Diagnostic errors and characteristics of patients seen at a general internal medicine outpatient clinic with a referral for diagnosis.

OBJECTIVES: Patients referred to general internal medicine (GIM) outpatient clinics may face a higher risk of diagnostic errors than non-referred patients. This difference in risk is assumed to be due to the differences in diseases and clinical presentations between referred and non-referred patients; however, clinical data regarding this issue are scarce. This study aimed to determine the frequency of diagnostic errors and compare the characteristics of referred and non-referred patients visit GIM outpatient clinics. METHODS: This study included consecutive outpatients who visited the GIM outpatient clinic at a university hospital, with or without referral. Data on age, sex, chief complaints, referral origin, and final diagnosis were collected from medical records. The Revised Safer Dx Instrument was used to detect diagnostic errors. RESULTS: Data from 534 referred and 599 non-referred patients were analyzed. The diagnostic error rate was higher in the referral group than that in the non-referral group (2.2 % vs. 0.5 %, p=0.01). The prevalence of abnormal test results and sensory disturbances was higher in the chief complaints, and the prevalence of musculoskeletal system disorders, connective tissue diseases, and neoplasms was higher in the final diagnoses of referred patients compared with non-referred patients. Among referred patients with diagnostic errors, abnormal test results and sensory disturbances were the two most common chief complaints, whereas neoplasia was the most common final diagnosis. Problems with data integration and interpretation were found to be the most common factors contributing to diagnostic errors. CONCLUSIONS: Paying more attention to patients with abnormal test results and sensory disturbances and considering a higher pre-test probability for neoplasms may prevent diagnostic errors in patients referred to GIM outpatient clinics.

Risk factors for falls among hospitalized medical patients - A systematic review and meta-analysis.

OBJECTIVE: To identify and quantify risk factors for in-hospital falls in medical patients. DATA SOURCES: Six databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar) were systematically screened until April 11, 2023, to identify relevant articles. STUDY SELECTION: All titles and abstracts of the retrieved articles were independently screened by two researchers who also read the full texts of the remaining articles. Quantitative studies that assessed risk factors for falls among adult patients acutely hospitalized were included in the review. Publications that did not capture internal medicine patients or focused on other specific populations were excluded. DATA EXTRACTION: Information on study characteristics and potential risk factors were systematically extracted. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. PRISMA and MOOSE guidelines were followed for reporting. DATA SYNTHESIS: The main outcome was any in-hospital falls. Using a random-effects meta-analysis model, association measures for each risk factor reported in five or more studies were pooled. Separate analyses according to effect measure and studies adjusted for sex and age at least were performed. Of 5,067 records retrieved, 119 original publications from 25 countries were included. In conclusion, 23 potential risk factors were meta-analyzed. Strong evidence with large effect sizes was found for a history of falls (OR 2.54; 95% CI 1.63- 3.96; I2 91%), antidepressants (pooled OR 2.25; 95% confidence interval [95% CI] 1.92-2.65; I2 0%), benzodiazepines (OR 1.97; 95% CI 1.68-2.31; I2 0%), hypnotics-sedatives (OR 1.90; 95% CI 1.53-2.36; I2 46%), and antipsychotics (OR 1.61; 95% CI 1.33-1.95; I2 0%). Furthermore, evidence of associations with male sex (OR 1.22, 95% CI 0.99-1.50, I2 65%) and age (OR 1.17, 95% CI 1.02-1.35, I2 72%) were found, but effect sizes were small. CONCLUSIONS: The comprehensive list of risk factors, which specifies the strength of evidence and effect sizes, could assist in the prioritization of preventive measures and interventions.

Disconnected Pancreatic Duct Syndrome: A Rare Complication of Pancreatitis.

