Reforming the core clerkship in internal medicine: the SGIM/CDIM Project. Society of General Internal Medicine/Clerkship Directors in Internal Medicine.

Dramatic changes in health care have stimulated reform of undergraduate medical education. In an effort to improve the teaching of generalist competencies and encourage learning in the outpatient setting, the Society of General Internal Medicine joined with the Clerkship Directors in Internal Medicine in a federally sponsored initiative to develop a new curriculum for the internal medicine core clerkship. Using a broad-based advisory committee and working closely with key stakeholders (especially clerkship directors), the project collaborators helped forge a new national consensus on the learning agenda for the clerkship (a prioritized set of basic generalist competencies) and on the proportion of time that should be devoted to outpatient care (at least one third of the clerkship). From this consensus emerged a new curricular model that served as the basis for production of a curriculum guide and faculty resource package. The guide features the prioritized set of basic generalist competencies and specifies the requisite knowledge, skills, and attitudes/values needed to master them, as well as a list of suggested training problems. It also includes recommended training experiences, schedules, and approaches to faculty development, precepting, and student evaluation. Demand for the guide has been strong and led to production of a second edition, which includes additional materials, an electronic version, and a pocket guide for students and faculty. A follow-up survey of clerkship directors administered soon after completion of the first edition revealed widespread use of the curricular guide but also important barriers to full implementation of the new curriculum. Although this collaborative effort appears to have initiated clerkship reform, long-term success will require an enhanced educational infrastructure to support teaching in the outpatient setting.

Evaluation of a national curriculum reform effort for the medicine core clerkship.

BACKGROUND: In 1995, the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM) developed and disseminated a new model curriculum for the medicine core clerkship that was designed to enhance learning of generalist competencies and increase interest in general internal medicine. OBJECTIVE: To evaluate the dissemination and use of the resulting SGIM/CDIM Core Medicine Clerkship Curriculum Guide. DESIGN: Survey of internal medicine clerkship directors at the 125 medical schools in the United States. MEASUREMENTS AND MAIN RESULTS: The questionnaire elicited information about the use and usefulness of the Guide and each of its components, barriers to effective use of the Guide, and outcomes associated with use of the Guide. Responses were received from 95 clerkship directors, representing 88 (70%) of the 125 medical schools. Eighty-seven (92%) of the 95 respondents were familiar with the Guide, and 80 respondents had used it. The 4 components used most frequently were the basic generalist competencies (used by 83% of those familiar with the Guide), learning objectives for these competencies (used by 83%), learning objectives for training problems (used by 70%), and specific training problems (used by 67%); 74% to 85% of those using these components found them moderately or very useful. The most frequently identified barriers to use of the Guide were insufficient faculty time, insufficient number of ambulatory care preceptors and training sites, and need for more faculty development. About 30% or more of those familiar with the Guide reported that use of the Guide was associated with improved ability to meet clerkship accreditation criteria, improved performance of students on the clerkship exam, and increased clerkship time devoted to ambulatory care. CONCLUSION: This federally supported initiative that engaged the collaborative efforts of the SGIM and the CDIM was successful in facilitating significant changes in the medicine core clerkship across the United States.

National survey of Clerkship Directors in Internal Medicine on the competencies that should be addressed in the medicine core clerkship.

PURPOSE: To prioritize competencies that should be addressed in the medicine core clerkship, assess factors influencing this prioritization, and estimate the percentage of clerkship time that should be devoted to inpatient versus outpatient care. METHODS: A national survey of the Clerkship Directors in Internal Medicine (CDIM) was used. Using explicit criteria, respondents assigned priority scores, on a 1 to 5 scale, to 17 general competencies and 60 disease-specific clinical competencies pertinent to care of adult patients in inpatient. ambulatory, intensive care, and emergency settings. RESULTS: Ninety-three (75%) of 124 CDIM members responded. The highest mean priority scores were assigned to 6 general competencies: case presentation skills (4.65), diagnostic decision-making (4.64), history and physical diagnosis (4.61), test interpretation (4.47), communication with patients (4.35), and therapeutic decision-making (4.12). Disease-specific clinical competency areas receiving the highest mean priority scores were: hypertension (4.57), coronary disease (4.53), diabetes mellitus (4.45), heart failure (4.42), pneumonia (4.39), chronic obstructive pulmonary disease (4.26), acid-base/electrolyte disorders (4.19), and acute chest pain (4.08). Priorities for general competencies were moderately correlated with importance to the practice of general internists (mean Spearman rho 0.49) and with importance to students pursuing careers outside internal medicine (mean Spearman rho 0.45), but only weakly correlated with the adequacy with which a competency was addressed in other parts of the curriculum. Respondents' mean recommended allocation of clerkship time was: 52% inpatient, 33% ambulatory care, 8% intensive care, and 7% emergency medicine. This time allocation did not differ by any characteristics of respondents. CONCLUSION: There is consensus among medicine clerkship directors that the medicine core clerkship should emphasize fundamental competencies and devote at least one third of the time to clinical competencies pertinent to ambulatory care.

