Knowledge of Pre- and Postexposure Prophylaxis for HIV Prevention Among Internal Medicine Residents in the United States.

Prescription rates of pre-exposure prophylaxis (PrEP) have remained low among noninfectious disease providers in the United States despite almost a decade since their introduction. For future primary care doctors, residency is the optimal time to build practice patterns around HIV prevention. We assessed baseline knowledge of PrEP in specific pre- and post-exposure prophylaxis content areas among internal medicine trainees who completed the Physician Education and Assessment Center HIV learning module between 2013 to 2020 (N = 12,060). Resident baseline PrEP knowledge was universally low; despite rising awareness of antiretroviral therapy for PrEP in successive years following the nadir of 41% in 2014, still only 56% of residents affirmed this means of HIV prevention by 2020. Knowledge remained limited regardless of academic year, local HIV prevalence, or training program type. Online module completion increased competence across all content areas. There is still a deficit in HIV prevention knowledge across U.S. internal medicine residents, suggesting insufficient education and exposure to HIV-related care.

Review of the published literature to characterise clinical excellence in COVID-19 care.

COVID-19 continues to be a major source of global morbidity and mortality. It abruptly stressed healthcare systems early in 2020 and the pressures continue. Devastating hardships have been endured by individuals, families and communities; the losses will be felt for years to come. As healthcare professionals and organisations stepped up to respond to the overwhelming number of cases, it is understandable that the focus has been primarily on coping with the quantity of the demand. During a pandemic, it is not surprising that few papers have drawn attention to the quality of the care delivered to those afflicted with illness. Despite the challenges, clinicians caring for patients with COVID-19 have risen to the occasion. This manuscript highlights aspirational examples from the published literature of thoughtful and superb care of patients with COVID-19 using an established framework for clinical excellence (formulated by the Miller-Coulson Academy of Clinical Excellence).

Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomized Clinical Trial.

BACKGROUND: This is the first randomized controlled trial evaluating the impact of note template design on note quality using a simulated patient encounter and a validated assessment tool. OBJECTIVE: To compare note quality between two different templates using a novel randomized clinical simulation process. DESIGN: A randomized non-blinded controlled trial of a standard note template versus redesigned template. PARTICIPANTS: PGY 1-3 IM residents. INTERVENTIONS: Residents documented the simulated patient encounter using one of two templates. The standard template was modeled after the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment, and deemphasized less useful elements. MAIN MEASURES: Note length; time to note completion; note template evaluation by resident authors; note evaluation by faculty reviewers. KEY RESULTS: 36 residents participated, 19 randomized to standard template, 17 to new. New template generated shorter notes (103 vs 285 lines, p < 0.001) that took the same time to complete (19.8 vs 21.6 min, p = 0.654). Using a 5-point Likert scale, residents considered new notes to have increased visual appeal (4 vs 3, p = 0.05) and less redundancy and clutter (4 vs 3, p = 0.006). Overall template satisfaction was not statistically different. Faculty reviewers rated the standard note more up-to-date (4.3 vs 2.7, p = 0.001), accurate (3.9 vs 2.6, p = 0.003), and useful (4 vs 2.8, p = 0.002), but less organized (3.3 vs 4.5, p < 0.001). Total quality was not statistically different. CONCLUSIONS: Residents rated the new note template more visually appealing, shorter, and less cluttered. Faculty reviewers rated both note types equivalent in the overall quality but rated new notes inferior in terms of accuracy and usefulness though better organized. This study demonstrates a novel method of a simulated clinical encounter to evaluate note templates before the introduction into practice. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04333238.

The genealogy of teaching clinical reasoning and diagnostic skill: the GEL Study.

