US Internists Research Articles

Nonradiographic axial spondyloarthritis: expanding the spectrum of an old disease: A narrative review.

Nonradiographic axial spondyloarthritis (nr-axSpA) represents a distinct phenotype within the spectrum of axial spondyloarthritis (axSpA), which is characterized by a range of clinical manifestations. Despite a high disease burden that is comparable to ankylosing spondylitis (also known as radiographic axSpA), there is an unmet need to recognize and effectively manage patients with active nr-axSpA.A targeted literature search was conducted in OVID (MEDLINE and Embase databases) to identify articles on nr-axSpA, including its definition, demographics, epidemiology, burden, diagnosis, clinical presentation, and treatment guidelines.The lack of adequate epidemiological data and incomplete understanding of nr-axSpA among rheumatologists and nonrheumatologists contributes to delayed referrals and diagnosis. This delay results in a substantial burden on patients, physically and psychologically, and the healthcare system. Targeted therapies, such as biologics, including inhibitors of tumor necrosis factor or interleukin-17A, have been approved and utilized for the management of nr-axSpA, and other novel therapeutics with different mechanisms of action are in development. Raising awareness among US internists regarding the prevalence of nr-axSpA, disease burden, clinical presentation, diagnostic tools, and available treatments is important for improved disease management.Future clinical investigations focusing on the development of markers that aid early diagnosis and predict treatment response may also improve the management of nr-axSpA. This review provides an overview of nr-axSpA with the aim of raising awareness of the disease among US internists, with an overarching goal to contribute toward the improved recognition and timely referral of these patients to rheumatologists for diagnosis and management.

A survey of chairpersons of departments of medicine about the current and future roles of clinical genetics in internal medicine

Purpose: The response of academic Departments of Medicine (DOM), who train the bulk of future US internists, to the increasing importance of clinical genetics is not known.Methods: A survey was distributed to 153 DOM chairpersons assessing the current and future roles of clinical genetics as related to internal medicine.Results: Eighty-five (56%) surveys with complete data were returned. A minority of DOM currently employ geneticists; most genetics education and services are provided by nongeneticists; the general competency of internists to deliver genetic services is unclear.Conclusions: Academic DOM have limited faculty expertise in clinical genetics; this may impact the ability to integrate genetics into internal medicine practice and training.

Cascades of Care After Incidental Findings in a US National Survey of Physicians

Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Perceived effectiveness of HPV test as a primary screening modality among US providers

BackgroundThe human papillomavirus (HPV) test, administered alone without the Papanicolaou (Pap) test, was recently recognized as a cervical cancer screening option in the United States by the Society of Gynecologic Oncology and the American Society for Colposcopy and Cervical Pathology, and the Food and Drug Administration has approved an HPV test for primary screening. MethodsSurveys of US internists, family practitioners, nurse practitioners, and obstetrician–gynecologists were conducted in 2009 and 2012 to investigate providers' perceptions of the effectiveness of the HPV test administered alone as a population-based screening modality (2009: N=1040, 141–494 per provider group; 2012: N=1039, 155–435 per provider group). ResultsThe majority in each provider group agreed that the HPV test administered alone is an effective screening modality in 2009 (75.3%–86.1%) and 2012 (79.5%–91.8%), and agreement rose significantly during this time period among family practitioners (χ2=15.26, df=1, p<0.001) and nurse practitioners (χ2=4.53, df=1, p=0.033). ConclusionsAgreement that the HPV test administered alone is an effective cervical cancer screening modality was widespread among providers in both 2009 and 2012, however implementation of guidelines for screening with the HPV test may be influenced by many other factors including reimbursement and patient preferences.

Cut-and-paste clinical notes confuse care, say US internists

Efforts to simplify clinical note-taking have unwittingly turned the patient record into a kind of medical Mad Libs, say top internists in the United States. The American College of Physicians (ACP) has launched an investigation in response to concerns that tick-box documentation and copy–paste

