Historical view of medical Spanish instruction in a medical school at the US-Mexico border region.

With a growing speaking Spanish population in the USA, it is necessary to help meet their healthcare needs. The Paul L. Foster School of Medicine is located in El Paso at the US-Mexico border. The medical Spanish curriculum is required for all medical students and begins on their first day of medical school, with conversational Spanish and medical Spanish through the preclerkship years. One of the key elements to the success of this course is the use of instructors with expertise in language instruction with an emphasis on task-based instruction. In addition to language instruction, this course also emphasizes instruction and experience in the culture of the US-Mexico border region. While taught medical Spanish, students are also prompted to understand when their skills are not adequate for the situation, in which case they need to enlist a skilled translator. Students report that, on a daily basis, they productively use what they learned in this preclerkship curriculum.

Continuity Clinic Model and Diabetic Outcomes in Internal Medicine Residencies: Findings of the Educational Innovations Project Ambulatory Collaborative.

BACKGROUND: Efforts to improve diabetes care in residency programs are ongoing and in the midst of continuity clinic redesign at many institutions. While there appears to be a link between resident continuity and improvement in glycemic control for diabetic patients, it is uncertain whether clinic structure affects quality measures and patient outcomes. METHODS: This multi-institutional, cross-sectional study included 12 internal medicine programs. Three outcomes (glycemic control, blood pressure control, and achievement of target low-density lipoprotein [LDL]) and 2 process measures (A1C and LDL measurement) were reported for diabetic patients. Traditional, block, and combination clinic models were compared using analysis of covariance (ANCOVA). Analysis was adjusted for continuity, utilization, workload, and panel size. RESULTS: No significant differences were found in glycemic control across clinic models (P = .06). The percentage of diabetic patients with LDL < 100 mg/dL was 60% in block, compared to 54.9% and 55% in traditional and combination models (P = .006). The percentage of diabetic patients with blood pressure < 130/80 mmHg was 48.4% in block, compared to 36.7% and 36.9% in other models (P < .001). The percentage of diabetic patients with HbA1C measured was 92.1% in block compared to 75.2% and 82.1% in other models (P < .001). Also, the percentage of diabetic patients with LDL measured was significantly different across all groups, with 91.2% in traditional, 70.4% in combination, and 83.3% in block model programs (P < .001). CONCLUSIONS: While high scores on diabetic quality measures are achievable in any clinic model, the block model design was associated with better performance.

Clinic Design and Continuity in Internal Medicine Resident Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative.

BACKGROUND: Many internal medicine (IM) programs have reorganized their resident continuity clinics to improve trainees' ambulatory experience. Downstream effects on continuity of care and other clinical and educational metrics are unclear. METHODS: This multi-institutional, cross-sectional study included 713 IM residents from 12 programs. Continuity was measured using the usual provider of care method (UPC) and the continuity for physician method (PHY). Three clinic models (traditional, block, and combination) were compared using analysis of covariance. Multivariable linear regression analysis was used to analyze the effect of practice metrics and clinic model on continuity. RESULTS: UPC, reflecting continuity from the patient perspective, was significantly different, and was highest in the block model, midrange in combination model, and lowest in the traditional model programs. PHY, reflecting continuity from the perspective of the resident provider, was significantly lower in the block model than in combination and traditional programs. Panel size, ambulatory workload, utilization, number of clinics attended in the study period, and clinic model together accounted for 62% of the variation found in UPC and 26% of the variation found in PHY. CONCLUSIONS: Clinic model appeared to have a significant effect on continuity measured from both the patient and resident perspectives. Continuity requires balance between provider availability and demand for services. Optimizing this balance to maximize resident education, and the health of the population served, will require consideration of relevant local factors and priorities in addition to the clinic model.

Determinants of Patient Satisfaction in Internal Medicine Resident Continuity Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative.