Disconnected pancreatic duct syndrome (DPDS) is a rare complication of a common disease. Typically, DPDS occurs in acute necrotizing pancreatitis (ANP), chronic pancreatitis, abdominal surgery, or trauma. We present a case of DPDS from acute non-necrotizing pancreatitis (ANNP). A 41-year-old male with a history of alcohol use and prior AP presented with progressive, severe left-sided abdominal pain that was worse with movement. Labs revealed a lipase of 95 U/L (normal range 11-82 U/L). Computed tomography (CT) of the abdomen/pelvis (A/P) with IV contrast demonstrated a large left-sided pleural effusion, non-necrotic pancreatic pseudocysts, and a large subdiaphragmatic fluid collection. Thoracentesis of the pleural effusion revealed an amylase of 601 U/L confirming pancreatic etiology. A subsequent magnetic resonance cholangiopancreatography (MRCP) confirmed complex peripancreatic ascites, rapid subdiaphragmatic fluid accumulation, and a fistula from the pancreatic tail to retroperitoneum concerning for a rapidly dissecting pancreatic pseudocyst. He ultimately underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent placement in the main pancreatic duct. His left-sided abdominal pain rapidly improved, and the patient was discharged. CT A/P one week after discharge showed a reduced size of subdiaphragmatic fluid collection. DPDS is usually seen in patients with a history of ANP. Our case demonstrates that it can also occur in ANNP, which has not previously been described in the literature. Therefore, a high index of clinical suspicion must be maintained for DPDS even in ANNP given its potential for severe complications.

Battlefield Acupuncture for the Treatment of Chronic Migraines.

A 70-year-old man presented with worsening migraines and was referred to a neurologist by their primary care doctor for further workup. Imaging and lab work were benign. The patient then underwent several trials of various first and second-line medications and anti-migraine devices to no avail. It was not until one session of battlefield acupuncture, where five needles were placed in the patient's ear for a few days, that the patient had a resolution of his symptoms.

Asthma Prevalence Among Adults in Qassim Region, Saudi Arabia.

BACKGROUND: Asthma is a major non-communicable disease affecting both children and adults and is the most common chronic disease among children. It has a significant effect on patient's daily lives, as well as a big economic impact on society, as it affects 262 million people of the population globally. According to the previous research conducted in the Aseer region in southwestern Saudi Arabia, the prevalence rate of bronchial asthma was found to be 19.2%. Also, a number of studies revealed a significant prevalence of asthma in Saudi Arabia. Therefore, it is simple and effective to measure specific asthma symptoms among the adult population by utilizing the European Community Respiratory Health Survey (ECRHS) criteria. OBJECTIVES: To investigate asthma prevalence and measure asthma symptoms among Saudi adults in Qassim, Saudi Arabia using the ECRHS. METHODS: This cross-sectional study targets the males and females living in the Qassim region of Saudi Arabia. The study was conducted by handing out a validated, self-administered questionnaire among adult male and female patients in the Qassim region of Saudi Arabia. Both descriptive and inferential statistics analyses were conducted. To test the association, both chi-square and Fisher's exact tests were carried out. For the test, a p-value less than 0.05 was considered statistically significant. RESULTS: The study involved 461 participants who met the inclusion criteria. The study found that 137 (29.9%) participants reported having tightness in their chests when they woke up. Among the respondents who reported these symptoms were 83 (60.1%) female and 55 (39.9%) male respondents. This shows a statistically significant difference between the gender and severity of chest tightness upon waking up (p = 0.008) with more females experiencing it than the male gender. More so, there was a statistically significant difference between the gender and severity of shortness of breath (p = 0.008), with more females (81, 60.4%) having the symptoms than the male gender (53, 39.6%). In addition, the study results reveal statistically significant gender differences among the patients who were diagnosed with asthma by the physician (p = 0.003), with more males (51, 65.4%) having been diagnosed than the female gender (27, 34.6%). Asthma attacks in the 12 months (p = 0.047) and the use of tobacco products (p = 0.001) were also found to have a statistically significant difference across the genders. This was shown by most males (26, 65.0%) who had asthma attacks in the 12 months and 70 (98.6%) who smoked any tobacco products than the few females (14, 35.0%) who reported to have had asthma attacks in the 12 months and one (1.4%) who reported smoking any tobacco products. CONCLUSION: This study noted that the prevalence of asthma symptoms varied based on the gender of the participants. Therefore, the study suggests that gender should be taken as an important factor while evaluating the severity and how asthma-related symptoms manifest.

Hashimoto Thyroiditis Coexisting With Breast Fibroadenoma.

