Internal Medicine Subspecialties Research Articles

The Accreditation Council for Graduate Medical Education requires that trainees show progressive milestone attainment in the practice-based learning and systems-based practice competencies. As part of the Clinical Learning Environment Review, sponsoring hospitals must educate trainees in health care quality improvement, provide them with specialty-specific quality data, and ensure trainee participation in quality improvement activities and committees. Subspecialty-specific quality improvement curricula in nephrology training programs have not been reported, although considerable curricular and assessment material exists for specialty residencies, including tools for assessing trainee and faculty competence. Nephrology-specific didactic material exists to assist nephrology fellows and faculty mentors in designing and implementing quality improvement projects. Nephrology is notable among internal medicine subspecialties for the emphasis placed on adherence to quality thresholds-specifically for chronic RRT shown by the Centers for Medicare and Medicaid Services Quality Incentive Program. We have developed a nephrology-specific curriculum that meets Accreditation Council for Graduate Medical Education and Clinical Learning Environment Review requirements, acknowledges regulatory quality improvement requirements, integrates with ongoing divisional quality improvement activities, and has improved clinical care and the training program. In addition to didactic training in quality improvement, we track trainee compliance with Kidney Disease Improving Global Outcomes CKD and ESRD quality indicators (emphasizing Quality Improvement Program indicators), and fellows collaborate on a yearly multidisciplinary quality improvement project. Over the past 6 years, each fellowship class has, on the basis of a successful quality improvement project, shown milestone achievement in Systems-Based Practice and Practice-Based Learning. Fellow quality improvement projects have improved nephrology clinical care within the institution and introduced new educational and assessment tools to the training program. All have been opportunities for quality improvement scholarship. The curriculum prepares fellows to apply quality improvement principals in independent clinical practice-while showing milestone advancement and divisional compliance with Clinical Learning Environment Review requirements.

General internal medicine (GIM), like other generalist specialties, has struggled to maintain its identity in the face of mounting sub-specialization over the past few decades. In Canada, the path to licensure for general internists has been through the completion of an extra year of training after three core years of internal medicine. Until very recently, the Royal College of Physicians and Surgeons of Canada (RCPSC) did not recognize GIM as a distinct entity. In response to a societal need to train generalist practitioners who could care for complex patients in an increasingly complex health care setting, the majority of universities across Canada voluntarily developed structured GIM training programs independent of RCPSC recognition. However, interest amongst trainees in GIM was declining, and the GIM workforce in Canada, like that in many other countries, was in danger of serious shortfalls. After much deliberation and consultation, in 2010, the RCPSC recognized GIM as a distinct subspecialty of internal medicine. Since this time, despite the challenges in the educational implementation of GIM as a distinct discipline, there has been a resurgence of interest in this field of medicine. This paper outlines the journey of the Canadian GIM to educational implementation as a distinct discipline, the impact on the discipline, and the implications for the international GIM community.

Graduate medical education is a critical time in the training of a rheumatologist, and purposeful evaluation of abilities during this time is essential for long-term success as an independent practitioner. The internal medicine subspecialties collectively developed a uniform set of reporting milestones by which trainees can be assessed and receive formative feedback, providing clarity of accomplishment as well as areas for improvement in training. Furthermore, the reporting milestones provide a schema for assessment and evaluation of fellows by supervisors. The internal medicine subspecialties were also tasked with considering entrustable professional activities (EPAs), which define the abilities of a subspecialty physician who has attained sufficient mastery of the field to be accountable to stakeholders and participate in independent practice. Although EPAs have been established for a few specialties, they had not yet been described for rheumatology. EPAs have value as descriptors of the comprehensive abilities, knowledge, and skills of a practicing rheumatologist. The rheumatology EPAs have a role in defining a specialist in rheumatology upon completion of training, and also represent the ways our specialty defines our abilities that are enduring throughout practice. We describe the collaborative process of the development of both the subspecialty reporting milestones and the rheumatology EPAs. The reporting milestones evolved through discussions and collaborations among representatives from the Association of Specialty Professors, the Alliance for Academic Internal Medicine, the American Board of Internal Medicine, and the Accreditation Council for Graduate Medical Education. The EPAs were a product of deliberations by the Next Accreditation System (NAS) working group of the American College of Rheumatology (ACR) Committee on Rheumatology Training and Workforce Issues. Twenty-three subspecialty reporting milestones and 14 rheumatology EPAs were advanced and refined over the course of 3 subspecialty reporting milestone development summits and 3 ACR NAS working group meetings, respectively. The subspecialty reporting milestones and rheumatology EPAs presented here stipulate reasonable and measurable expectations for rheumatologists-in-training. Together, these tools aim to promote enrichment and greater accountability in the training of fellows. Additionally, the EPAs define, for all stakeholders, the expertise of a rheumatologist in practice.

The vast majority of general internal medicine (GIM) programs in Canada have become distinct entities that provide training in additional competencies and leadership above and beyond those required for the specialty of internal medicine. In December 2010, after many years of effort, GIM finally achieved recognition as a distinct subspecialty by the Royal College of Physicians and Surgeons of Canada. A GIM Working Group has finalized the objectives and requirements for a 2-year subspecialty training program in GIM that will follow after the existing 3-year core internal medicine training program. These documents have now been approved by the Royal College.