The genealogy of graduate medical education in America begins at the bedside. However, today's graduate medical trainees work in a training environment that is vastly different from medical training a century ago. The goal of the Graduate Medical Education Laboratory (GEL) Study, supported by the American Medical Association's (AMA) "Reimagining Residency" initiative, is to determine the factors in the training environment that most contribute to resident well-being and developing diagnostic skills. We believe that increasing time at the bedside will improve clinical skill, increase professional fulfillment, and reduce workplace burnout. Our graduate medical education laboratory will test these ideas to understand which interventions can be shared among all training programs. Through the GEL Study, we aim to ensure resident readiness for practice as we understand, then optimize, the learning environment for trainees and staff.

Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers.

Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP's preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs' PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers ("all trained") (42%) or having an onsite PrEP specialist ("on-site specialist") (43%). Only 15% preferred referring patients out of the practice to a specialist ("refer out"). Compared to those who preferred to "refer out," participants who preferred the "all trained" model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the "refer out" or on-site specialist" models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.

A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV is effective, yet many providers continue to lack knowledge and comfort in providing this intervention. It remains unclear whether internal medicine (IM) residents receive appropriate training in PrEP care and if this affects their future practices. OBJECTIVE: We sought to evaluate the relationship between current IM residents' prior PrEP training and knowledge, comfort, and practice regarding the provision of PrEP. DESIGN AND PARTICIPANTS: We created an online survey to assess IM residents' knowledge, attitudes, and behaviors related to PrEP. The survey was distributed among five IM programs across the USA. KEY RESULTS: We had a 35% response rate. Of 229 respondents, 96% (n = 220) had heard of PrEP but only 25% (n = 51) had received prior training and 11% (n = 24) had prescribed PrEP. Compared with those without, those with prior training reported good to excellent knowledge scores regarding PrEP (80% versus 33%, p < 0.001), more frequent prescribing (28% versus 7%, p = 0.001), and higher comfort levels with evaluating risk for HIV, educating patients, and monitoring aspects of PrEP (75% versus 26%, 56% versus 16%, and 47% versus 8%, respectively; all p values < 0.0001). While only 25% (n = 51) had received prior training, 75% (n = 103) of respondents reported that training all providers at their continuity clinic sites would improve implementation. CONCLUSIONS: We found that prior training was associated with higher levels of self-reported PrEP knowledge, comfort, and prescribing behaviors. Given the significant need for PrEP, IM residents should be trained to achieve adequate knowledge and comfort levels to prescribe it. This study demonstrates that providing appropriate PrEP training for IM residents may lead to an increase in the pool of graduating IM residents prescribing PrEP.

Low-grade Schwann cell neoplasms with leptomeningeal dissemination: clinicopathologic and autopsy findings.

Leptomeningeal dissemination of low-grade Schwann cell neoplasms is an exceptionally rare occurrence and has not been well documented in the literature. We encountered 2 cases of leptomeningeal dissemination of low-grade Schwann cell neoplasms. Patient 1 was a 63-year-old woman with neurofibromatosis type 1 and a progressive low-grade malignant peripheral nerve sheath tumor developing from a diffuse/plexiform orbital neurofibroma that arose in childhood. The neoplasm demonstrated local and leptomeningeal dissemination intracranially leading to the patient's death. There was partial loss of H3K27 tri-methylation, p16 and collagen IV. Patient 2 was a 60-year-old man without neurofibromatosis type 1 who presented with cranial nerve symptoms and a disseminated neoplasm with a Schwann cell phenotype. The neoplasm stabilized after irradiation and chemotherapy, but the patient died of medical complications. Autopsy findings documented disseminated leptomeningeal disease in the intracranial and spinal compartment. H3K27M tri-methylation was preserved. The clinicopathologic and autopsy findings are studied and presented, and the literature is reviewed.

A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians.