A 34-year-old female with co-existing multiple breast nodules being treated simultaneously presented to the outpatient clinic with fatigue as the chief complaint which had progressively worsened over one year. Ultrasound showed a heterogeneous parenchymal ectopic pattern suggestive of thyroiditis, with no suspicion of nodules and cysts. Laboratory results showed raised levels of thyroid-stimulating hormone (TSH), serum anti-thyroglobulin antibody, and serum thyroid peroxidase antibody. Levothyroxine sodium at a dosage of 50 µg/day was prescribed to the patient, following which the patient had normal TSH levels on follow-up after two months. Simultaneously the patient was under investigation for the breast nodules that were seen as the patient's medical history when she presented to the endocrinology clinic. She was diagnosed with fibroadenoma with a canalicular pattern, without ductal atypia in both breasts and malignancy.

Primary Care: Its Pokemon Moment.

Primary care in the United States is undergoing bursts of evolution in response to health system stresses, changing demographics, and expansion of risk and value-based reimbursement structures. The impact of primary care remains substantive and associated with improved population health. However, the spectrum of services, the nature of the physicians involved and new ways of including the patient in her, or his own care suggests that a new definition of primary care be considered, and patient expectations be heeded and understood. Evolutionary bursts yield new traits and in primary care, they are spawning new care models with significant implications for general internal medicine, internal medicine/pediatrics trained individuals and medicine subspecialties given the focus of these models on Medicare Advantage. Ultimately, changes in reimbursement and creative incentives will be two factors among many that will solidify the next stage of primary care in the United States.

Uncommon Association Between Gastrointestinal Stromal Tumors (GIST) and Pheochromocytoma With Abdominal Wall Relapse: Case Report and Literature Review.

Gastrointestinal stromal tumors (GISTs) represent a rare form of gastrointestinal neoplasm. This report details a medical case involving a 44-year-old woman who underwent bilateral pheochromocytoma resection, GIST gastrectomy, and laparoscopic adrenalectomy with intestinal resection. Despite an initially positive response to oral imatinib, treatment was delayed due to economic constraints. This delay resulted in a critical event marked by abdominal GIST metastasis to the abdominal wall, subsequent rupture leading to hemoperitoneum, and emergency surgery. Following an adequate postsurgical recovery, she was successfully discharged prior to medication adjustments.

Generative Artificial Intelligence in Patient Education: ChatGPT Takes on Hypertension Questions.

Introduction Uncontrolled hypertension significantly contributes to the development and deterioration of various medical conditions, such as myocardial infarction, chronic kidney disease, and cerebrovascular events. Despite being the most common preventable risk factor for all-cause mortality, only a fraction of affected individuals maintain their blood pressure in the desired range. In recent times, there has been a growing reliance on online platforms for medical information. While providing a convenient source of information, differentiating reliable from unreliable information can be daunting for the layperson, and false information can potentially hinder timely diagnosis and management of medical conditions. The surge in accessibility of generative artificial intelligence (GeAI) technology has led to increased use in obtaining health-related information. This has sparked debates among healthcare providers about the potential for misuse and misinformation while recognizing the role of GeAI in improving health literacy. This study aims to investigate the accuracy of AI-generated information specifically related to hypertension. Additionally, it seeks to explore the reproducibility of information provided by GeAI. Method A nonhuman-subject qualitative study was devised to evaluate the accuracy of information provided by ChatGPT regarding hypertension and its secondary complications. Frequently asked questions on hypertension were compiled by three study staff, internal medicine residents at an ACGME-accredited program, and then reviewed by a physician experienced in treating hypertension, resulting in a final set of 100 questions. Each question was posed to ChatGPT three times, once by each study staff, and the majority response was then assessed against the recommended guidelines. A board-certified internal medicine physician with over eight years of experience further reviewed the responses and categorized them into two classes based on their clinical appropriateness: appropriate (in line with clinical recommendations) and inappropriate (containing errors). Descriptive statistical analysis was employed to assess ChatGPT responses for accuracy and reproducibility. Result Initially, a pool of 130 questions was gathered, of which a final set of 100 questions was selected for the purpose of this study. When assessed against acceptable standard responses, ChatGPT responses were found to be appropriate in 92.5% of cases and inappropriate in 7.5%. Furthermore, ChatGPT had a reproducibility score of 93%, meaning that it could consistently reproduce answers that conveyed similar meanings across multiple runs. Conclusion ChatGPT showcased commendable accuracy in addressing commonly asked questions about hypertension. These results underscore the potential of GeAI in providing valuable information to patients. However, continued research and refinement are essential to evaluate further the reliability and broader applicability of ChatGPT within the medical field.