Pediatric fellowship training programs are the primary source of subspecialty practitioners who care for our nation's children. There are 16 Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric subspecialties made up of 837 individual training programs that graduated over 8500 trainees from 2004 to 2013 in addition to those who graduated from combined board specialty programs that include a pediatric training component.1Table C7. Full-time faculty appointment status at US medical schools for completed residents, by specialty. Residents who last completed training 2004–2013. Association of American Medical Colleges. Available at: https://www.aamc.org/data/448498/c7table.html. Accessed May 11, 2016.Google Scholar Explicit in the requirements for graduate medical education (GME) accreditation is the key role of the program director (PD), who is responsible for overseeing all educational activities, assessing all trainee and faculty performance, maintaining and distributing all program policies and procedures, directing programmatic evaluation and process improvement, and monitoring compliance with all ACGME regulations.2Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in the subspecialties of pediatrics. Available at: https://www.acgme.org/Portals/0/320_general_pediatric_subs_PRs_RC.pdf. Accessed May 11, 2016.Google Scholar Prior study has identified inadequate PD time as a barrier to complying with ACGME requirements in the nonpediatric subspecialties.3Boulware D.W. The subspecialty fellowship training program director: essentials and expectations.Am J Med. 2002; 112: 686-688Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Dedicated administrative time has been identified as necessary for innovation and curricular design, and has been linked to ongoing accreditation by the ACGME.4Rivera V. Yukawa M. Aronson L. et al.Teaching geriatric fellows how to teach: a needs assessment targeting geriatrics fellowship program directors.J Am Geriatr Soc. 2014; 62: 2377-2382Crossref PubMed Scopus (9) Google Scholar, 5Doughty C.B. Kessler D.O. Zuckerbraun N.S. et al.Simulation in pediatric emergency medicine fellowships.Pediatrics. 2015; 136: e152-e158Crossref PubMed Scopus (21) Google Scholar, 6Byrne J. Straub H. DiGiovanni L. et al.Evaluation of ethics education in obstetrics and gynecology residency programs.Am J Obstet Gynecol. 2015; 212: 397.e1-397.e8Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 7Laeeq K. Weatherly R.A. Masood H. et al.Barriers to the implementation of competency-based education and assessment: a survey of otolaryngology program directors.Laryngoscope. 2010; 120: 1152-1158PubMed Google Scholar, 8Kahn J.M. Feemster L.C. Fruci C.M. et al.Attitudes of pulmonary and critical care training program directors toward quality improvement education.Ann Am Thorac Soc. 2015; 12: 587-590Crossref PubMed Scopus (5) Google Scholar, 9Beeson M.S. Characteristics of emergency medicine program directors.Acad Emerg Med. 2006; 13: 166-172Crossref PubMed Scopus (0) Google Scholar, 10Harris E.R. Abdel-Wahab M. Spangler A.E. et al.Results of the Association of Directors of Radiation Oncology Programs (ADROP) survey of radiation oncology residency program directors.Int J Radiat Oncol Biol Phys. 2009; 74: 327-337Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 11Arora T.K. Kaplan B.J. Who are surgery program directors and what do they need?.J Surg Educ. 2008; 65: 504-511Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 12Chaudhry S.I. Caccamese S.M. Beasley B.W. What predicts residency accreditation cycle length? Results of a national survey.Acad Med. 2009; 84: 356-361Crossref PubMed Scopus (7) Google Scholar The ACGME program requirements for core residency programs and many nonpediatric subspecialties now delineate program administration time requirements for PDs, associate PDs, and other support staff. The time allotted differs by specialty and varies in specification from hours per week to a percentage of total effort.13Accreditation Council for Graduate Medical EducationSpecialty-specific references for DIOs: expected time for program director.2015https://www.acgme.org/Portals/0/PDFs/Specialty-specific%20Requirement%20Topics/DIO-Expected_Time_Coordinator.pdfGoogle Scholar Current requirements set forth by the ACGME range from 10% to 50% full-time equivalent (FTE) staff for the core medical and surgical specialties and for many of the subspecialty fellowships accredited by the American Board of Medical Specialties. For core pediatric residency programs, support of administrative efforts are specifically delineated in the core program requirements: “The program director must devote a minimum of 0.5 FTE regardless of the size of the program.”14Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in pediatrics. Revised 2015. Available at: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/320_pediatrics_07012015.pdf. Accessed August 1, 2015.Google Scholar Core pediatric residency programs have recommendations for additional effort support in a graded increase on the basis of the size of the program and includes PDs, associate PDs, residency coordinators, and liaisons. Currently the “ACGME Program Requirements for Graduate Medical Education in the Subspecialties of Pediatrics” do not delineate any specific required time allotment for fellowship PDs but requires “sufficient protected time.”2Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in the subspecialties of pediatrics. Available at: https://www.acgme.org/Portals/0/320_general_pediatric_subs_PRs_RC.pdf. Accessed May 11, 2016.Google Scholar The goal of this study was to describe current time allotted for PDs in pediatric subspecialty fellowship training programs and to delineate the minimum time required for program administration to meet the regulations outlined by the ACGME. The study was conducted in 2 phases through the use of an anonymous national survey of fellowship PDs. An initial survey was created by the author group using a modified Delphi technique through 5 iterations and consisted of 23 items, including demographic data, definition of an FTE in the respondent's institution, time allotted to administer the program, and the time needed by the respondent to administer their program. The survey was created in REDCap hosted by Vanderbilt University Medical Center.15Harris P.A. Taylor R. Thielke R. et al.Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform. 2009; 42: 377-381Crossref PubMed Scopus (23149) Google Scholar This survey was distributed from August 20, 2013, to October 16, 2013, using the Association of Pediatric Program Directors (APPD) Fellowship Program Director (FPD) e-mail list. As a result of an initial low response rate, these data were considered pilot data. The study survey was refined using a modified Delphi technique through an additional 3 iterations, and distribution was expanded to include both the Council of Pediatric Subspecialties electronic mailing list and the APPD FPD e-mail list. The study survey was shortened to 6 core items with branching logic, expanding to 9 items if the FPD indicated leadership of 2 programs. The study survey was resent via the distribution lists between February 23 and April 2, 2015, with 2 reminder e-mails and verbal reminders at the APPD spring meeting. All survey responses were anonymous. Basic demographic data were collected including the subspecialty program and number of fellows in the program. The name of the respondent and the institution of origin of the response were not recorded in the study survey. The FPD time assessment included 2 questions: “How much time (%FTE) do you currently expend in your role as PD?” and “How much time (%FTE) do you feel is required to effectively function in your role as PD?” Data were collected regarding additional resources in order to evaluate the impact of these different administrative supports on the time estimated for program leadership. These supports included the institutional presence of a super fellowship director (SFD), vice chair for education (VCE), associate fellowship program director (APD), program coordinator (PC), or research director (RD). Approval for this project was obtained from the Vanderbilt University Medical Center institutional review board with exempt status. Medians and interquartile ranges (IQR) were used to determine the time expended and the time needed to direct a subspecialty training program on the basis of the number of fellows in the training program (program size) and the subspecialty. Independent t test without assumption of equal variances was used to compare means of FPD time needed in the presence and absence of other resources as defined above. The difference was calculated by subtracting the mean %FTE with the resource available by the mean %FTE without the resource available with 95% confidence intervals. Analyses were performed by SPSS 20 software (IBM SPSS, Chicago, Ill). A 2-tailed P value of < .05 was considered statistically significant. A total of 558 (76%) anonymous responses for the study survey were recorded from the 737 registered individuals in the combined e-mail distribution lists. Ten of the surveys were incomplete and not included in analysis. Of the 548 completed responses, 535 responses were from FPDs of single programs and 13 (2.4%) were from PDs leading more than one program. These dual-program responses were excluded from the analysis sample because the small number limited comparative analysis. Data from APPD indicated that 665 FPDs, 43 associate FPDs, and 5 co-FPDs were registered with the organization at that time and had e-mail accounts listed. Overall, the cohort of completed responses reflects approximately 75% (535/713) of the FPD and associate FPDs registered with APPD and 73% of the 737 recipients listed on the combined APPD FPD and Council of Pediatric Subspecialties e-mail distribution lists. Additionally, these responses reflect 64% (535/837) of pediatric subspecialty programs listed with the ACGME, assuming no duplicate responses. In response to the question about “time you currently expend in your role as PD,” PDs reported a median %FTE expended of 17% (IQR, 10–25). The time expended varied by program size, with the smallest programs (0–3 fellows) reporting a median 10% (IQR, 10–20) and the largest programs (≥10 fellows) reporting a median of 25% (IQR, 20–34) (Table 1). These estimates reflect the time PDs currently spend and were different from the “time you feel is required to effectively function in your role as PD.” The time estimated to effectively function in the role also varied by program size, with an overall median of 25% (IQR, 20–30) and ranged from 20% (IQR, 15–25) for the smallest programs to 34% (IQR, 25–50) for the largest programs (Table 1). These time estimates also varied by subspecialty; however, sample size limited the ability to further analyze the effect of program size within a specific subspecialty (Table 2).Table 1FTE Expended Versus Required by FPDs Based on Program SizeProgram Sizen% FTE Expended, Median (IQR)% FTE Required, Median (IQR)All53517 (10–25)25 (20–30)0–3 fellows21910 (10–20)20 (15–25)4–6 fellows17215 (10–20)25 (20–30)7–9 fellows9020 (15–30)30 (20–40)≥10 fellows5425 (20–34)34 (25–50)FPD indicates fellowship program director; FTE, full-time equivalent; and IQR, interquartile range. Open table in a new tab Table 2FTE Expended and Required for Specific Pediatric and Pediatric-Affiliated SubspecialtiesSubspecialtyn% FTE Expended, Median (IQR)% FTE Required, Median (IQR)Adolescent1520 (15–25)25 (20–35)Allergy immunology424 (12–30)30 (23–34)Behavior development3520 (10–30)20 (20–30)Cardiology3620 (11–25)25 (20–30)Child abuse2315 (10–25)20 (20–25)Critical care3320 (15–30)30 (20–38)Emergency3525 (20–30)30 (25–50)Endocrinology3310 (9–15)15 (15–25)Gen pediatrics110 (10–10)10 (10–10)Gastroenterology2115 (10–20)20 (15–20)Hematology oncology4720 (15–30)30 (20–35)Hospital medicine1210 (3–19)20 (20–20)Infectious diseases5615 (10–20)20 (16–30)Nephrology1413 (10–20)18 (10–26)Child neurology920 (13–21)25 (20–35)Neonatology9520 (15–30)30 (20–40)Pulmonology4210 (9–20)20 (15–25)Rheumatology1910 (5–15)15 (15–20)Sports medicine320 (10–20)15 (15–20)Palliative hospice110 (10–10)20 (20–20)Sleep medicine115 (15–15)33 (33–33)Genetics0——Transplant hepatology0——FTE indicates full-time equivalent; IQR, interquartile range. Open table in a new tab FPD indicates fellowship program director; FTE, full-time equivalent; and IQR, interquartile range. FTE indicates full-time equivalent; IQR, interquartile range. Data regarding other resources available to support program administration and their impact on the estimated mean time required were analyzed. Of the 535 completed responses, 465 (87%) reported having a PC, 219 (41%) an APD, 149 (28%) a VCE, 90(17%) a SFD, and 75 (14%) an RD. With respect to FPD time expended, the presence of a PC did not significantly alter the reported PD time for any size program. Overall, programs with an APD reported increased time needed, from 17% to 21% (P < 0.01). The presence of a RD reduced reported time for programs overall, from 22% to 18% (P = 0.043). The presence of an SFD or VCE did not confer a significant difference in PD time needed. Small and inconsistent effects of these additional resources on PD time were analyzed by size of program and showed no specific trend. Sufficient time for program administration, curriculum design, and education innovation is crucial in any graduate medical education program and is associated with accreditation status. The data demonstrate that pediatric subspecialty FPDs currently may not have adequate protected time to effectively administer their programs. Additionally, the data inform a stepwise increase in the time allotted to meet the ACGME requirements of “sufficient protected time” for PDs specified in the “ACGME Program Requirements for Graduate Medical Education in the Subspecialties of Pediatrics.”2Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in the subspecialties of pediatrics. Available at: https://www.acgme.org/Portals/0/320_general_pediatric_subs_PRs_RC.pdf. Accessed May 11, 2016.Google Scholar The minimum specific recommendations would be 20% FTE for programs with 0 to 3 fellows, 25% FTE for 4 to 6 fellows, 30% FTE for 7 to 9 fellows, and 35% FTE for ≥10 fellows, regardless of subspecialty. These recommendations do not include the time necessary to meet the requirements for scholarly activity of the PD (Section II.A.3.d), as research and administrative activities have insufficient overlap. These recommendations correlate with the ranges identified by multiple ACGME review committees for time requirements in nonpediatric subspecialty training programs, as extracted from the ACGME resource “Expected Time for Program Director.”16Accreditation Council for Graduate Medical Education. Specialty-specific references for DIOs: expected time for program director. Updated February 2016. Available at: https://www.acgme.org/Portals/0/PDFs/Specialty-specific%20Requirement%20Topics/DIO-Expected_Time_PD.pdf. Accessed May 11, 2016.Google Scholar Recommendations for protected time for PDs in the internal medicine subspecialties have required time support ranging from “20–50% depending on the size of the program,” though the specific details for incremental increases are not specified. Among the surgical subspecialties, the range of recommended time is 10% to 50%. For those subspecialty programs spanning multiple review committees at the ACGME, the recommended time is 10% to 50%. On the basis of this study, the recommendation for FPD time in the pediatric subspecialties ranges from 20% to 35%, well within established precedent of the ACGME. The ACGME has established that even core pediatric residency programs require 50% FTE allotted to the PD, and for programs with 12 to 30 residents, there must be a minimum of 75% FTE time combined between the PD and associate PD.14Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in pediatrics. Revised 2015. Available at: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/320_pediatrics_07012015.pdf. Accessed August 1, 2015.Google Scholar The relationship of time required by an FPD and access to other programmatic resources was investigated. Only the presence of a research director was associated with any reduction in PD time, likely reflecting the significant portion of fellowship training occupied with scholarly activity pursuits. A majority of programs had a program coordinator, likely explaining the lack of association with reduced FPD time. However, no data were collected regarding the %FTE allotted to the PC or the scope of their duties (single program vs multiple programs). Data from the initial pilot study suggest that FPDs would enhance curriculum design, education innovation, and faculty development with additional time allotted rather than focusing on regulation compliance. Currently, PDs spend a significant portion of their current administrative time assuring minimal compliance with ACGME and institutional regulations for training programs. In the current academic medicine environment, competing pressures to provide patient-generated revenue or independent grant funding limit other divisional faculty member time to assist an FPD. Hence, in the era of the ACGME Next Accreditation System self-study and Clinical Learning Environment Review visits, the PD's efforts in ongoing programmatic enhancement will be essential to both maintaining an excellent program and maintaining program compliance with the regulations and maintenance of accreditation. The first limitation of these data include the use of self-reported time assessment rather than objective observational data collection. A prospective observational time study would be impractical and is logistically not feasible. Second, in order to optimize the response rate, the study collected anonymous survey responses, thus limiting our ability to filter for duplicate responses from an individual program. Third, the survey tool used to collect the data is not a validated instrument; however, the survey was created by content experts, which supports a component of validity evidence for responses collected using the tool. Additionally, these study findings are in agreement with that of the current standards set forth by the ACGME. Fourth, we did not define FTE in terms of hours per week or days per month in the survey tool, but rather allowed respondents to provide their estimate of the percentage of time. Clinical effort is difficult to standardize to hours per week or days per month as a result of the variety inherent in the mix of outpatient and inpatient efforts, combined with specialties that are moving to shift work, such as intensive care and emergency medicine. Finally, it is not clear if the time reported by FPDs included the additional time provided by an associate PD, if present in their program. Thus, specific recommendations for APD time cannot be made from our study beyond including them in the total time recommended for the FPD. Despite these limitations, the strength of our study is the large sample size for the cohort of interest, representing approximately 75% of the FPDs listed in APPD and 64% of the programs listed with the ACGME. The findings presented in this study represent the most valid and objective data available to support specific recommendations for time allotment to PDs in the subspecialties of pediatrics. The recommendations include a gradation of time that is based on the size of the training program, from 20% to 35%, which is in alignment with subspecialty training in other disciplines. PD administration time is crucial for program enhancement, which is in turn embedded in the current process for maintenance of accreditation. We realize the financial burden such a recommendation poses; however, excellence in GME requires a sufficient time investment by a cohort of dedicated educators, not unlike the premise that excellence in research requires the time of a dedicated investigator. Areas of future investigation could include a detailed time study of program coordinator efforts and scope of duties as well as more detailed data regarding the definition of %FTE expended or salary support compensation across the nation.