Views of internists towards uses of PGD

Preimplantation genetic diagnosis (PGD) is increasingly available, but how physicians view it is unclear. Internists are gatekeepers and sources of information, often treating disorders for which PGD is possible. This quantitative study surveyed 220 US internists, who were found to be divided. Many would recommend PGD for cystic fibrosis (CF; 33.7%), breast cancer (BRCA; 23.4%), familial adenomatous polyposis (FAP; 20.6%) and familial hypertrophic cardiomyopathy (19.9%), but few for social sex selection (5.2%); however, in each case, >50% were unsure. Of those surveyed, 4.9% have suggested PGD to patients. Only 7.1% felt qualified to answer patient questions about it. Internists who would refer for PGD had completed medical training less recently and, for CF, were more likely to have privately insured patients (P<0.033) and patients who reported genetic discrimination (P<0.013). Physicians more likely to refer for BRCA and FAP were less likely to have patients ask about genetic testing. This study suggests that internists often feel they have insufficient knowledge about it and may refer for PGD based on limited understanding. They view possible uses of PGD differently, partly reflecting varying ages of onset and disease treatability. These data have critical implications for training, research and practice.Preimplantation genetic diagnosis (PGD) allows embryos to be screened prior to transfer to a woman’s womb for various genetic markers. This procedure raises complex medical, social, psychological and ethical issues, but how physicians view it is unclear. Internists are gatekeepers and sources of information, often treating disorders for which PGD use is possible. We surveyed 220 US internists, who were found to be divided: many would recommend PGD for cystic fibrosis (CF; 33.7%), breast cancer (BRCA; 23.4%), familial adenomatous polyposis (FAP; 20.6%), and familial hypertrophic cardiomyopathy (FHC; 19.9%) and a few for sex selection (5.2%); but in each case, >50% were unsure. Of those surveyed, 4.9% have suggested PGD to patients. Only 7.1% felt qualified to answer patient questions. Internists who would refer for PGD completed medical training less recently and, for CF, were more likely to have privately insured patients and patients who reported genetic discrimination. Physicians more likely to refer for BRCA and FAP were less likely to have patients ask about genetic testing. This quantitative study suggests that internists often feel they have insufficient knowledge and may refer for PGD based on limited understanding. They view possible uses of PGD differently, partly reflecting varying ages of onset and disease treatability. Internists should be made aware of the potential benefit of PGD, but also be taught to refer patients, when appropriate, to clinical geneticists who could then refer the patient to an IVF/PGD team. These data thus have critical implications for training, research and practice.

Placebo: A pleasing effect

Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician. Hippocrates (c460 bc–c377 bc), Precepts, VI Placebo means ‘I will please’ in Latin. The word is used in the funeral mass, the Vespers for the Dead: ‘Placebo domine in regione vivorum’ (Ps. cxvi, 9) translates as ‘I will please the Lord in the land of the living’. In the fourteenth century, a placebo was used to describe a hired mourner paid to pretend to weep at a funeral. The English used placebo as a term of abuse to denote a sycophant or flatterer. In The Canterbury Tales, Chaucer writes ‘Flatteres been the develes chappeleyns that singen were Placebo’. The word placebo later evolved to describe an inactive substance. The Oxford English Dictionary, however, recognises the existence of a beneficial placebo effect, defining placebo as ‘an inactive or other sham form of therapy administered to a patient usually to compare its effects with those of a real drug or treatment, but sometimes for the psychological benefit to the patient through believing they are receiving treatment’. The placebo effect has been studied intensively. Does the patient improve because of a belief that the placebo works or is it primarily a function of the doctor–patient relationship? Placebo seems most likely to work in diseases with a strong psychological component. A recent study of patients with irritable bowel syndrome, a condition with a strong psychosomatic component, tried to tease out this question.1 Patients were randomised to be observed, to be given placebo acupuncture or to be given placebo acupuncture plus a warm patient–practitioner relationship (including an initial 45-min visit) for 3–6 weeks. The proportion of patients reporting adequate relief was 28% for observation, 44% for placebo acupuncture and 62% for placebo acupuncture plus patient–practitioner relationship. The patient–practitioner relationship was the most robust component.1 One intriguing aspect is that some patients improved even when they received sham acupuncture but were told by their practitioner that it was a research study so the practitioner was not allowed to talk to them while giving the treatment. Is it ethical to prescribe placebo deliberately, outside a trial? A survey found that 46–58% of US internists and rheumatologists prescribed placebo treatments regularly, usually over-the-counter analgesics (41%) or vitamins (38%), but also potentially harmful treatments such as antibiotics (13%) and sedatives (13%). Two thirds of the physicians who prescribed placebo told the patients it was a potentially beneficial treatment not usually used for this condition, not exactly a lie but a bit economical with the truth, while 5% disarmingly told the patients they were receiving an inactive drug.2 A study from Duke University found that patients given an identical placebo, but told either that it was a regular-cost placebo ($2.50 per tablet) or a cut-price placebo (10¢ per tablet), got better pain relief if they thought they were getting the more expensive placebo.3 This study won a 2008 IgNobel prize, prizes awarded for studies that make you laugh and then make you think (see http://www.bmj.com/cgi/section_pdf/337/oct08_1/a1998.pdf). The message I take home is that the psyche is complex, and it is best to develop a caring, trusting relationship with patients and their families. Knowingly prescribing an inactive treatment, particularly a potentially harmful one, sits uncomfortably with the concept of the importance of trust. It is ironic that placebo, a word that started as a term of abuse to describe an impostor who feigned real emotions, evolved to describe a treatment with no effect, only to find that the ‘ineffective’ treatment was sometimes effective because it affected emotions.