Clinical Reasoning: Perspectives of Expert Clinicians on Reasoning Through Complex Clinical Cases.

Introduction Clinical reasoning is a core skill for physicians; most doctors do not attain the level of expertise associated with that of an expert clinician (EC). The purpose of this study is to identify the clinical reasoning strategies ECs prioritize when reasoning through complex cases. Methods We interviewed 14 ECs and performed a thematic analysis to identify strategies ECs prioritize when reasoning through complex clinical cases. The authors chose ECs based on the recognition of clinical and teaching expertise by trainees and other faculty members (ECs within our institution) and institutional recognition of high achievement in medicine and medical education (ECs outside our institution). We used a semi-structured guide to interview each EC, then reviewed and coded the interview transcriptions. We developed themes based on agreements between all transcript reviewers.  Results We interviewed 11 male and three female ECs, one from outside the study institution. Two (14%) ECs were primary care physicians, and the remaining were sub-specialists. The authors organized strategies for clinical reasoning through complex cases around four themes, which were as follows: (1) connecting clinical reasoning to patient context; (2) embracing uncertainty, then reducing it; (3) returning to the patient's bedside; and (4) remaining humble to limit diagnostic errors. Conclusion Clinical reasoning is a core clinical skill of physicians, and this article describes clinical reasoning strategies prioritized by ECs for complex clinical cases. Recognition and integration of these strategies into medical training and clinical educator practice may facilitate the evolution of clinical reasoning skills and reduce diagnostic errors.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2023.

The expansive scope of internal medicine can make it challenging for clinicians to stay informed about new literature that changes practice. Guideline updates and synthesis of relevant evidence can facilitate incorporation of advancements into clinical practice. The titles and abstracts from the seven general medicine journals with highest impact factors and relevance to outpatient internal medicine were reviewed by six internal medicine physicians. Coronavirus disease 19 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Mayo Clinic Proceedings were reviewed. Additionally, article synopsis collections and databases were evaluated: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster ACCESSSS/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, seven practice-changing articles were included.

Sustainability in Internal Medicine: A Year-Long Ward-Wide Observational Study.

Population aging and multimorbidity challenge health system sustainability, but the role of assistance-related variables rather than individual pathophysiological factors in determining patient outcomes is unclear. To identify assistance-related determinants of sustainable hospital healthcare, all patients hospitalised in an Internal Medicine Unit (n = 1073) were enrolled in a prospective year-long observational study and split 2:1 into a training (n = 726) and a validation subset (n = 347). Demographics, comorbidities, provenance setting, estimates of complexity (cumulative illness rating scale, CIRS: total, comorbidity, CIRS-CI, and severity, CIRS-SI subscores) and intensity of care (nine equivalents of manpower score, NEMS) were analysed at individual and Unit levels along with variations in healthcare personnel as determinants of in-hospital mortality, length of stay and nosocomial infections. Advanced age, higher CIRS-SI, end-stage cancer, and the absence of immune-mediated diseases were correlated with higher mortality. Admission from nursing homes or intensive care units, dependency on activity of daily living, community- or hospital-acquired infections, oxygen support and the number of exits from the Unit along with patient/physician ratios were associated with prolonged hospitalisations. Upper gastrointestinal tract disorders, advanced age and higher CIRS-SI were associated with nosocomial infections. In addition to demographic variables and multimorbidity, physician number and assistance context affect hospitalisation outcomes and healthcare sustainability.

The Gut-Brain Axis in Autoimmune Diseases: Emerging Insights and Therapeutic Implications.

The gut-brain axis (GBA) is a two-way communication system that is influenced by signals from the nervous system, hormones, metabolism, the immune system, and microbes. The GBA may play a key role in gastrointestinal and neurological illnesses. Signaling events from the gut can regulate brain function. As a result, mounting data point to a connection between autoimmune disorders (AIDs), both neuroinflammatory and neurodegenerative diseases, and the GBA. Clinical, epidemiological, and experimental studies have shown that a variety of neurological illnesses are linked to alterations in the intestinal environment, which are suggestive of disease-mediated inter-organ communication between the gut and the brain. This review's objective is to draw attention to the clinical and biological relationship between the gut and the brain, as well as the clinical importance of this relationship for AIDs, neurodegeneration, and neuroinflammation. We also discuss the dysbiosis in the gut microbiota that has been linked to various AIDs, and we make some assumptions about how dietary changes such as prebiotics and probiotics may be able to prevent or treat AIDs by restoring the composition of the gut microbiota and regulating metabolites.