A certification exam for the new sub-specialty of General Internal Medicine (GIM) was recently developed by an examination board at the Royal College of Physicians and Surgeons (RCPSC). The board sought to create an exam that would reflect the challenges faced by practising general internists, while minimizing repetition of material already assessed by the Internal Medicine certification exam. In this paper, the authors present evidence for the validity of the content of the exam.

Introduction: Cardiac rehabilitation (CR) has a proven morbidity and mortality benefit, yet rates of referral remain low. We sought to elucidate the knowledge, utilization, referral, and endorsement practices of cardiac rehabilitation in a tertiary care centre. Methods: A 13-question survey was electronically distributed to all Internal Medicine residents, Cardiology residents and subspecialty fellows, General Internal Medicine attendings and Cardiology attendings practising in a tertiary care centre. The survey assessed the physicians’ knowledge of what CR entails, its benefits, patient eligibility and personal practices with respect to CR referral. Results: The survey was distributed to 153 physicians with a response rate of nearly 60 percent. Compared to their medicine counterparts, Cardiology residents and staff had significantly improved knowledge with respect to what CR entails and eligibility criteria for referral (6.92 vs. 6.11 out of 9, p=0.036; 12.04 vs. 10.76 out of 17, p = 0.013). Medicine residents and staff were less likely to be familiar with CR guidelines (72.02 vs. 32.69, p<0.01), and were less likely to discuss the importance of CR attendance with their patients (43.28 vs. 71.15, p=0.0002). A higher proportion of those in Medicine also reported being unsure of both how to refer eligible patients (59.12 vs. 13.46, p<0.0001) and which patients were eligible for CR (64.92 vs. 23.08, p<0.0001). Higher knowledge scores and familiarity with CR guidelines was associated with higher self-reported referral rates. Conclusion: This survey has identified clear physician barriers, most significant among internal medicine residents and staff. These barriers can help inform interventions to improve CR referral and enrolment rates.

