle-aged female IM doctors continued rural work compared to male doctors.