Conducting a matched-pairs historical cohort study with a computer-based ambulatory medical record system.

We describe techniques for using the Computer-Stored Ambulatory Record (COSTAR) at the Massachusetts General Hospital to conduct a historical cohort study of the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on blood pressure control. A query language was used to identify patients satisfying clinical and data-availability criteria, to match these patients with clinically similar patients not exposed to NSAIDs, and to collect data from the COSTAR records of both groups of patients to determine any differences in outcome. We analyzed over 30,000 patient records to select 90 pairs of patients used in the study. This approach to clinical research uses data collected for purpose of patient care and so does not require the separate recording of patient data for clinical research. Using computer-based medical record systems with a query language allows selection and matching of patients using detailed demographic and clinical criteria. The ability to conduct such studies is an advantage of computer-based medical record systems over the paper record system.

The training of physicians outside the hospital.

The current ambulatory training of medical residents in the primary care program and the traditional program of the Massachusetts General Hospital, Boston, are described. All residents are assigned to work in a single medical group practice unit during their three years of training. Block outpatient rotations make up 32% of the primary care program and 6% of the traditional program schedules, while total ambulatory experiences, including weekly continuity sessions, make up 39% and 15%, respectively. Several components are important for a successful program. Above all is a vigorous group practice providing a sizable panel of patients with complex clinical problems from which residents can learn. Also important are financial support from the hospital and government or private grants and a commitment to outpatient teaching by the medical and nonmedical specialty staff.

Comparing ambulatory care practices of primary care and traditional medicine residents.

Although special residency programs preparing internists for primary care have been in existence for a decade, little is known about whether these tracks have achieved their goals. As part of a multicenter evaluation of ambulatory care at four university hospitals, 1,040 patient care encounters were reviewed for 16 primary-care and 41 traditional medicine residents. Using a chart-based audit, the authors examined 16 discrete items of patient care to assess resident management in the following areas: screening for colorectal carcinoma, management of hypertension, benzodiazepine drug prescribing, and management of chronic lung disease. Their hypothesis that primary care residents would score higher than traditional medicine residents in the areas of screening, prevention, and prescribing of drugs was not supported. There was no association between type of training and performance of a task with the following exception: second-year primary care residents screened for colorectal carcinoma in 86% (126) of patients whose charts were audited, while second-year traditional medicine residents did so in 77% (160) (P less than 0.025). This difference was not maintained when the residents were reaudited 1 year later. Both groups of residents scored high in all areas with the following exceptions: documentation of the amount of sedative dispensed and immunization of susceptible patients against pneumococcus and influenza. The ambulatory practices of both groups of residents exceeded expectations, probably because of the wider influence of primary care training.

An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients.

We examined by medical-record review why long-term digitalis therapy was prescribed in 150 outpatients, the reasons were: supraventricular tachyarrhythmias (35): supraventricular tachyarrhythmias and heart failure (33); and heart failure with sinus rhythm (82). In the patients without supraventricular tachyarrhythmias we scrutinized the diagnosis of heart failure using a clinicoradiographic scoring system and found the diagnosis unlikely in 32 patients. When these 32 patients are combined with the 31 patients who had only one occurrence of supraventricular tachyarrhythmias or heart failure, 42% of the patients were on long-term digitalis therapy for a questionable reason. We conclude that a substantial fraction of general medical outpatients might benefit from digitalis withdrawal, if evidence for heart failure is lacking or if the reason prompting digitalis therapy is isolated to the distant past.

Heart failure in outpatients: a randomized trial of digoxin versus placebo.