SummaryMy work, my crucial achievement, has been in the management of the transition of the conduct of cancer research/management from basic researchers/surgeons to medical oncologists (figure 1).This transition can be divided into four categories:1.The development, progression and consolidation of global Medical Oncology in Asian countries, especially in Japan.2.Building a close collaboration with European Society of Medical Oncology (ESMO) and receiving strong support from ESMO, through (A) Adaptation of the ESMO/ASCO Core Curriculum in Medical Oncology,1.Hansen H.H. Bajorin D.F. Muss H.B. et al.Recommendations for a Global Core Curriculum in Medical Oncology.Ann Oncol. 2004; 15: 1603-1612doi:10.1093/annonc/mdh447Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar (B) Mutual ESMO/Japanese Society of Medical Oncology (JSMO) joint symposia during their respective meetings, (C) making Annals of Oncology JSMO's official scientific publication,2.Kerr D.J. New wave.Ann Oncol. 2008; 19: 3-4doi:10.1093/annonc/mdm556Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar along with (D) my own work as an Associate Editor of Annals of Oncology (2011–2014), (E) my work as ESMO's National/Regional Representative and Membership Committee member (2005–2011).3.Leadership of clinical research in Japan as a key opinion leader and primary investigator in IND (investigational new drug) trials and a chairman of the Japanese Clinical Oncology Group (JCOG; 2000–2009), organising a governmental clinical trial group; and the development of new gold standards in the treatment of malignant diseases, especially in thoracic malignancy by investigator-initiated randomised controlled clinical trials.4.Encouraging translational research and the publication of numerous articles, especially in the area of the identification of molecular targets for anticancer drugs, as Chief of the Pharmacology Division in the National Cancer Center Research Institute.PrefaceWhen I began my training in Medical Oncology, cancer research, including translational research, was conducted by basic researchers, and cancer treatment, including chemotherapy, was conducted by surgeons. There was no place for medical oncologists to play an active part in cancer research and treatment. ESMO was established 40 years ago and now has more than 10 000 professionals as members, and medical oncology has been recognised as a subspecialty of Internal Medicine in Western countries. However, there were no such comparable developments in Japan. There had been no systematic education systems for medical oncology in the majority of universities in Japan, and it had only been addressed during training regarding the possible diseases afflicting each organ. For a long time in Japan, cancer was considered as a disease for only surgeons to treat. Recently, many new drugs which require specialised knowledge and skills have been introduced into clinical practice.3.Saijo N. Progress in cancer chemotherapy with special stress on molecular targeted therapy.Jpn J Clin Oncol. 2010; 40: 855-862doi:10.1093/jjco/hyq035Crossref PubMed Scopus (19) Google Scholar In addition, progress in molecular biology and clinical studies has clarified common features in cancers from different organs.4.Saijo N. Critical comments for roles of biomarkers in the diagnosis and treatment of cancer.Cancer Treat Rev. 2012; 38: 63-67doi:10.1016/j.ctrv.2011.02.004Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar5.Saijo N. Present status and problems on molecular targeted therapy of cancer.Cancer Res Treat. 2012; 44: 1-10doi:10.4143/crt.2012.44.1.1Crossref PubMed Scopus (22) Google Scholar It is clear that systemic cancer therapy should be performed by medical oncologists with sufficient knowledge and a level of clinical skill based on cross-specialty training.The creation of the JSMOIn 1993, the Japanese Study Group for Medical Oncology (JSGMO), the antecedent of the JSMO founded by myself and Dr Masahiro Fukuoka and Dr Yutaka Ariyoshi, started an annual meeting to strengthen the recognition of medical oncology in Japan (figure 2). JSGMO organised a symposium once or twice a year on clinical trials and translational studies, with 16 symposia held until 2002. However, we could not increase the number of members involved in medical oncology, and there was little excitement for clinical trials during that time. The average numbers of attending scientists were 500–800, even though ICH-GCP for IND trials was initiated in 1998. JSGMO's strategic plan was then fundamentally renewed to establish a system for the board certification of medical oncologists in Japan. For this purpose, JSGMO was renewed as JSMO in 2002. At the first meeting, approximately 600 members attended and discussed future perspectives in Medical Oncology. The infrastructure of JSMO was consolidated to enable the realisation of examinations for the board certification of medical oncologists. For example, JSMO provides CME credit for attending educational events. In addition to its annual scientific meeting, JSMO organised educational seminars twice a year for developing essential knowledge of Medical Oncology, and a best of ASCO meeting as an advanced course. At both activities, 500–800 investigators attended. JSMO published two textbooks on medical oncology, one for undergraduate students: INTRODUCTION OF MEDICAL ONCOLOGY6.Nyuumonn Syuyou Naikagaku. Introduction of Medical Oncology, Shinohara Syuppannsya, Second Edition. 2015. http://www.shinoharashinnsya.co.jpGoogle Scholar and another for young postgraduate doctors who would be candidates to become Board Certified Medical Oncologists: NEW TEXTBOOK OF MEDICAL ONCOLOGY.7.Shin Rinnsyousyuyougaku. New Textbook of Medical Oncology, Nannkoudou Sya, Fouth Edition. 2015. http://www.nankodo.co.jpGoogle Scholar The number of members rapidly increased and as of November 2015 reached more than 9300, with more than 5500 investigators attending the Annual meeting (figure 3).Figure 2The history of the Japanese Society for Medical Oncology.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Trends in JSMO growth. JSMO, Japanese Society of Medical Oncology.View Large Image Figure ViewerDownload Hi-res image Download (PPT)From the beginning, global Societies such as ESMO and ASCO have supported JSMO in various ways. For example, JSMO adopted the Global Core Curriculum of ASCO/ESMO,1.Hansen H.H. Bajorin D.F. Muss H.B. et al.Recommendations for a Global Core Curriculum in Medical Oncology.Ann Oncol. 2004; 15: 1603-1612doi:10.1093/annonc/mdh447Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar and recently JSMO adopted ASCO's Conflict of Interest policy.8.American Society of Clinical Oncology American Society of Clinical Oncology: policy for relationships with companies: background and rationale.J Clin Oncol. 2013; 31: 2043-2046doi:10.1200/JCO.2013.49.5002Crossref PubMed Scopus (16) Google Scholar Annals of Oncology, the official journal of ESMO, also became that of JSMO in 2008. Examinations for the board certification of medical oncologists began in 2005.To apply for the examination, an applicant should have (A) worked for at least 5 years in a JSMO-certified hospital after completing 2 years of basic clinical training and (B) submitted 30 case reports which should include haematological, breast, thoracic and gastrointestinal malignancies. The examination includes both oral and written components. In 2006, 47 individuals passed the first examination session and became Board Certified Medical Oncologists. As of 2015, a total of 1060 physicians have become JSMO Board Certified Medical Oncologists (figure 4). The pass rate for the examination is approximately 60%, which is low compared with that for certified specialties in other societies. However, JSMO views this lower rate of success in a positive light as the Society wants to certify only well-educated and qualified medical oncologists, and therefore JSMO intends to maintain this relatively low pass rate.Figure 4JSMO board Certified Medical Oncologists. JSMO, Japanese Society of Medical Oncology.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Requirements for a medical oncologist certified by JSMOCertified Medical Oncologists are specialised physicians trained in the investigation and care of patients with cancer. They play an integral role in cancer management by multidisciplinary teams, providing special expertise to patients through their knowledge of systemic treatment of cancer with cytotoxic chemotherapy, hormone therapy, molecular targeted drugs and immunotherapy. In Japan, these therapies have been provided historically within the framework of medical subspecialties based on the specific organ in which each cancer developed. JSMO certifies physicians who are capable of providing systemic therapy reflecting the progress of cancer research as Board Certified Medical Oncologists.Board-Certified Medical Oncologists are required to:1.Understand the biology of cancer and the clinical pharmacology of the drugs used to treat this disease;2.Develop new treatment strategies through translational research;3.Learn skills in management and service delivery for various cancer sites and to understand the complex issues, such as clinical conditions and the social background of each patient, involved in introducing new treatments;4.Have a central role in the planning, conduct and promotion of clinical trials based on scientific methodology and logical ideas;5.Learn and understand palliative care in order to provide expert consultations;6.Play a definite role in the practice of treating oncology emergencies, a service designed to ensure appropriate and urgent management of complications of cancer itself and its treatments;7.Integrate a team of medical staff with multiple specialties;8.Contribute to the development of medical oncology by educating trainees and to provide an excellent educational environment;9.Be a driver for the prevention of cancer.JSMO contributes to the progress of cancer treatment and public health by certifying well-trained physicians as Board Certified Medical Oncologists.The contribution of JSMO to the basic act for anticancer measures in JapanThe Japanese government has now also recognised the importance of both medical oncology and radiation oncology. Historically, the majority of cancer care in Japan, including chemotherapy, was performed by surgeons. On 16 June 2006, the Japanese government enacted a law specifically focused on cancer and its management, the ‘Basic Act for Anticancer Measures’.The law came into force on 12 April 2007, some 5 years after the founding of JSMO. The law has three basic policies:Section 1, promotion of prevention and earlier detection of cancer; Section 2, promotion of full equality of medical care for all cases of cancer; and Section 3, the promotion of cancer research. To realise Section 2, Article 14 states as follows: “The Government and Prefectures shall establish necessary policies to bring up medical doctors and other medical staff who have expertise in surgery, radiotherapy, chemotherapy, and other cancer managements.”To give shape to the missions and visions of the Act, the Ministry of Health, Labor, and Welfare (MHLW) started to nominate prefectural and regional ‘Cancer Management Hospitals’, known as Chiiki Gann Shinryo Renkei: Kyoten Byouin—Regional Cancer Care Core Hospital-, which should have appropriate medical staff members and facilities.In addition, the Ministry of Education, Culture, Sports, Science, and Technology (MEXT) has proposed the Cancer Professional Educational Plan, known as GANNPRO. The main purpose of GANNPRO is to increase the number of cancer specialists, including medical and radiation oncologists, oncology pharmacists and nurses, by demonstrating support for these specialties.The efforts of MHLW and MEXT seem outwardly to be changing medical practice for cancer treatment in Japan. The number of registered Cancer Management Hospitals has increased to approximately 400 and new divisions of medical and radiation oncology have been founded at several universities. However, more than 60% of registered Cancer Management Hospitals still have no JSMO Board Certified Medical Oncologists. All patients have the right to receive reasonable medical care in qualified hospitals and, in order to address this issue, the criteria for the registration of Cancer Management Hospitals by MHLW should be revised. Furthermore, hospitals that have at least two or three JSMO Board Certified Medical Oncologists should be financially rewarded to improve their infrastructure.Future directions of JSMO as a global society for oncologyJSMO was initially established as an educational organisation, with practical success in instruction regarding the role of medical oncology in Japan. New information on translational/basic research and clinical trials is primarily reported during either the ASCO or ESMO meeting, not during the JSMO annual meeting. Despite the continued importance of educational activities at the JSMO annual meeting, the focus on scientific data regarding new targeted agents is increasing in Japan, as well as in other Asian countries.9.Thongprasert S. Duffield E. Saijo N. et al.Health-related quality of life in a randomized phase III first line study of gefitinib versus carboplatin/paclitaxel in clinically selected patients from Asia with advanced NSCLC (IPASS).J Thorac Oncol. 2011; 6: 1872-1880doi:10.1097/JTO.0b013e31822adaf7Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Some molecularly targeted drugs have exhibited substantial differences among ethnicities regarding effectiveness and toxicities.10.Saijo N. The role of pharmacoethnicity in the development of cytotoxic and molecular targeted drugs in oncology.Yonsei Med J. 2013; 54: 1-14doi:10.3349/ymj.2013.54.1.1Crossref PubMed Scopus (18) Google Scholar11.Saijo N. Targeted therapies: tyrosine kinase inhibitors—New standard for NSCLC therapy.Nat Rev Clin Oncol. 2010; 7: 618-619doi:10.1038/nrclinonc.2010.168Crossref PubMed Scopus (11) Google Scholar In addition, research in diseases prominent in Asia, such as gastric cancer and hepatocellular malignancies, is also developing.The next JSMO annual meeting is on 28–30 July 2016 in Kobe, Japan and the Meeting President will be Professor Hironobu Minami (figure 5). Through collaborations with the Chinese Society Clinical Oncology, the Korean Association of Clinical Oncology, Singapore Society of Oncology and the Medical Oncology Group of Australia Incorporated, JSMO will contribute to the promotion of activities in the field of medical oncology in Asia.Figure 5The JSMO 2016 Annual Meeting. JSMO, Japanese Society of Medical Oncology. Japanese Society of Medical Oncology.