Common Complaints of the Hands and Feet.

Primary care providers frequently care for complaints of the hands and feet. Here, the author describes the typical presentations of hand osteoarthritis, carpal tunnel syndrome, ganglion cysts, plantar fasciitis, onychomycosis, and Morton neuroma. Useful physical examination techniques are described. The history and physical examination are usually sufficient to diagnose these conditions without the need for more advanced testing. All of these conditions have evidence-based therapy that can be initiated by the primary care provider. These treatments as well as reasons to refer to a specialist are reviewed.

A Cautionary Tale: The 2019 Orphaning of Hahnemann's Graduate Medical Trainees.

Hahnemann University Hospital provided care for Philadelphians starting in 1848, but its recent history has been riddled with financial turmoil that culminated in its rapid closure in summer 2019. As the hospital shuttered its doors to patients, it also orphaned 583 medical trainees. This crisis exposed vulnerabilities in graduate medical education (GME). In a firsthand account of the situation that developed in Philadelphia and reached academic institutions across the country, the authors reflect on lessons learned that may help leaders at other institutions mitigate the inevitable difficulties that arise when academic hospitals close. These lessons pertain to handling panic and administrative burdens in the aftermath of closure, the importance of well-defined processes, a clear understanding of GME funding, and strategies for placement of trainees that minimize disruption of their education.

Development and Implementation of a Novel Learner-driven Precepting Model for Pulmonary Fellowship.

Background: Ambulatory education is currently underemphasized in pulmonary and critical care medicine (PCCM) fellowship training. Existing clinic precepting models, originally developed for students and residents, do not meet the unique needs of fellow-level trainees. Objective: We aimed to develop and implement a novel fellow-led precepting model to improve ambulatory education for PCCM trainees. Methods: We performed a mixed-methods needs assessment, including surveys, focus groups, and direct observations, to explore perceptions of ambulatory training, define current precepting practices, and identify target areas for improvement. On the basis of these findings, we developed, implemented, and evaluated a novel model for PCCM outpatient precepting. Results: A targeted needs assessment identified that current precepting practices did not meet fellows' needs for graduated autonomy, development of assessment and management skills, and self-directed learning. We developed and implemented a novel, learner-driven precepting model (Set the Stage, Tell the Story, Educational Goals, Preliminary Plan, Uncertainties, Plan Recap [STEP-UP]), designed to prioritize clinical reasoning skills and self-identification of learning goals. Implementation of the STEP-UP model improved perceptions of overall outpatient training and precepting. However, we faced several barriers to uptake of the new model, including increased cognitive burden of integrating a new process. Conclusion: A robust assessment of ambulatory education at a single PCCM fellowship program identified a need to align precepting processes with the unique goals of advanced trainees. We developed a learner-driven precepting model focused on development of clinical reasoning skills and self-directed educational objectives. Additional study is warranted to refine, adapt, and test the model in different setting.

The Graduate Medical Education (GME) Gold Rush: GME Slots and Funding as a Financial Asset.

The unprecedented displacement of more than 550 trainees that occurred because of the closure of Hahnemann University Hospital has demonstrated that the medical education community, Centers for Medicare and Medicaid Services, and the Accreditation Council for Graduate Medical Education were unprepared for a graduate medical education (GME) crisis of this scale. The authors offer a first-hand perspective of the chaotic environment that ensued following the announcement of the hospital's closure and of the challenges faced by trainees and program leadership looking to ensure trainees found a landing program that was a good fit for them. The authors review the complexity of GME funding and how the owners of Hahnemann University Hospital leveraged this in an attempt to offset debt. The lessons learned from the authors' experience can help inform the medical education community's response to this type of crisis in the future.

Seeking a stable foundation to build on: 1st-Year residents' views of high-value care teaching.

Background: United States (US) residency programs have been recently mandated to teach the concept of high-value care (HVC) defined as care that balances the benefits of interventions with their harms and costs. We know that reflective practice is a key to successful learning of HVC; however, little is known about resident perceptions of HVC learning. To better inform HVC teaching in graduate medical education, we asked 1st-year residents to reflect on their HVC learning. Methods: We conducted three focus groups (n = 36) and online forum discussion (n = 13) of 1st-year internal medicine residents. A constructivist grounded theory approach was used to assess transcripts for recurrent themes to identify the perspectives of residents shared about HVC learning. Results: Residents perceived their learning of HVC as limited by cultural and systemic barriers that included limited time, fear of missing a diagnosis, perceived expectations of attending physicians, and poor cost transparency. While the residents reported considerable exposure to the construct of HVC, they desired a more consistent framework that could be applied in different situations. In particular, residents reported frustration with variable incentives, objectives, and definitions pertaining to HVC. Suggestions for improvement in HVC teaching outlined three main needs for: (1) a generalizable framework to systematically approach each case that could be later adapted to independent practice; (2) objective real-time data on costs, benefits, and harms of medical interventions; and (3) standardized approach to assess resident competency in HVC. Discussion: As frontline clinicians and the intended target audience for HVC education, 1st-year residents are in a unique position to provide feedback to improve HVC teaching in residency. Our findings highlight the learners' desire for a more systematic approach to HVC teaching that includes the development of a stable generalizable framework for decision-making, objective data, and standardized assessment. These findings contrast current educational interventions in HVC that aim at reducing the overuse of specific practices.

Cardiovascular Testing in Asymptomatic Patients: Carotid Duplex, Cardiac Stress Testing, Screen for Peripheral Arterial Disease.

Approximately one-third of deaths in the United States are from cardiovascular disease. Managing modifiable risk factors is paramount to reducing risk of heart disease and stroke. It is logical to try to identify patients with silent disease that may predispose them to significant morbidity and mortality. Unfortunately, it is unclear if routine screening for the presence of carotid stenosis, coronary artery disease, and peripheral arterial disease is beneficial. Many of these tests are expensive. This review explores the evidence behind screening tests, costs associated with the tests, and the implications of positive screening for each of the 3 listed conditions.

Urokinase-deficient and urokinase receptor-deficient mice have impaired neutrophil antimicrobial activation in vitro.

Leukocytes express both urokinase-type plasminogen activator (uPA) and the urokinase receptor (uPAR, CD87). We have shown that neutrophil recruitment to the lung during P. aeruginosa pneumonia is impaired in uPAR-deficient (uPAR-/-) mice but is normal in uPA-/- mice. However, both uPA-/- mice and uPAR-/- mice have impaired lung clearance of P. aeruginosa compared with wild-type (WT) mice. To determine the role of uPA and uPAR in antibacterial host defense, we compared neutrophil bacterial-phagocytosis, respiratory burst, and degranulation among uPA-/-, uPAR-/-, and WT mice. Neutrophil phagocytosis was significantly diminished comparing uPA-/- and uPAR-/- mice with WT mice at all time points. The generation of superoxide by both uPA-/- and uPAR-/- neutrophils was about half of that seen in WT neutrophils. Degranulation of azurophilic granules was significantly diminished in uPA-/- neutrophils compared with either uPAR-/- or WT neutrophils. By contrast, agonist-stimulated release of specific granules was not diminished in either uPA-/- or uPAR-/- mice compared with WT. We conclude that the uPA/uPAR system modulates several of the crucial steps in neutrophil activation that result in bacterial killing and effective innate host defense.