Copper Deficiency: An Overlooked Diagnosis.

Copper deficiency may often be overlooked due to physicians' poor awareness of the disease. Delayed diagnosis and therapy may lead to poor prognosis of neurological function. Here, we present a 68-year-old male with an approximately one-year history of unsteady feet who had visited several clinical departments and was finally diagnosed with copper deficiency. In the present case, it took approximately one year to diagnose the condition, and the therapy of copper supplementation led to only slight improvement in subjective symptoms. Physicians should be more aware of this condition for a good prognosis of the disease.

Tracheomalacia in Adults: An Uncommon Cause of Dyspnea.

Tracheomalacia (TM), the most common congenital tracheal defect, is due to compromised cartilage integrity, manifesting in the narrowing of expiratory airways and various respiratory symptoms. While TM is common in infants and toddlers, it is rarely found in adults, often due to acquired injuries or chronic lung diseases. We present a unique case of a 67-year-old man with persistent dyspnea and hoarseness for two years. Despite a history of smoking, he had no signs of pulmonary disease and had a consistently high oxygen saturation during episodes of dyspnea. His dyspnea was of unknown etiology until a diagnostic bronchoscopy revealed tracheal stenosis and flaccidity of cartilaginous structures, with pronounced collapse during expiration. This atypical presentation highlights the complexity of TM in adults. It underscores the importance of considering it as a differential diagnosis, particularly in male smokers with gradual, persistent dyspnea and a minimal history of pulmonary disease.

Cerebral Abscess Due to Nocardia beijingensis Associated With HIV: Case Report and Mini Review.

Brain abscesses are severe focal infections of the central nervous system. We report the case of a 37-year-old patient with a recent diagnosis of HIV, who presented with weakness in the left arm that progressed to left hemiplegia, ipsilateral paresthesia, holo cranial headache, fever accompanied by chills, and left tonic-clonic movements. A craniectomy and lesion resection were performed along with antimicrobial treatment. Subsequently, the patient persisted with left hemiplegia, which significantly improved after the procedure and gradually through physical physiotherapy. During the investigation, we complete medical history, physical examination, Image tests, laboratory tests, and cultures. After the finalization of the approach, the final diagnosis was a brain abscess due to Nocardia beijingensis associated with HIV. The patient was managed with anticonvulsants: levetiracetam, antimicrobials: ceftriaxone, trimethoprim/sulfamethoxazole, metronidazole, and vancomycin, Craniotomy plus resection of two brain abscesses, Steroidal anti-inflammatory: dexamethasone and antiretroviral therapy. With this, the patient was discharged successfully from the hospital.

Artificial Intelligence in the Detection of Barrett's Esophagus: A Systematic Review.

Barrett's esophagus (BE) remains a significant precursor to esophageal adenocarcinoma, requiring accurate and efficient diagnosis and management. The increasing application of machine learning (ML) technologies presents a transformative opportunity for diagnosing and treating BE. This systematic review evaluates the effectiveness and accuracy of machine learning technologies in BE diagnosis and management by conducting a comprehensive search across PubMed, Scopus, and Web of Science databases up to the year 2023. The studies were organized into five categories: computer-aided systems, natural language processing and text-based systems, deep learning on histology and biopsy images, real-time and video analysis, and miscellaneous studies. Results indicate high sensitivity and specificity across machine learning applications. Specifically, computer-aided systems showed sensitivities ranging from 84% to 100% and specificities from 64% to 90.7%. Natural language processing and text-based systems achieved an accuracy as high as 98.7%. Deep learning techniques applied to histology and biopsy images displayed sensitivities up to greater than 90% and a specificity of 100%. Furthermore, real-time and video analysis technologies demonstrated high performance with assessment speeds of up to 48 frames per second (fps) and a mean average precision of 75.3%. Overall, the reviewed literature underscores the growing capability and efficiency of machine learning technologies in diagnosing and managing Barrett's esophagus, often outperforming traditional diagnostic methods. These findings highlight the promising future role of machine learning in enhancing clinical practice and improving patient care for Barrett's esophagus.