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Establishment of global standards for treatment of lung cancerContribution for the development of new anticancer drugsThe development of new anticancer drugs is extremely important to improve the survival time of patients with cancer. From 1989 to 1997, I worked as a chairman of the Pharmacology Division of National Cancer Center Research Institute. Famous pharmacologists were invited on the basis of a Comprehensive 10-year Strategy for Cancer Control to transfer new ideas and techniques. They included Dr Anne W Hamburger, Dr Peter Twentyman, Dr Kenneth D Tew, Dr John Lazo, Dr Youcef Rustum, Dr Enrico Mihich, Dr Eckard Podak, Dr Kristin Olsen, Dr Awtar Krishan, Dr Suzan Arbuck, Dr Rosemarie Mick, Dr Dean Brenner, Dr David Curiel, Dr Haim Tapiero, Dr K Bojanowsky, Dr Wang S Hong, Dr Young S. Lee and Dr Hyo J. Kuh. Many mechanisms of drug resistance, especially for platinum compounds, have been identified,12.Kurokawa H. Ishida T. Nishio K. et al.Gamma-glutamylcystein synthetase gene overexpression results in increased activity of the ATP-dependent glutathione S-conjugate export pump and cisplatin resistance.Biochem Biophys Res Commun. 1995; 216: 258-264Crossref PubMed Scopus (69) Google Scholar, 13.Suzuki T. Nishio K. Sasaki H. et al.cDNA cloning of a short type of mdr protein homologue, SMRP, from human lung cancer cell lines.Biochem Biophys Res Commun. 1997; 238: 790-794Crossref PubMed Scopus (39) Google Scholar, 14.Oshita F. Yamamoto N. Fukuda M. et al.Correlation of therapeutic outcome in NSCLC and DNA damage assayed by polymerase chain reaction in leukocytes damaged in vitro.Cancer Res. 1995; 55: 2334-2337PubMed Google Scholar, 15.Morikage T. Ohmori T. Nishio K. et al.Modulation of cisplatin sensitivity and accumulation by amphotericin B in cisplatin-resistant human lung cancer cell lines.Cancer Res. 1993; 53: 3302-3307PubMed Google Scholar, 16.Niimi S. Nakagawa K. Sugimoto Y. et al.Mechanism of cross resistance to CPT-11 in human ovarian cancer cell line selected by cisplatin.Cancer Res. 1992; 52: 328-333PubMed Google Scholar, 17.Kasahara K. Fujiwara Y. Sugimoto Y. et al.Determinants of response to DNA topoisomerase II inhibitors doxorubicin and etoposide in human lung cancer cell lines.J Natl Cancer Inst. 1992; 84: 113-118doi:10.1093/jnci/84.2.113Crossref PubMed Scopus (87) Google Scholar and these studies led to the clarification of molecular targets of cytotoxic drugs. Many drug-resistant cells were provided to pharmaceutical companies to screen better anticancer drugs. The suggestions for best administration schedules and combination regimens have been obtained from these translational studies.18.Kanzawa F. Nishio K. Kubota N. et al.Antitumor activities of a new indolocarbazole substance, NB-506, and establishment of NB-506 resistant cell line, SBC-3/NB.Cancer Res. 1995; 55: 2806-2813PubMed Google Scholar The trial for the selection of a personalised regimen was done by drug sensitivity testing.19.Fukuda M. Nishio K. Kanzawa F. et al.Synergism between cisplatin and topoisomerase I inhibitors NB506 and SN38.Cancer Res. 1996; 56: 789-793PubMed Google Scholar In my role as a primary investigator for the efficient and scientific development of a majority of key anticancer drugs, pharmacokinetic/pharmacodynamic studies done by Pharmacology Division were extremely important.20.Kaniwa N. Sugiyama E. Kim S.-R. et al.Genotype-based methods for anticipating gemcitabine-related severe toxicities May lead to false negative results.J Clin Oncol. 2007; 25: 4855-4856doi:10.1200/JCO.2007.13.4577Crossref PubMed Scopus (1) Google Scholar, 21.Minami H. Ohe Y. Niho S. et al.Comparison of pharmacokinetics and pharmacodynamics of docetaxel and cisplatin in elderly and non-elderly patients: Why is toxicity increased in elderly patients?.J Clin Oncol. 2004; 22: 2901-2908doi:10.1200/JCO.2004.10.163Crossref PubMed Scopus (80) Google Scholar, 22.Yamamoto N. Tamura T. Kamiya T. et al.Correlation between docetaxel clearance and estimated cytochrome p450 activity by urinary metabolite of exogenous cortisol.J Clin Oncol. 2000; 18: 2301-2308Crossref PubMed Scopus (94) Google Scholar, 23.Yamamoto N. Tamura T. Nishiwaki Y. et al.Limited sampling model for area under the concentration versus time curve of irinotecan and its application to a multi-centric phase II trial.Clin Cancer Res. 1997; 3: 1087-1092PubMed Google Scholar, 24.Sasaki Y. Ohtsu A. Ono K. et al.Simultaneous administration of CPT-11 and 5-FU: Alteration of PKs of CPT-11 and SN-38 in patients with advanced colorectal cancer.J Natl Cancer Inst. 1994; 86: 1096-1098doi:10.1093/jnci/86.14.1096Crossref PubMed Scopus (68) Google ScholarActivity in the JCOGJCOG, supported by governmental funds, has been initiated as a multidisciplinary treatment group for malignant diseases in 197825.Shimoyama M. Fukuda H. Saijo N. et al.Japan Clinical Oncology Group (JCOG).Jpn J Clin Oncol. 1998; 28: 158-162doi:10.1093/jjco/28.3.158Crossref PubMed Scopus (31) Google Scholar26.Saijo N. Preface for JCOG review series.Jpn J Clin Oncol. 2011; 41: 1155doi:10.1093/jjco/hyr127Crossref PubMed Scopus (3) Google Scholar and organised as a cooperative study group which has by-laws, a protocol review system and a monitoring committee since 1985. JCOG conducts multidisease, multidisciplinary treatments including commercially available drugs, radiation therapy and surgery. JCOG consists of an Executive Committee, Data Center, Operational Office and 16 Study Groups covering the majority of organ tumours except for paediatric tumours and leukaemia. The Lung Cancer Study Group (LCSG) led by myself joined in 1982 and it played a major role in the establishment of JCOG itself because LCSG is a pioneer and opinion leader for clinical trials, especially randomised controlled trials. I worked as a JCOG chair from 2001 to 2009. I invited Dr Steven Piantadosi and Dr Robert Makuch and worked with them to strengthen the statistical centre.27.Piantadosi S. Saijo N. Tamura T. Basic design considerations for clinical trials in oncology.Jpn J Cancer Res. 1992; 83: 547-558doi:10.1111/j.1349-7006.1992.tb00124.xCrossref PubMed Scopus (6) Google Scholar28.Piantadosi S. Saijo N. Tamura T. Guidelines for analysis and reporting of clinical trials in oncology.Jpn J Cancer Res. 1993; 84: 929-937doi:10.1111/j.1349-7006.1993.tb00180.xCrossref PubMed Scopus (4) Google Scholar At that time, there was only one staff member in the operational office. Specialists of medical oncology and radiation oncology in the field of lung cancer have been invited on the basis of a 10-year Comprehensive Cancer Control Strategy and we worked with them. They included Dr James R Jett, Dr Bruce E Johnson, Dr Andrew Trissi, Dr David H Johnson, Dr Jack Ruckdeshel, Dr Everett E Vokes, Dr Roy R Herbst, Dr Raymond Ablatt, Dr Wilfred EE Eberhardt, Dr Rafael Rosell and Dr Sumitra Thongprasert. During my term of office as a chairman, the number of staff members in the JCOG data centre has dramatically increased and the study design of clinical trials has been globalised. In addition, other cooperative study groups which have a data centre and operational offices have begun to be organised. In recent years, total protocols handled by JCOG are 70–100, and patient accrual is 2600–3000 per year. In addition to the studies of LCSG, many prestigious clinical trials have been conducted, especially in the comparison of surgical procedures such as “Left thoraco-abdominal approach versus abdominal-trans-hiatal approach for gastric cancer of the cardia or subcardia: a randomised controlled trial” 29.Sasako M. Sano T. Yamamoto S. Japan Clinical Oncology Group (JCOG9502) et al.Left trancoabdominal approach versus abdominal-transhiatal approach for gastric cancer of the cardia or subcardia:a randomized controlled trial.Lancet Oncol. 2006; 7: 644-651doi:10.1016/S1470-2045(06)70766-5Abstract Full Text Full Text PDF PubMed Scopus (325) Google Scholar and “D2 Lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer”. 30.Sasako M. Sano T. Yamamoto S. Japan Clinical Oncology Group (JCOG9501) et al.D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer.N Engl J Med. 359. 2008: 453-462doi:10.1056/NEJMoa0707035Crossref Scopus (822) Google Scholar Recent major publications of JCOG studies from 2011 to 2015 were in Lancet Oncology (4), J Clin Oncol (5), Ann Surgery (2), Annals Oncol (4), and Br J Surgery (5). Among them, five were studies of LCSG and the cumulative impact factor is highest in LCSG.Small cell lung cancerAs part of JCOG (Japanese Clinical Oncology Group), our group has conducted many pivotal trials for the establishment of global standards of care for limited and extensive small cell lung cancer (SCLC).When I graduated from University, SCLC was primarily treated with mitomycin C alone in the National Cancer Center (Japan). In the late 1970s, ACNU (a water-soluble nitrosourea compound), developed by Sankyo Co (Japan), showed surprising antitumour effects in SCLC preclinically,31.Saijo N. Niitani H. Irimajiri N. et al.Effect of ACNU on Sato lung carcinoma.Oncology. 1979; 36: 7-10doi:10.1159/000225309Crossref PubMed Scopus (3) Google Scholar and clinically it was very active in extensive disease (ED)-SCLC.32.Saijo N. Niitani H. Experimental and clinical effect of ACNU in Japan, with special emphasis on small cell lung cancer.Cancer Chemother Pharmacol. 1980; 4: 165-171doi:10.1007/BF00254013Crossref PubMed Scopus (35) Google Scholar The survival time of ED-SCLC treated with ACNU has reached the state of the art in the 1970s. Unfortunately, further development of the drug after phase II trials was stopped because of prolonged thrombocytopenia. JCOG conducted a three-armed RCT (randomised controlled trial) comparing CAV (cyclophosphamide+adriamycin+vincristine) versus PE (cisplatin+etoposide) versus CAV alt PE to determine new standard chemotherapy of PE and also to evaluate non-cross resistant chemotherapy. CAV alt PE showed superiority only in LD (limit disease)-SCLC by post study stratification. Although the results were essentially negative, the data were published in the Journal of the National Cancer Institute33.Fukuoka M. Furuse K. Saijo N. et al.Randomized trial of cyclophosphamide, doxorubicin, and vincristine versus cisplatin and etoposide versus alternation of these regimens in small-cell lung cancer.J Natl Cancer Inst. 1991; 83: 855-861doi:10.1093/jnci/83.12.855Crossref PubMed Scopus (414) Google Scholar and investigators of the cooperative study group were encouraged because of the first completion of a large-scale randomised trial in Japan. Adverse events for the PE regimen were mild compared with other regimens, and this regimen has contributed to the establishment of a global consensus in the SCLC workshop held in Helsingor (Denmark). Another key trial against LD-SCLC comparing concurrent versus sequential chemoradiotherapy (accelerated hyperfractionation) could not meet the primary end point (the superiority of the concurrent arm) statistically, although it showed a tendency to better survival in the concurrent group. The results were published in the Journal of Clinical Oncology,34.Takada M. Fukuoka M. Kawahara M. et al.Phase III study of concurrent versus sequential thoracic radiotherapy in combination with cisplatin and etoposide for limited-stage small-cell lung cancer: results of the Japan Clinical Oncology Group Study 9104.J Clin Oncol. 2002; 20: 3054-3060doi:10.1200/JCO.2002.12.071Crossref PubMed Scopus (546) Google Scholar and a global consensus in favour of concurrent chemoradiotherapy in LD-SCLC was obtained. Many strategies to improve the treatment of SCLC failed to show survival benefit for new treatments.35.Kubota K. Hida T. Ishikura S. et al.(JCOG 0202) Etoposide and cisplatin versus irinotecan and cisplatin in patients with LD-SCLC treated with etoposide and cisplatin plus concurrent accelerated hyper fractionated thoracic radiotherapy.Lancet Oncol. 2014; 15: 106-113doi:10.1016/S1470-2045(13)70511-4Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar An RCT comparing PE versus IP (irinotecan+cisplatin) conducted by JCOG clearly showed the survival benefit of the IP regimen and the results appeared in the New England Journal of Medicine.36.Noda K. Nishiwaki Y. Kawahara M. Japan Clinical Oncology Group (JCOG9511) et al.Irinotecan plus cisplatin compared with etoposide plus cisplatin for extensive small-cell lung cancer.N Engl J Med. 2002; 346: 85-91doi:10.1056/NEJMoa003034Crossref PubMed Scopus (1258) Google Scholar Although American studies failed to demonstrate reproducibility, the IP regimen became one of the standards for the treatment of ED-SCLC. Many trials were performed with newly developed amrubicin in Japan, which has recently been used as a second-line regimen.37.Satouchi M. Kotani Y. Shibata T. Japan Clinical Oncology Group (JCOG0509) et al.Phase III study comparing amrubicin plus cisplatin with irinotecan plus cisplatin in the treatment of ED-SCLC.J Clin Oncol. 2014; 32: 1262-1268doi:10.1200/JCO.2013.53.5153Crossref PubMed Scopus (60) Google Scholar38.Sekine I. Okamoto H. Horai T. et al.A randomized phase III study of single agent amrubicin vs carboplatin/etoposide in elderly patients with ED-SCLC.Clin Lung Cancer. 2014; 15: 96-102doi:10.1016/j.cllc.2013.11.006Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Recently, JCOG reported that a weekly IPE (irinotecan+cisplatin+etoposide) regimen shows better survival compared with the US standard: topotecan as a second-line treatment after IP or PE failure.39.Goto K. Ohe Y. Seto T. Japan Clinical Oncology Group (JCOG0605) et al.A randomized phase III study of CDDP, etoposide and irinotecan versus topotecan as second line chemotherapy in patients with sensitive relapsed SCLC.J Clin Oncol. 2014; 32: 7504Crossref Google ScholarNon-small cell lung cancerNo active drug existed for the treatment of non-SCLC (NSCLC) before the development of CDDP (cisplatin). Combinations of 3–5 drugs failed to obtain reproducible responses and survival benefit of chemotherapy was viewed sceptically in NSCLC before 1980.Our first RCT in NSCLC was the comparison of carbazilquinone+MMC versus pepleomycin+MMC. The response rates of both regimens were less than 15% and OS was less than 8 months. Death by interstitial pneumonia was observed in 13.2% of pat