BACKGROUND: Among health care providers, prescription of HIV pre-exposure prophylaxis (PrEP) has been low. Little is known specifically about primary care physicians (PCPs) with regard to PrEP awareness and adoption (i.e., prescription or referral), and factors associated with adoption. OBJECTIVE: To assess PrEP awareness, PrEP adoption, and factors associated with adoption among PCPs. DESIGN: Cross-sectional online survey conducted in April and May 2015. RESPONDENTS: Members of a national professional organization for academic primary care physicians (n = 266). MAIN MEASURES: PrEP awareness, PrEP adoption (ever prescribed or referred a patient for PrEP [yes/no]), provider and practice characteristics, and self-rated knowledge, attitudes, and beliefs associated with adoption. KEY RESULTS: The survey response rate was 8.6 % (266/2093). Ninety-three percent of respondents reported prior awareness of PrEP. Of these, 34.9 % reported PrEP adoption. In multivariable analysis of provider and practice characteristics, compared with non-adopters, adopters were more likely to provide care to more than 50 HIV-positive patients (vs. 0, aOR = 6.82, 95 % CI 2.06-22.52). Compared with non-adopters, adopters were also more likely to report excellent, very good, or good self-rated PrEP knowledge (15.1 %, 33.7 %, 30.2 % vs. 2.5 %, 18.1 %, 23.8 %, respectively; p < 0.001) and to perceive PrEP as extremely safe (35.1 % vs. 10.7 %; p = 0.002). Compared with non-adopters, adopters were less likely to perceive PrEP as being moderately likely to increase risk behaviors ("risk compensation") (12.8 % vs. 28.8 %, p = 0.02). CONCLUSIONS: While most respondents were aware of PrEP, only one-third of PrEP-aware PCPs reported adoption. Adopters were more likely to have experience providing HIV care and to perceive PrEP as extremely safe, and were less likely to perceive PrEP use as leading to risk compensation. To enhance PCP adoption of PrEP, educational efforts targeting PCPs without HIV care experience should be considered, as well as training those with HIV care experience to be PrEP "clinical champions". Concerns about safety and risk compensation must also be addressed.

Primary Care Physicians' Willingness to Prescribe HIV Pre-exposure Prophylaxis for People who Inject Drugs.

Pre-exposure prophylaxis for HIV (PrEP) is recommended for people who inject drugs (PWID). Despite their central role in disease prevention, willingness to prescribe PrEP to PWID among primary care physicians (PCPs) is largely understudied. We conducted an online survey (April-May 2015) of members of a society for academic general internists regarding PrEP. Among 250 respondents, 74% (n = 185) of PCPs reported high willingness to prescribe PrEP to PWID. PCPs were more likely to report high willingness to prescribe PrEP to all other HIV risk groups (p's < 0.03 for all pair comparisons). Compared with PCPs delivering care to more HIV-infected clinic patients, PCPs delivering care to fewer HIV-infected patients were more likely to report low willingness to prescribe PrEP to PWID (Odds Ratio [95% CI] = 6.38 [1.48-27.47]). PCP and practice characteristics were not otherwise associated with low willingness to prescribe PrEP to PWID. Interventions to improve PCPs' willingness to prescribe PrEP to PWID are needed.

Evolution of an attenuated HIV-1 isolate in an elite suppressor.

Elite controllers or suppressors (ES) control viral replication without antiretroviral therapy. While many ES are infected with replication-competent virus, others have evidence of infection with attenuated isolates. Here we report a case of an ES infected with an HIV-1 isolate that contained a 38-base pair deletion in nef that led to a reading frame shift and a premature stop codon. Interestingly, clones amplified from plasma or cultured from CD4(+) T cells between 2006 and 2008 contained one of two separate compensatory deletions that restored the reading frame. A new insertion generated by duplication of adjacent sequences was found in isolates obtained in 2010 and this evolution was accompanied by the development of low level viremia. This article provides evidence of the evolution of an attenuated HIV-1 isolate toward greater virulence in an elite suppressor.

Factors affecting clinician educator encouragement of routine HIV testing among trainees.