Physicians’ attitudes towards disclosure of prognostic information: A survey among a representative cross-section of 1605 Norwegian physicians

ObjectiveTo investigate if attitudes towards disclosure of prognostic information vary by speciality, previous experience and demographic factors in a general physician population. MethodsA postal survey among a representative sample of Norwegian physicians across all specialities (N=1605), using a translated questionnaire previously used to study attitudes towards disclosing prognostic information among US internists. ResultsA response rate of 70% was obtained after one reminder. 85% of the responders agreed to the helpfulness of an optimistic attitude. A factor analysis revealed three meaningful factors: ‘Prognostic communication is stressful’, ‘Fearing loss of reputation’ and ‘Reinforcement of positive prospects’. In multivariable models significantly more female than male physicians found aspects of prognostication straining (β=0.143, p<0.001). Those more experienced in communication of prognostic information towards end of life were less likely to support using reinforcement of positive prospects (β=0.067, p=0.001). ConclusionAfter years of focusing on patient autonomy and open communication between patient and physician many Norwegian physicians display attitudes that might hide the true content of prognostic information from the patients. Practice implicationsMany physicians think they are inadequately trained in prognostication and communication of prognostic information, suggesting that increased education and training are needed if patients’ wishes for information on prognosis are to be met in an individualised manner.

Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists

Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists

Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists

Objective To describe the attitudes and behaviours regarding placebo treatments, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment...

Physicians’ Responses to Resource Constraints

A common dilemma that confronts physicians in clinical practice is the allocation of scarce resources. Yet the strategies used by physicians in actual situations of resource constraint have not been studied. This study explores the strategies and rationales reported by physicians in situations of resource constraints encountered in practice. A national survey of US internists, oncologists, and intensive care specialists was performed by computer-assisted telephone interviews. As part of this survey, we asked physicians to tell us about a recent ethical dilemma encountered in practice. A subset of respondents reported difficulties regarding resource allocation. Transcripts of open-ended responses were coded for content based on consensus. Of the 600 physicians originally identified, 537 were eligible and 344 participated (response rate, 64%). Internists do not make allocation decisions alone but rather engage in negotiation in their resolution. Furthermore, these decisions are not made as dichotomous choices. Rather they often involve alternative solutions in the face of complexities of both the health care system and situations where limited resources must be allocated. Justice is not commonly the justification for rationing. Physicians' experiences in situations of resource constraints appear to be more complex than the normative literature on health care rationing assumes. In addition, reasoning about justice in health care seems to play only a small part in clinical decision making. Bridging this gap could be an important step in fostering fair allocation of resources in difficult cases.

A survey of chairpersons of departments of medicine about the current and future roles of clinical genetics in internal medicine.

The response of academic Departments of Medicine (DOM), who train the bulk of future US internists, to the increasing importance of clinical genetics is not known. A survey was distributed to 153 DOM chairpersons assessing the current and future roles of clinical genetics as related to internal medicine. Eighty-five (56%) surveys with complete data were returned. A minority of DOM currently employ geneticists; most genetics education and services are provided by nongeneticists; the general competency of internists to deliver genetic services is unclear. Academic DOM have limited faculty expertise in clinical genetics; this may impact the ability to integrate genetics into internal medicine practice and training.

Immunizations, Immunoprophylaxis, and Chemoprophylaxis to Prevent Selected Infections

VACCINES have played a vital role in improving health care in the United States. One need only remember that from 1951 to 1955 the United States averaged more than 35 000 cases of paralytic poliomyelitis annually, whereas in 1984 there were only eight reported cases. Nonetheless, there continue to be difficulties with immunization programs. Complacency is a major one; there are times when the glamour of modern curative medicine has overshadowed the steady, undramatic activities involved in immunization programs. This is particularly true when adult immunizations are considered. The emphasis on disease prevention, so dominant in the training of pediatricians, has not been as strong in the training received by US internists or general practitioners. The low 20% figure of yearly influenza immunizations given to high-risk patients is eloquent but sad testimony to this problem. Table 1 summarizes commonly used vaccines and immunoprophylactic agents. This review briefly describes the efficacy