ESMO Open

Feb 1, 2016
Nagahiro Saijo

Over the past decade, the clinical spectrum of autoimmune encephalitis has expanded with the emergence of several new clinicopathological entities. In particular, autoimmune encephalitis has recently been described in association with antibodies to surface receptors and ion channels on neurological tissues. Greater clinician awareness has resulted in autoimmune encephalitis being increasingly recognised in patients with unexplained neurological and psychiatric symptoms and signs. The clinical spectrum of presentations, as well as our understanding of disease mechanisms and treatment regimens, is rapidly developing. An understanding of these conditions is important to all subspecialties of Internal Medicine, including neurology and clinical immunology, psychiatry, intensive care and rehabilitation medicine. This review provides a contemporary overview of the aetiology, investigations and treatment of the most recently described autoimmune encephalitides.

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Editors and the Section Editors for this issue. EDITORS Thomas F. PattersonThomas F. PattersonDr Thomas F. Patterson received his Bachelor of Arts degree from Baylor University, Waco, Texas, USA and his Medical Doctorate from the University of Texas Medical School at Houston, USA. He completed his internship and residency at Vanderbilt University Medical School, in Nashville, Tennessee, USA, and Yale-New Haven Hospital, USA, and a fellowship in infectious diseases at Yale University School of Medicine, New Haven, Connecticut, USA, where he also served as an Assistant Professor of Medicine. Dr Patterson currently is a Professor of Medicine in Infectious Diseases and Chief, Division of Infectious Diseases at the University of Texas Health Science Center in San Antonio, Texas. He is also an Attending Physician at the South Texas Veterans Healthcare System, Audie Murphy Division, San Antonio and Director of the San Antonio Center for Medical Mycology. He has extensive experience in opportunistic fungal infections. His clinical and research interests focus on the diagnosis and treatment of fungal diseases particularly in immunocompromised hosts. He has been involved in developing new antifungal drugs and in clinical trials of new antifungal compounds. Dr Patterson has published and lectured extensively on fungal infections. He is a previous member of the American Board of Internal Medicine Subspecialty on Infectious Diseases and is co-Editor-in-Chief of the popular mycology website www.doctorfungus.org. He is a Fellow of the American College of Physicians and Fellow, Infectious Diseases Society of America. He is a Past-President of the Texas Infectious Disease Society and currently serves as President of the Immunocompromised Host Society. Robert C. ReadRobert C. ReadProfessor Robert C. Read trained in Medicine at the University of Sheffield, UK, and completed his Doctorate Degree at Imperial College London, UK. He is Professor of Infectious Diseases and Honorary Consultant Physician in Infectious Diseases at University Hospital Southampton, and heads the Department of Clinical and Experimental Sciences at the University of Southampton Medical School, UK. Professor Read trained in Infectious Disease and Internal Medicine in various posts in Leeds, Bristol, London and Nottingham, at the National Heart and Lung Institute, Imperial College London, and at the Division of Infectious Diseases, University of California, San Francisco (UCSF) at San Francisco General Hospital, USA, and was previously Professor of Infectious Diseases at the University of Sheffield. His research interests include the pathogenesis and prevention of rapidly lethal infections, notably meningococcal sepsis, influenza and pneumococcal disease. Professor Read has had leadership roles in the UK National Institute of Health Research Clinical Research Network, the European Society for Clinical Microbiology and Infectious Diseases, and the Infectious Disease Society of America. He is an appointed member of expert advisory groups for the UK Medicines and Healthcare Products Regulatory Agency, the UK Department of Health and the European Medicines Agency. He is a full member of the UK Joint Committee for Vaccines and Immunisation (JCVI). He is Editor-in-Chief of the Journal of Infection. SECTION EDITORS David H. DockrellDavid H. DockrellProfessor Dockrell is a graduate of Trinity College Dublin, Ireland. After initial medical training in Dublin he moved to the Mayo Clinic, USA, where he completed general internal medicine and infectious disease training. During this period he developed his subspecialty interests in HIV medicine and infections in immunocompromised hosts. His laboratory interests have focused on the role of macrophages in host defense and in the pathogenesis of HIV and bacterial infection. In particular his laboratory has investigated the role of cell death programs in enhancing microbial killing, with a particular focus on pneumococcal disease and other respiratory infections, and on how viruses such as HIV can manipulate these responses. In 1998 Prof. Dockrell moved to the University of Sheffield, UK, and has been supported by Wellcome Clinical Fellowships, including a Wellcome Senior Clinical Fellowship between 2005 and 2012. He has authored over 100 publications and book chapters. Prof. Dockrell acts as Academic Director for Communicable diseases at Sheffield Teaching Hospitals. He has contributed to several national treatment guidelines and serves on a number of research panels and professional bodies. Karen E. RogstadKaren E. RogstadKaren E. Rogstad is a Consultant in HIV and Sexual Health at Sheffield Teaching Hospitals NHS foundation Trust and an Undergraduate Dean at the University of Sheffield Medical School, UK. She has a particular interest in young people with regards to HIV and HIV testing, sexual health, confidentiality and child sexual exploitation. She is a co-author of several guidelines including standards on young people, HIV testing, standards for HIV services, physical signs of child sexual abuse and reckless transmission of HIV. Additional interests include medical leadership and quality in healthcare systems. She was a member of a government taskforce on violence against women and children and led a government funded grant to develop a national proforma Spotting the Signs to assist in the detection of child sexual exploitation in sexual healthcare settings. She is Editor of the ABC of Sexually Transmitted Infections and module editor of e-HIV-STI, an online educational resource. Suzanne E. GeerlingsSuzanne E. GeerlingsSuzanne E. Geerlings is an infectious disease specialist and since 2015 Professor in Internal Medicine at the Academic Medical Center in Amsterdam, the Netherlands. The subject of her thesis (2000) was “Asymptomatic bacteriuria in women with diabetes mellitus”, for which she received two awards. She is currently project leader of several projects granted by the Netherlands Organisation for Health Research and Development or Aidsfonds, participating in many projects mainly concerning urinary tract infections, HIV-infection and quality of care, and member of different working groups for the development of (inter)national guidelines for the treatment of urinary tract infections or HIV.