BACKGROUND: Adoption of CDC recommendations for routine, voluntary HIV screening of all Americans age 13­64 years has been slow. One method to increase adherence to clinical practice guidelines is through medical school and residency training. OBJECTIVE: To explore the attitudes, barriers, and behaviors of clinician educators (CEs) regarding advocating routine HIV testing to their trainees. DESIGN/PARTICIPANTS: We analyzed CE responses to a 2009 survey of Society of General Internal Medicine members from community, VA, and university-affiliated clinics regarding HIV testing practices. MAIN MEASURES: Clinician educators were asked about their outpatient practices, knowledge and attitudes regarding the revised CDC recommendations and whether they encouraged trainees to perform routine HIV testing. Associations between HIV testing knowledge and attitudes and encouraging trainees to perform routine HIV testing were estimated using bivariate and multivariable logistic regression. RESULTS: Of 515 respondents, 367 (71.3%) indicated they supervised trainees in an outpatient general internal medicine clinic. These CEs demonstrated suboptimal knowledge of CDC guidelines and over a third reported continued risk-based testing. Among CEs, 196 (53.4%) reported that they encourage trainees to perform routine HIV testing. Higher knowledge scores (aOR 5.10 (2.16, 12.0)) and more positive attitudes toward testing (aOR 8.83 (4.21, 18.5)) were independently associated with encouraging trainees to screen for HIV. Reasons for not encouraging trainees to screen included perceived low local prevalence (37.2%), competing teaching priorities (34.6%), and a busy clinic environment (34.0%). CONCLUSIONS: Clinician educators have a special role in the dissemination of the CDC recommendations as they impact the knowledge and attitudes of newly practicing physicians. Despite awareness of CDC recommendations, many CEs do not recommend universal HIV testing to trainees. Interventions that improve faculty knowledge of HIV testing recommendations and address barriers in resident clinics may enhance adoption of routine HIV testing.

General internists' beliefs, behaviors, and perceived barriers to routine HIV screening in primary care.

The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in primary care but little is known about general internists' views of this practice. We conducted a national, cross-sectional, Internet-based survey of 446 general internists in 2009 regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient internal medicine practices. Internists' awareness of revised CDC guidelines was high (88%), but only 52% had increased HIV testing, 61% offered HIV screening regardless of risk, and a median 2% (range 0-67%) of their patients were tested in the past month. Internists practicing in perceived higher risk communities reported greater HIV screening. Consent requirements were a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. Interventions that promote HIV screening regardless of risk and streamlined consent requirements will likely increase adoption of routine HIV screening in general medicine practices.

Provider and practice characteristics associated with use of rapid HIV Testing by general internists.

BACKGROUND: Rapid HIV testing could increase routine HIV testing. Most previous studies of rapid testing were conducted in acute care settings, and few described the primary care providers' perspective. OBJECTIVE: To identify characteristics of general internal medicine physicians with access to rapid HIV testing, and to determine whether such access is associated with differences in HIV-testing practices or perceived HIV-testing barriers. DESIGN: Web-based cross-sectional survey conducted in 2009. PARTICIPANTS: A total of 406 physician members of the Society of General Internal Medicine who supervise residents or provide care in outpatient settings. MAIN MEASURES: Surveys assessed provider and practice characteristics, HIV-testing types, HIV-testing behavior, and potential barriers to HIV testing. RESULTS: Among respondents, 15% had access to rapid HIV testing. In multivariable analysis, physicians were more likely to report access to rapid testing if they were non-white (OR 0.45, 95% CI 0.22, 0.91), had more years since completing training (OR 1.06, 95% CI 1.02, 1.10), practiced in the northeastern US (OR 2.35; 95% CI 1.28, 4.32), or their practice included a higher percentage of uninsured patients (OR 1.03; 95% CI 1.01, 1.04). Internists with access to rapid testing reported fewer barriers to HIV testing. More respondents with rapid than standard testing reported at least 25% of their patients received HIV testing (51% versus 35%, p = 0.02). However, access to rapid HIV testing was not significantly associated with the estimated proportion of patients receiving HIV testing within the previous 30 days (7.24% vs. 4.58%, p = 0.06). CONCLUSION: Relatively few internists have access to rapid HIV testing in outpatient settings, with greater availability of rapid testing in community-based clinics and in the northeastern US. Future research may determine whether access to rapid testing in primary care settings will impact routinizing HIV testing.