BACKGROUND: Many internal medicine programs have reorganized their resident continuity clinics to improve the ambulatory care experience for residents. The effect of this redesign on patient satisfaction is largely unknown. METHODS: Our multi-institutional, cross-sectional study included 569 internal medicine residents from 11 programs participating in the Educational Innovations Project Ambulatory Collaborative. An 11-item patient satisfaction survey from the Consumer Assessment of Healthcare Providers and Systems was used to assess patient satisfaction, comparing patient satisfaction in traditional models of weekly continuity clinic with 2 new clinic models. We then examined the relationship between patient satisfaction and other practice variables. RESULTS: Patient satisfaction responses related to resident listening and communication skills, knowledge of medical history, perception of adequate visit time, overall rating, and willingness to refer to family and friends were significantly better in the traditional and block continuity models than the combination model. Higher ambulatory workload was associated with reduced patient perception of respect shown by the physician. The percentage of diabetic patients with glycated hemoglobin < 8% was positively correlated with number of visits, knowledge of medical history, perception of respect, and higher scores for recommending the physician to others. The percentage of diabetic patients with low density lipoprotein < 100 mg/dL was positively correlated with the physician showing respect. CONCLUSIONS: Patient satisfaction was similar in programs using block design and traditional models for continuity clinic, and both outperformed the combination model programs. There was a delicate balance between workload and patient perception of the physician showing respect. Care outcome measures for diabetic patients were associated with aspects of patient satisfaction.

Redefining revision total hip arthroplasty based on hospital admission status.

This study examined patient demographics, length of hospital stay, and discharge disposition in those undergoing nonelective revision total hip arthroplasty (rTHA) vs elective rTHA. Data from 23 000 patients with hip revisions from 2005 through 2007 were extracted from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. We examined patient admission status, demographics, length of stay, and discharge location. We found that patients undergoing nonelective rTHA were older, were female, had more comorbidities, stayed an excess of 1.61 days in the hospital, and required a skilled care facility after discharge compared with those undergoing elective rTHA. We found that rTHA outcomes varied based on patient hospital admission status. Patients who elected to have rTHA had less comorbidities, cost, and likelihood of being discharged into a skilled care facility.

Rural-urban differences in surgical procedures for Medicare beneficiaries.

OBJECTIVE: To determine whether Medicare beneficiaries in rural areas were less likely to undergo a variety of surgical procedures compared with their urban counterparts. DESIGN, SETTING, AND PATIENTS: Cross-sectional study of Medicare beneficiaries. MAIN OUTCOME MEASURE: Any incidence of the surgical procedures studied. RESULTS: Compared with urban Medicare beneficiaries, rural Medicare beneficiaries were more likely to undergo a broad array of surgical procedures: 35% more likely for carotid endarterectomy (odds ratio [OR] = 1.35; 95% confidence interval [CI], 1.33-1.38), 32% for lumbar spine fusion (OR = 1.32; 95% CI, 1.29-1.35), 30% for knee replacement surgery (OR = 1.30; 95% CI, 1.28-1.31), 28% for abdominal aortic aneurysm repair (OR = 1.28; 95% CI, 1.24-1.31), 22% for prostatectomy (OR = 1.22; 95% CI, 1.19-1.24), 19% for hip replacement surgery (OR = 1.19; 95% CI, 1.17-1.21), 18% for aortic valve replacement (OR = 1.18; 95% CI, 1.14-1.21), 16% for open reduction and internal fixation of the femur (OR = 1.16; 95% CI, 1.14-1.18), and 15% for appendectomy (OR = 1.15; 95% CI, 1.11-1.19). To determine whether these differences could be explained by known confounding variables, we then used logistic regression to adjust for age, sex, race/ethnicity, median household income, average house value, mean poverty ratio, and state of residence. Rural beneficiaries were still more likely to undergo all of these surgical procedures. CONCLUSIONS: Medicare beneficiaries living in rural areas were more likely to undergo a broad array of surgical procedures compared with those living in urban areas. While allaying some concern about rural access to surgical procedures, the uniformity of these results raises concern that people living in rural areas may have an overall poorer quality of health.

Outcomes in patients with rheumatoid arthritis and myocardial infarction.