BackgroundAntibiotics are often administered to terminally ill patients until death, and antibiotic use contributes to the emergence of multidrug-resistant organisms (MDROs). We investigated antibiotic use and the isolation of MDROs among patients who died in general medical wards.MethodsAll adult patients who died in the general internal medicine wards at four acute care hospitals between January and June 2013 were enrolled. For comparison with these deceased patients, the same number of surviving, discharged patients was selected from the same divisions of internal medicine subspecialties during the same period.ResultsDuring the study period, 303 deceased patients were enrolled; among them, 265 (87.5%) had do-not-resuscitate (DNR) orders in their medical records. Antibiotic use was more common in patients who died than in those who survived (87.5% vs. 65.7%, P<0.001). Among deceased patients with DNR orders, antibiotic use was continued in 59.6% of patients after obtaining their DNR orders. Deceased patients received more antibiotic therapy courses (two [interquartile range (IQR) 1–3] vs. one [IQR 0–2], P<0.001). Antibiotics were used for longer durations in deceased patients than in surviving patients (13 [IQR 5–23] vs. seven days [IQR 0–18], P<0.001). MDROs were also more common in deceased patients than in surviving patients (25.7% vs. 10.6%, P<0.001).ConclusionsPatients who died in the general medical wards of acute care hospitals were exposed to more antibiotics than patients who survived. In particular, antibiotic prescription was common even after obtaining DNR orders in patients who died. The isolation of MDROs during the hospital stay was more common in these patients who died. Strategies for judicious antibiotic use and appropriate infection control should be applied to these patient populations.

Given that approximately 70% of current endocrinology fellows are women, female physicians will compose the majority of the future endocrinology workforce. This gender shift partly reflects an apparent waning of interest in endocrinology among male trainees. It also coincides with a projected shortage of endocrinologists overall. Female physicians face unique challenges in the workplace. To continue to attract trainees to the specialty and support their success, it is imperative that these challenges be recognized, understood, and addressed. A PubMed search using the terms "female physician" and "physician gender" covering the years 2000-2015 was performed. Additional references were identified through review of the citations of the retrieved articles. The following topics were identified as key to understanding the impact of this gender shift: professional satisfaction, work-life balance, income, parenthood, academic success, and patient satisfaction. Several changes can be predicted to occur as endocrinology becomes a female-predominant specialty. Although professional satisfaction should remain stable, increased burnout rates are likely. Work-life balance challenges will likely be magnified. The combined effects of occupational gender segregation and a gender pay gap are predicted to negatively impact salaries of endocrinologists of both genders. The underrepresentation of women in academic leadership may mean a lesser voice for endocrinology in this arena. Finally, gender biases evident in patient satisfaction measures--commonly used as proxies for quality of care--may disproportionately impact endocrinology. Endocrinology is predicted to become the most female-predominant subspecialty of internal medicine. The specialty of endocrinology should take a lead role in advocating for changes that support the success of female physicians. Strengthening and supporting the physician workforce can only serve to attract talented physicians of both genders to the specialty, which will be key to meeting the needs of the increasing numbers of patients with endocrine disorders.

Medical oncology is a subspecialty of internal medicine that focuses on the treatment of cancer. Cancer is the second leading cause of mortality in the U.S. Therefore death is a frequent subject for oncologists. However, oncology training emphasizes cancer therapy with little guidance on counseling in preparation for death. Physicians such as the writer Atul Gawande are working to bring back the topic of death into the physician-patient conversation. Furthermore, many religions, including the Bahá’í Faith, can help to address how death is perceived and discussed by physicians. The purpose of this article is to review my personal experience as an oncologist and as a Bahá’í, as it relates to the topic of death.

Training young physicians to perform research is challenging on many levels. Thus, many internal medicine training programs, including both core and subspecialty programs, struggle with providing a rigorous and successful research experience for their trainees. Here, the authors report on the rationale, design, practical implementation and outcome of a new program that was developed at the University Gastroenterology Fellowship Training Program. Before program inception, 33% of trainees presented original research at scientific meetings or published their work in peer-reviewed journals. After implementation, 100% of trainees accomplished these metrics. Additionally, the proportion of trainees remaining in academic medicine increased from 14% before implementation of the program to 51% after it began. Several elements were viewed to be critically important for the program including the following: communication of expectations and development of a robust program structure, dedicated protected time, a dedicated research curriculum, programmatic support, mentorship and oversight as well as accountability/tracking of accomplishments. The authors conclude that institutions able to adopt these or similar approaches will reap the many rewards of discovery research performed by trainees.

The subspecialty consultation represents a potentially powerful opportunity for resident learning, but barriers may limit the educational exchanges between fellows (subspecialty registrars) and residents (house officers). We conducted a focus group study of internal medicine (IM) residents and subspecialty fellows to determine barriers against and factors facilitating resident-fellow teaching interactions on the wards, and to identify opportunities for maximising teaching and learning. We conducted four focus groups of IM residents (n=18) and IM subspecialty fellows (n=16) at two academic medical centres in the USA during February and March 2013. Participants represented trainees in all 3years of residency training and seven IM subspecialties. Four investigators analysed the transcripts using a structured qualitative framework approach, which was informed by literature on consultation and the theoretical framework of activity theory. We identified two domains of barriers and facilitating factors: personal and systems-based. Sub-themes in the personal domain included fellows' perceived resistance to consultations, residents' willingness to engage in teaching interactions, and perceptions and expectations. Sub-themes in the systems-based domain included the process of requesting the consult, the quality of the consult request, primary team structure, familiarity between residents and fellows, workload, work experience, culture of subspecialty divisions, and fellows' teaching skills. These barriers differentially affected the two stages of the consult identified in the focus groups (initial interaction and follow-up interaction). Residents and fellows want to engage in positive teaching interactions in the context of the clinical consult; however, multiple barriers influence both parties in the hospital environment. Many of these barriers are amenable to change. Interventions aimed at reducing barriers to teaching in the setting of consultation hold promise for improving teaching and learning on the wards.

Electronic Health Records (EHRs) have been shown to markedly alter clinical workflows and are associated with lower professional satisfaction scores among providers post-implementation. In light of these issues, questions exist regarding what barriers currently exist in EHRs to adequately meet the workflow needs of providers. The objective of this study was to describe what physicians perceive to be the current barriers to information gathering and overall workflow when using electronic health records (EHRs) to evaluate new patients. A web-based national survey was distributed to practicing physicians in primary care, general internal medicine, medicine subspecialties, general surgery, surgery subspecialties, general pediatrics, and pediatrics subspecialties from June to September 2014. Prominent themes pertaining to information gathering and overall workflow in the EHR were identified from narrative survey responses using constant comparison and axial coding to arrive at a grounded theory. Narrative responses from 327 physicians were obtained and analyzed from a total of 1385 respondents (24%). Major identified themes included: 1) Physicians struggle with unintuitive workflows and negative time impact; 2) EHR documentation was excessive and often of poor clinical value; 3) Provider-provider communication is negatively impacted by EHR challenges; and 4) Frustration with EHRs led to mistrust of vendors and clinical administration responsible for building and selecting the EHR software. Barriers such as inefficient workflows, increased time demands, and inconsistent documentation practices exist in EHRs that prevent ideal information gathering when evaluating a new patient. Results from this study could provide insights into new EHR interface redesign and development, and into new physician EHR training opportunities.

Therapeutic Revolution: The History of Medical Oncology From Early Days to the Creation of the Subspecialty is a book about the history of medical oncology, the extraordinary turbulence that permeated the early years of the field, and the events that led to this subspecialty of internal medicine [...]