A multicenter study of internal medicine residents' perceptions of training, competence, and performance in outpatient HIV care.

Routine HIV screening is recommended by the Centers for Disease Control and Prevention (CDC), but it is unknown how well internal medicine residents are trained in HIV risk assessment, testing, counseling, and initial management of HIV patients. We sought to determine internal medicine residents' attitudes about HIV training and the factors that influence their HIV care performance utilizing a cross-sectional survey of 321 second- and third-year internal medicine residents from four programs in Baltimore, Boston, Detroit, and New York City between March and June 2006. Measurements included HIV care experience; attitudes, competency, and adequacy of HIV training; and basic HIV care performance and factors impacting performance. Two hundred twenty-three residents (69%) completed the survey. While 50% of residents reported over 30 HIV inpatient encounters in the past year, the majority of residents had limited outpatient exposure providing care for only 1-5 HIV outpatients. Managing HIV patients was rated an excellent educational opportunity by 89% of residents and 77% planned to care for HIV patients in the future. However, 39% stated that they did not feel competent to provide HIV outpatient care. Higher rates of residents reported deficiency in outpatient HIV training compared to outpatient non-HIV training (p < 0.05) or inpatient HIV training (p < 0.05). Residents reported substandard HIV risk assessment, testing, counseling, and initial management performance. Self-reported proficiency correlated with the number of HIV outpatients cared for and perceived training adequacy. Current residency training in HIV care remains largely inpatient-based and residents frequently rate HIV outpatient training as inadequate.

"We'll do this together": the role of the first person plural in fostering partnership in patient-physician relationships.

BACKGROUND: Partnership is integral to therapeutic relationships, yet few studies have examined partnership-fostering communication behaviors in the clinic setting. We conducted this study to better understand how statements in which physicians use the first person plural might foster partnership between patient and provider. METHODS: We audio-recorded encounters between 45 HIV providers and 418 patients in the Enhancing Communication and HIV Outcomes (ECHO) Study. We used the Roter Interaction Analysis System (RIAS) to code for statements made by the physician that used the first person plural to refer to themselves and their patient. Using multiple logistic regression, we examined the associations between the occurrence of one or more first person plural statements with patient ratings of provider communication. To better understand the meaning of first person plural statements, we conducted a qualitative analysis. MAIN RESULTS: Providers were mostly white (69%) and Asian (24%); 57% were female. Patients were black (60%), white (25%), and Hispanic (15%); 33% were female. One or more first person plural statements occurred in 92/418 (22%) of encounters. In adjusted analyses, encounters with first person plural statements were associated with younger patient age (OR 0.97, 95% CI 0.94-0.99), higher patient depression scores (highest tertile compared to lowest tertile: OR 1.89, 95% CI 1.01-3.51), the patient not being on anti-retroviral therapy (OR 0.53, 95% CI 0.29-0.93), and older provider age (OR 1.05, 95% CI 1.00-1.09). After adjustment, patients were less likely to highly rate their provider's communication style if first person plural statements were used (AOR 0.57, 95% CI 0.33-0.96). There were 167 first person plural statements made by physicians in the 418 encounters. Qualitative analysis revealed that many first person plural features had at least one negative feature such as being overtly persuasive ("That's going to be our goal"), indirect ("What can we do to improve your diet?"), or ambiguous ("Let's see what we can do"), although there were also positive statements that involved patients in the health-care process, contributed to a mutual understanding, and addressed the patients' goals. CONCLUSIONS: Contrary to our hypotheses, use of first person plural was not associated with higher ratings of provider communication, probably because some of these statements were overtly persuasive, indirect, or ambiguous. Physicians should become aware of benefits and pitfalls of using the first person plural with patients. Further research is needed to determine the most effective methods through which providers can build alliances with patients.