BACKGROUND: Patients with rheumatoid arthritis have an increased risk for accelerated atherosclerosis. It is unknown, however, whether rheumatoid arthritis also increases in-hospital mortality after a myocardial infarction or influences the therapy patients receive. METHODS: A cross-sectional analysis of 1,112,676 patients with myocardial infarction in the 2003-2005 Nationwide Inpatient Sample was performed. RESULTS: Patients with rheumatoid arthritis were 39% more likely to receive medical therapy (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.30-1.49) than interventional therapy. By using logistic regression, we adjusted for confounding variables to determine the effect of rheumatoid arthritis on the selection of therapy and found that rheumatoid arthritis itself was associated with a 38% increased likelihood of undergoing thrombolysis (OR, 1.38; 95% CI, 1.10-1.71) and a 27% increased likelihood of undergoing percutaneous coronary intervention (OR, 1.27; 95% CI, 1.17-1.39). For the primary outcome measure, we determined that patients with rheumatoid arthritis overall had a 24% better in-hospital mortality compared with other patients with a myocardial infarction (OR, 0.76; 95% CI, 0.68-0.86), which was 34% better after adjusting for confounding variables (OR, 0.66; 95% CI, 0.59-0.74). This better in-hospital mortality was seen in patients with rheumatoid arthritis undergoing medical therapy (adjusted OR, 0.67; 95% CI, 0.59-0.75) and percutaneous coronary intervention (adjusted OR, 0.47; 95% CI, 0.32-0.70), but not in patients undergoing thrombolysis or coronary artery bypass grafting. CONCLUSIONS: Among patients with myocardial infarction, rheumatoid arthritis was associated with an increased use of thrombolysis and percutaneous coronary intervention. Moreover, patients with rheumatoid arthritis had an in-hospital survival advantage, particularly those undergoing medical therapy and percutaneous coronary intervention.

Rural-urban differences in behaviors to prevent skin cancer: an analysis of the Health Information National Trends Survey.

BACKGROUND: There is concern that rural residents may be less likely to engage in behaviors to reduce their risk for skin cancer compared with urban residents. OBJECTIVES: First, we sought to determine whether rural residents are less likely to use sunscreen and engage in other skin cancer preventive measures. Second, we sought to determine whether such actions are sufficiently explained by factors known to affect these behaviors or whether such actions are affected by rurality. METHODS: We analyzed the 2005 Health Information National Trends Survey, a survey of the noninstitutionalized, adult population performed by the National Cancer Institute. We used logistic regression analysis to adjust for confounding by age, race, income, education, health insurance, smoking, sex, marital status, and region. RESULTS: Compared with urban residents, rural residents were 33% less likely (odds ratio = 0.67; 95% confidence interval, 0.57-0.80) to wear sunscreen when exposed to the sun for more than 1 hour. After adjusting for the above confounding variables, however, rural individuals were just as likely as urban individuals to use sunscreen with sun exposure. LIMITATIONS: Inability to adjust for unmeasured confounding variables, such as occupational sun exposure, is a limitation. CONCLUSION: Rural residents were less likely to use sunscreen. This decreased use of sunscreen, however, was explained by differences in age, race, income, education, and other confounding factors that negatively influence the use of sunscreen.

Evaluating Emergency Medicine Faculty at End-of-Shift.

INTRODUCTION: Faculty often evaluate learners in the emergency department (ED) at the end of each shift. In contrast, learners usually evaluate faculty only at the end of a rotation. In December 2007 Southern Illinois University School of Medicine changed its evaluation process, requiring ED trainees to complete end-of-shift evaluations of faculty. OBJECTIVE: Determine the feasibility and acceptance of end-of-shift evaluations for emergency medicine faculty. METHODS: We conducted this one-year observational study at two hospitals with 120,000 combined annual ED visits. Trainees (residents and students) anonymously completed seven-item shift evaluations and placed them in a locked box. Trainees and faculty completed a survey about the new process. RESULTS: During the study, trainees were assigned 699 shifts, and 633 end-of-shift evaluations were collected for a completion rate of 91%. The median number of ratings per faculty was 31, and the median number of comments was 11 for each faculty. The survey was completed by 16/22 (73%) faculty and 41/69 (59%) trainees. A majority of faculty (86%) and trainees (76%) felt comfortable being evaluated at end-of-shift. No trainees felt it was a time burden. CONCLUSION: Evaluating faculty following an ED shift is feasible. End-of-shift faculty evaluations are accepted by trainees and faculty.