The view that digitalis clinically benefits patients with heart failure and sinus rhythm lacks support from a well-controlled study. Using a randomized, double-blind, crossover protocol, we compared the effects of oral digoxin and placebo on the clinical courses of 25 outpatients without atrial fibrillation. According to a clinicoradiographic scoring system, the severity of heart failure was reduced by digoxin in 14 patients; in nine of these 14, improvement was confirmed by repeated trials (five patients) or right-heart catheterization (four patients). The other 11 patients had no detectable improvement from digoxin. Patients who responded to digoxin had more chronic and more severe heart failure, greater left ventricular dilation and ejection-fraction depression, and a third heart sound. Multivariate analysis showed that the third heart sound was the strongest correlate of the response to digoxin (P less than 0.0001). These data suggest that long-term digoxin therapy is clinically beneficial in patients with heart failure unaccompanied by atrial fibrillation whose failure persists despite diuretic treatment and who have a third heart sound.

Inpatient performance of primary care residents: impact of reduction in time on the ward.

The inpatient (ward/intensive-care-unit) performance of primary care medical residents was compared with that of their peers in the standard internal medicine residency program. The primary care residents spent half as much time on inpatient rotations as did their peers in the first two years of training. History-taking, physical examination, case presentation, record-keeping, patient management, and overall performance were assessed and scored by the attending physicians using the American Board of Internal Medicine's Clinical Performance Evaluation Form. The performances of the two groups were nearly identical, suggesting that substantial time in the first two years of residency can be devoted to ambulatory training without markedly compromising development of acute care skills.

Cardiac risk factors and complications in non-cardiac surgery.

In an attempt to assess cardiac risk in non-cardiac surgery, 1001 patients over 40 years of age who underwent major operative procedures were examined preoperatively, observed through surgery, studied with at least one postoperative electrocardiogram, and followed until hospital discharge or death. Documented postoperative myocardial infarction occurred in only 18 patients; though most of these patients had some pre-existing heart disease, there were few preoperative factors which were statistically correlated with postoperative infarction. Postoperative pulmonary edema was strongly correlated with preoperative heart failure, but 21 of the 36 patients who developed pulmonary edema did not have any prior history of heart failure. Nearly all of these 21 patients were elderly, had abnormal preoperative electrocardiograms, and had intraabdominal or intrathoracic surgery. In the absence of an acute infarction, bifascicular conduction defects, with or without PR interval prolongation, never progressed to complete heart block. Spinal anesthesia protected against postoperative heart failure but not against other cardiac complication. By multivariate regression analysis, postoperative cardiac death was significantly correlated with (a) myocardial infarction in the previous 6 months; (b) third heart sound or jugular venous distention immediately preoperatively; (c) more than five premature ventricular contractions per minute documented at any time preoperatively; (d) rhythm other than sinus, or premature atrial contractions on preoperative electrocardiogram; (e) age over 70 years; (f) significant valvular aortic stenosis; (g) emergency operation; (h) a 33% or greater fall in systolic blood pressure for more than 10 minutes intraoperatively. Notably unimportant factors included smoking, glucose intolerance, hyperlipidemia, hypertension, peripheral atherosclerotic vascular disease, angina, and distant myocardial infarction.

Multifactorial index of cardiac risk in noncardiac surgical procedures.

To determine which preoperative factors might affect the development of cardiac complications after major noncardiac operations, we prospectively studied 1001 patients over 40 years of age. By multivariate discriminant analysis, we identified nine independent significant correlates of life-threatening and fatal cardiac complications: preoperative third heart sound or jugular venous distention; myocardial infarction in the preceding six months; more than five premature ventricular contractions per minute documented at any time before operation; rhythm other than sinus or presence of premature atrial contractions on preoperative electrocardiogram; age over 70 years; intraperitoneal, intrathoracic or aortic operation; emergency operation; important valvular aortic stenosis; and poor general medical condition. Patients could be separated into four classes of significantly different risk. Ten of the 19 postoperative cardiac fatalities occurred in the 18 patients at highest risk. If validated by prospective application, the multifactorial index may allow preoperative estimation of cardiac risk independent of direct surgical risk.

Residency training in primary care internal medicine. Report of an operational program.

The Primary Care Program at the Massachusetts General Hospital is designed to develop competence in the full range of problems encountered by general internists delivering primary care. House staff spend 3 years in the program, which starts with internship, includes a senior residency, and fulfills the requirements for board eligibility in internal medicine. Half of the training is provided in outpatient care settings. House staff assume responsibility for organization and operation of an ambulatory medical unit. In addition, there is supervised instruction in office gynecology, orthopedics, ear, nose and throat, dermatology, and psychiatry. Close integration with the traditional inpatient-oriented training program is maintained to ensure commensurate growth and competence in management of acute, life-threatening disease.