A Textbook Case of Human T-lymphotropic Virus-1 (HTLV-1)-Induced Adult T-cell Leukemia Treated With Cyclophosphamide, Hydroxydaunorubicin, Oncovin, and Prednisone/Prednisolone (CHOP).

Human T-lymphotropic virus-1 (HTLV-I) is an enveloped, single-stranded RNA virus of the Retroviridae family. The virus causes two well-recognized disease associations: adult T-cell leukemia/lymphoma (ATL) and HTLV-I-associated myelopathy (HAM), also known as tropical spastic paraparesis (TSP). We report a case of HTLV-1-induced adult T-cell lymphoma/leukemia in a 45-year-old female who presented with complaints of swelling on the right side of her neck and rash on her upper and lower extremities and abdomen. The patient also had a history of strongyloidiasis infection and Crohn's disease. She was found to have hypercalcemia and multiple lytic lesions of the bone found on the imaging. She also tested positive for HTLV-1 and T cell-positive for cluster of differentiation (CD) 2, CD3, partial CD5, and minimal CD56, later confirmed by the bone marrow (BM) and skin punch biopsies. ATL is characterized by the clonal proliferation of CD4+ T cells containing randomly integrated HTLV-I provirus, often associated with T-cell receptor gene rearrangements. ATL, in its aggressive forms, has one of the poorest prognoses of non-Hodgkin lymphoma. It is essential to raise awareness of ATL, although further research and trials are needed to solidify the treatment options to prevent mortality.

Necrotizing Autoimmune Myopathy: A Case Report on Statin-Induced Rhabdomyolysis.

Statin-induced necrotizing myopathy (SINM) is an uncommon but severe complication associated with statin medication. SINM can develop at any point after a person starts taking steroids. It is now being acknowledged as a component of the broader category of "statin-induced myopathy." Like other immune-mediated necrotizing muscle diseases, statin-induced myositis is identified by weakness in proximal muscles, increased serum creatine kinase (CK) levels, and, in some cases, dysphagia and respiratory distress. In addition, there is evidence of muscle cell damage when examined under a microscope, occurring with minimal or no infiltration of inflammatory cells. Diagnosing SINM promptly is frequently challenging due to its unpredictable development over time, with symptoms sometimes emerging many years after the initial exposure to statins. One distinctive characteristic of SINM is the continued presence of muscle inflammation and elevated CK levels even after discontinuing statin treatment. Currently, no clinical trials are available to guide how to manage statin-induced immune-mediated necrotizing myopathy (IMNM). Here, we present a case of a 42-year-old woman diagnosed with SINM and was found to have persistently elevated CPK despite discontinuation of statins. Our case also suggests that intravenous (IV) immunoglobins and steroids are an effective and well-tolerated alternative to immunosuppressants.

Longitudinal Integrated Ambulatory, Didactic, and Evidenced-Based Medicine Curriculum in Internal Medicine.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) endorses evolving scholarly education regarding evidence-based medicine (EBM) and its clinical application in Internal Medicine (IM). The IM residents at Navy Medical Readiness and Training Center San Diego (NMRTC-SD) communicated the need for both increased ambulatory didactic sessions as well as a formal EBM curriculum. Prior to the academic year of 2021-2022, no formal ambulatory or EBM curriculum existed. In July 2021, an integrated EBM-ambulatory curriculum was implemented. METHODS:  A pre-curriculum needs assessment was performed and thereafter an eight-session integrated ambulatory-EBM curriculum was implemented in the 2021-2022 academic year. Faculty members facilitated small group discussions focused on a particular didactic topic and EBM principle and integrated the learning of both into one session. After each session, residents completed a feedback form. At the end of the year, a post-curriculum needs assessment was collected. KEY RESULTS: Thirty-four residents of all post-graduate years (PGY) levels participated from July 2021 to June 2022. Primary outcomes were satisfaction with the didactic portion of the curriculum, perception of receipt of adequate training in EBM principles, and perception of level of competency in practicing EBM principles. Overall, participants reported a substantial increase in satisfaction with didactic teaching and a large increase in the perceived competency in practicing EBM principles. CONCLUSION: This integrated didactic-EBM curriculum represents an effective method of incorporating didactic topics in IM with the teaching and application of EBM principles, which improved resident satisfaction with the curricula and self-perception of competency in critically appraising medical literature.