Mortality after coronary artery revascularization of patients with rheumatoid arthritis.

OBJECTIVE: Patients with rheumatoid arthritis have an increased risk for accelerated atherosclerosis. It is not known, however, whether this disorder is associated with a higher risk of complications after coronary artery revascularization. METHODS: We conducted a cross-sectional study of patients in the 2003-2005 Nationwide Inpatient Sample. To determine whether patients with rheumatoid arthritis had higher in-hospital mortality after coronary artery revascularization, we used logistic regression to adjust for age, sex, race/ethnicity, income, rural-urban residency, diabetes, hypertension, hyperlipidemia, Charlson comorbidities (including myocardial infarction, congestive heart failure, and diabetes), elective admission, weekend admission, and primary payer. RESULTS: Among patients undergoing coronary artery revascularization, those with rheumatoid arthritis were 49% less likely to die while hospitalized compared with those without rheumatoid arthritis (odds ratio, 0.51; 95% confidence interval, 0.40-0.65) after adjusting for the above confounders. In subgroup analyses that adjusted for the same confounders, patients with rheumatoid arthritis also had a 61% improvement of in-patient mortality when they underwent percutaneous coronary interventions (odds ratio, 0.39; 95% confidence interval, 0.29-0.54) along with a median of 0.32 less days hospitalized (95% confidence interval, 0.28-0.34 days). Similarly, patients with rheumatoid arthritis undergoing coronary artery bypass grafting had a 31% improvement of in-patient mortality (odds ratio, 0.69; 95% confidence interval, 0.48-0.99), with a median of 1.36 less days hospitalized (95% confidence interval, 0.72-1.12 days). CONCLUSION: Among patients undergoing coronary artery revascularization, patients with rheumatoid arthritis have an in-hospital survival advantage along with reduced days of hospitalization compared with patients without rheumatoid arthritis.

Joint replacement surgeries among medicare beneficiaries in rural compared with urban areas.

OBJECTIVE: People in rural areas live farther away from hospitals than do people in urban areas. Thus, there is concern that people living in rural areas may be less willing or able to undergo elective surgical procedures. This study was undertaken to determine whether Medicare beneficiaries in rural areas were less likely to have elective total knee or hip replacement surgeries compared with their urban counterparts. METHODS: We performed a cross-sectional study of Medicare beneficiaries, controlling for age, sex, race/ethnicity, and economic status. Beneficiaries were assigned to rural versus urban areas based on their zip code of residence and the 10-point Rural-Urban Commuting Area designation. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. RESULTS: Compared with urban beneficiaries, rural beneficiaries were 27% more likely to have total knee or hip replacement surgeries (OR 1.27 [95% CI 1.26-1.28]). After adjusting for age, sex, race/ethnicity, median household income, average house value, mean poverty ratio, and state of residence, rural beneficiaries were still 14% more likely to have total joint replacement surgeries (OR 1.14 [95% CI 1.13-1.16]). Differential use of surgery before and after receiving Medicare eligibility did not explain the findings. While significant sex, racial, and ethnic disparities were present in both rural and urban areas, for the most part these disparities were ameliorated rather than accentuated in rural areas. CONCLUSION: Contrary to expectations, our findings indicate that Medicare beneficiaries living in rural areas are more likely to undergo total knee or hip replacement surgeries.

Health literacy skills in rural and urban populations.