BackgroundDuring the four-month internal medicine clerkship in their final year, undergraduate medical students are closely involved in patient care. Little is known about what constitutes their typical learning experiences with respect to patient diversity within the different subspecialties of internal medicine and during on call hours.Methods25 final year medical students (16 female, 9 male) on their internal medicine clerkship participated in this observational single-center study. To detail the patient diversity encountered by medical students at a university hospital during their 16-week internal medicine clerkship, all participants self-reported their patient contacts in the different subspecialties and during on call hours on patient encounter cards. Patients’ chief complaint, suspected main diagnosis, planned diagnostic investigations, and therapy in seven different internal medicine subspecialties and the on call medicine service were documented.Results496 PECs were analysed in total. The greatest diversity of chief complaints (CC) and suspected main diagnoses (SMD) was observed in patients encountered on call, with the combined frequencies of the three most common CCs or SMDs accounting for only 23% and 25%, respectively. Combined, the three most commonly encountered CC/SMD accounted for high percentages (82%/63%), i.e. less diversity, in oncology and low percentages (37%/32%), i.e. high diversity, in nephrology. The percentage of all diagnostic investigations and therapies that were classified as “basic” differed between the subspecialties from 82%/94% (on call) to 37%/50% (pulmonology/oncology). The only subspecialty with no significant difference compared with on call was nephrology for diagnostic investigations. With respect to therapy, nephrology and infectious diseases showed no significant differences compared with on call.ConclusionsInternal medicine clerkships at a university hospital provide students with a very limited patient diversity in most internal medicine subspecialties. Shadowing the on call resident or shorter rotations could provide a more extended patient diversity.

Beginning in the 2014-2015 training year, the US Accreditation Council for Graduate Medical Education (ACGME) required that nephrology Clinical Competency Committees assess fellows' progress toward 23 subcompetency "context nonspecific" internal medicine subspecialty milestones. Fellows' advancement toward the "ready for unsupervised practice" target milestone now is tracked in each of the 6 competencies: Patient Care, Medical Knowledge, Professionalism, Interpersonal Communication Skills, Practice-Based Learning and Improvement, and Systems-Based Practice. Nephrology program directors and subspecialty societies must define nephrology-specific "curricular milestones," mapped to the nonspecific ACGME milestones. Although the ACGME goal is to produce data that can discriminate between successful and underperforming training programs, the approach is at risk to produce biased, inaccurate, and unhelpful information. We map the ACGME internal medicine subspecialty milestones to our previously published nephrology-specific milestone schema and describe entrustable professional activities and other objective assessment tools that inform milestone decisions. Mapping our schema onto the ACGME subspecialty milestone reporting form allows comparison with the ACGME subspecialty milestones and the curricular milestones developed by the American Society of Nephrology Program Directors. Clinical Competency Committees may easily adapt and directly translate milestone decisions reached using our schema onto the ACGME internal medicine subspecialty competency milestone-reporting format.

Ultrasonography is no longer limited to radiology suites and echocardiography laboratories. Portable ultrasound machines are now widely available in intensive care units, general medical floors, and many ambulatory clinics; trainees are even beginning to store handheld devices in their white coats alongside Advanced Cardiovascular Life Support cards, penlights, and stethoscopes. Not surprisingly, internal medicine residents are eager to learn more about medical ultrasound.1,2 Although the technology has already arrived, our knowledge of how to train internal medicine physicians and ensure safe and proper use of this powerful tool is lagging. Point-of-care ultrasound has great potential to improve patient outcomes and should be integrated into internal medicine training programs. However, integration of this technology should not be done in a haphazard fashion. Just as we have moved beyond the apprenticeship model of see-one, do-one, teach-one for procedural training in medicine, we must approach ultrasound education with a structured and rigorous curricular approach.3–6 As with any diagnostic tool, the risks of inadequate training and assessment are potentially catastrophic. While missing trivial mitral regurgitation on the bedside echocardiogram of a hemodynamically stable patient may not have dire consequences, a false-negative finding in the setting of a hypotensive patient with a pneumothorax or pericardial effusion is unacceptable. In addition, excessive reliance on new technology could detract from fundamental physical examination skills7; an ultrasound examination is not always necessary to diagnose common conditions or certain life-threatening conditions that require immediate treatment. Internists must be able to detect tracheal deviation and a pulsus paradoxus on clinical examination, even if a portable ultrasound is within reach. Another concern with the increased use of bedside ultrasound is the likely increase in detection of “incidentalomas.” The impact these incidental findings have on further testing and medical costs has not yet, to our knowledge, been explored. While there are limited data regarding ultrasound training for internal medicine trainees, other specialties and subspecialties within internal medicine have described key components of competency.8,9 There is evidence that emergency medicine physicians are able to obtain key diagnostic and procedural ultrasound skills with limited training.10 Some research suggests that internal medicine physicians can similarly obtain key skills for focused ultrasonography with short training sessions.11,12 In this issue of the Journal of Graduate Medical Education, Skalski and colleagues13 report their experience training internal medicine residents in point-of-care ultrasound of the aorta and kidneys. The authors should be applauded for taking a rigorous approach to training and assessing the effect of a focused curriculum. Following limited, simulation-based training, 84% of internal medicine residents were able to obtain high-quality images of the abdominal aorta and kidney of a standardized patient, compared with only 16% before training. In addition, self-reported confidence increased markedly following the training session, with the vast majority of residents feeling somewhat or extremely confident in identifying the aorta and kidney with ultrasound, and reporting that they will use ultrasound more in the future. Although it is encouraging that residents quickly gained competence in successfully obtaining images of the normal abdominal aorta and normal kidney, the implications of this study are not clear. While, on the surface, increased confidence may seem to be a positive result, we know too well that confidence is not equivalent to competence.2,14 In fact, this confidence in a select skill, in a normal model, may place residents at risk for false reassurance and overuse of ultrasound. One must also question what the most important and appropriate uses of point-of-care ultrasound are in the hands of an internist. Although the aorta and kidney are relatively easy organs to identify with ultrasound and are relevant to many conditions we treat, is it necessary for internal medicine physicians to image these organs? Perhaps initially, we should focus on the evaluation of pleural effusions, ascites, and targets for vascular access because it is clear that ultrasound-guided procedures improve patient outcomes.3,15,16 Algorithms for acute onset dyspnea to rule out a pneumothorax or a rapid echocardiogram in the setting of shock may be more appropriate for the general practitioner, and identifying an aortic aneurysm may be more suited for a trained radiologist. It is clear that point-of-care ultrasound technology has arrived; it is now our responsibility to harness its power and train residents carefully. We must teach not only the technical aspects but also the appropriate use and potential pitfalls. As an initial step, internal medicine governing bodies must decide as a community what skills are necessary for the field so that competency guidelines can be clearly delineated. This will promote the creation of valid training methods and assessment tools. Once these fundamentals are established, we must train the trainers. If we are to expand our armamentarium as internists to include ultrasound, supervising faculty must become competent. When trainees arrive on the floor with their own portable ultrasound machines and their attending is not well versed in this technology, there is great potential for inappropriate use. We should learn from the emergency medicine physicians, who not only have clear guidelines for training, but also ensure continuous quality control with attending physicians overreading trainees' ultrasound studies and providing feedback. The literature offers many successful models for procedural training.17,18 Some level of mastery learning should be required to ensure a high level of ultrasound skills before allowing trainees to make clinical decisions in real time. Finally, we do not know details about skill retention of point-of-care ultrasound skills for internists. Practicing clinicians will need to use these skills regularly in practice and/or be reassessed periodically to ensure that a high level of skill is maintained. Although ultrasound is exciting and has changed our field tremendously, we must approach this technology carefully. The field is open for novel training methods and assessment tools. We have no doubt that ultrasound can lead to better care for our patients, but this requires a systematic approach with careful curricular development and continuous assessment.

Internal Medicine Subspecialties Research Articles

Related Topics

Articles published on Internal Medicine Subspecialties

Integrating Quality Improvement Education into the Nephrology Curricular Milestones Framework and the Clinical Learning Environment Review.

The Evolution of General Internal Medicine (GIM)in Canada: International Implications.

What Is a Rheumatologist and How Do We Make One?

General Internal Medicine Subspecialty Training Update

Recommended Protected Time for Pediatric Fellowship Program Directors: A Needs Assessment Survey

English

Assessing Physician Barriers to Cardiac Rehabilitation Referral Rates in a Tertiary Teaching Centre

Highlights for ESMO 40: celebration review for lifetime achievement awards

Autoimmune encephalitis.

Editorial introductions

Frequent Prescription of Antibiotics and High Burden of Antibiotic Resistance among Deceased Patients in General Medical Wards of Acute Care Hospitals in Korea.

Female Physicians and the Future of Endocrinology.

Primum Non Nocere

Development of a Successful Scholarly Activity and Research Program for Subspecialty Trainees

Teaching during consultation: factors affecting the resident-fellow teaching interaction.

Barriers to Information Access in Electronic Health Records during Initial Patient Visits: A Qualitative Study

Book Review: Therapeutic Revolution: The History of Medical Oncology From Early Days to the Creation of the Subspecialty

Overspecialized and undertrained? Patient diversity encountered by medical students during their internal medicine clerkship at a university hospital.

Implementation of Nephrology Subspecialty Curricular Milestones

A "Sound" Approach.

Lead the way for us