OBJECTIVE: To determine whether health literacy is lower in rural populations. METHOD: We analyzed health, prose, document, and quantitative literacy from the National Assessment of Adult Literacy study. Metropolitan Statistical Area designated participants as rural or urban. RESULTS: Rural populations had lower literacy levels for all literacy types (P<0.001 for each). After adjusting for known confounders, there was no longer a difference in health or prose literacy (P>0.05). However, rural populations had higher document (P=0.04) and quantitative (P=0.01) literacy. CONCLUSION: Health literacy is lower in the rural population although this difference is explained by known confounders.

Effect of number of clinics and panel size on patient continuity for medical residents.

BACKGROUND: Accreditation Council for Graduate Medical Education program requirements for internal medicine residency training include a longitudinal, continuity experience with a panel of patients. OBJECTIVE: To determine whether the number of resident clinics, the resident panel size, and the supervising attending physician affect patient continuity. To determine the number of clinics and the panel size necessary to maximize patient continuity. DESIGN: We used linear regression modeling to assess the effect of number of attended clinics, the panel size, and the attending physician on patient continuity. PARTICIPANTS: Forty medicine residents in an academic medicine clinic. MEASUREMENTS: Percent patient continuity by the usual provider of care method. RESULTS: Unadjusted linear regression analysis showed that patient continuity increased 2.3% ± 0.7% for each additional clinic per 9 weeks or 0.4% ± 0.1% for each additional clinic per year (P  =  .003). Conversely, patient continuity decreased 0.7% ± 0.4% for every additional 10 patients in the panel (P  =  .04). When simultaneously controlling for number of clinics, panel size, and attending physician, multivariable linear regression analysis showed that patient continuity increased 3.3% ± 0.5% for each additional clinic per 9 weeks or 0.6% ± 0.1% for each additional clinic per year (P < .001). Conversely, patient continuity decreased 2.2% ± 0.4% for every additional 10 patients in the panel (P < .001). Thus, residents who actually attend at least 1 clinic per week with a panel size less than 106 patients can achieve 50% patient continuity. Interestingly, the attending physician accounted for most of the variability in patient continuity (51%). CONCLUSIONS: Patient continuity for residents significantly increased with increasing numbers of clinics and decreasing panel size and was significantly influenced by the attending physician.

Giant cell arteritis presenting as small bowel infarction.

Giant cell arteritis predominantly affects cranial arteries and rarely involves other sites. We report a patient who presented with small bowel obstruction because of infarction from mesenteric giant cell arteritis. She had an unusual cause of her obstruction and a rare manifestation of giant cell arteritis. In spite of aggressive therapy with steroids, she died a month later because of multiple complications. We discuss the diagnosis and management of small bowel obstruction and differential diagnosis of vasculitis of the gastrointestinal tract. We were able to find 11 cases of bowel involvement with giant cell arteritis in the English literature. This case report illustrates that giant cell arteritis can be a cause of small bowel obstruction and bowel infarction. In the proper clinical setting, vasculitides need to be considered early in the differential diagnosis when therapy may be most effective.

Diagnostic approach to polyarticular joint pain.

Identifying the cause of polyarticular joint pain can be difficult because of the extensive differential diagnosis. A thorough history and a complete physical examination are essential. Six clinical factors are helpful in narrowing the possible causes: disease chronology, inflammation, distribution, extra-articular manifestations, disease course, and patient demographics. Patients with an inflammatory arthritis are more likely to have palpable synovitis and morning stiffness; if the condition is severe, they may have fever, weight loss, and fatigue. Viral infections, crystal-induced arthritis, and serum sickness reactions are common causes of acute, self-limited polyarthritis. Because chronic arthritides may present abruptly, they need to be considered in patients who present with acute polyarticular joint pain. Joint palpation can help to distinguish inflammatory synovitis from the bony hypertrophy and crepitus that typically occur with osteoarthritis. Extra-articular manifestations of rheumatologic disease may be helpful in arriving at a more specific diagnosis. Many classic rheumatologic laboratory tests are nonspecific. A complete blood count, urinalysis, and a metabolic panel may provide more useful diagnostic clues. Plain-film radiographs may demonstrate classic findings of specific rheumatologic diseases; however, radiographs can be normal or only show nonspecific changes early in the disease process.