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Access to safe and stable housing has both a direct and indirect effect on health. Experiencing homelessness and housing instability can induce stress and trauma, worsening behavioral health and substance use. The absence of safe and stable living conditions can make it challenging to rest, recuperate, and recover from health ailments and can pose barriers to treatment adherence. Homelessness and housing instability is associated with high rates of numerous diseases and chronic conditions. Its cyclical relationship with other social drivers of health can exacerbate health disparities. As a result, unhoused persons experience unique health challenges and require a health care system and professionals designed to meet their distinct needs. Physicians and other health professionals have a role in educating themselves about the needs of unhoused patients as well as making themselves aware of community and government resources available to these populations. Policymakers must support health professionals in these efforts by supporting the data infrastructure needed to facilitate these referrals to resources, supporting research into best practices for caring for these populations, and investing in community-based organization capacity. Policy action is needed to address the underlying drivers of homelessness, including a dearth of affordable housing, while also addressing the short-term need for safe shelter now. In this position paper, the American College of Physicians (ACP) recognizes the need to address universal access to housing to fulfill one's right to health. ACP offers several recommendations to prevent homelessness and promote the necessary health care and social needs of unhoused populations., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2795.

A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular., Competing Interests: Conflict of interest: C.B.: none declared. R.B.: personal fees from Bayer, Bristol-Myers Squibb, LEO-Pharma, Pfizer, VIATRIS, and research support by the Bavarian State Ministry of Health; CPC University of Colorado; FADOI, Italy. S.Be.: proctor and speaker fees from Boston Scientific, Edwards, Abbott, fees go to the department. S.Bi.: none declared. L.V.A.B.: consultant for Medtronic, Boston Scientific, Adagio, and ACUTUS, fees go to the department. G.B.: speaker fees from Bayer, Boehringer Ingelheim, Boston Scientific, Daiichi-Sankyo, Janssen, and Sanofi. S.Bo.: Consultant for Medtronic, Boston Scientific, Microport, and Zoll. A.J.C.: personal fees from Abbott, Boston Scientific, Medtronic, Pfizer/BMS, Daiichi Sankyo, Bayer and Sanofi. T.D.P.: no personal disclosures to report. Consultancy activity for Boston Scientific, invoiced through institutional research fund. W.D.: consulting and speaker fees from Ai Mediq, Bayer, Boehringer Ingelheim, Medtronic, Boston Scientific, Vifor Pharma; travel support from Pharmacosmos; research support from EU (Horizon2020), German Ministry of Education and Research, German Center for Cardiovascular Research, Vifor Pharma. S.G.: consulting and speaker fees from Boston Scientific. M.G.: Advisory Board Member for Boston Scientific; proctor for Boston Scientific, Abbott; fees for lectures and travel grants: from Boston Scientific, Abbott, Occlutech, Pfizer. K.G.H.: speaker’s honoraria, consulting fees, lecture honoraria and/or study grants from Abbott, Amarin; Alexion, AstraZeneca, Bayer Healthcare, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Daiichi-Sankyo, Edwards Lifesciences, Medtronic, Novartis, Pfizer, Portola, Premier Research, Sanofi, SUN Pharma, and W.L. Gore and Associates. J.E.N.-K.: consultant to Boston Scientific, Medtronic, Edwards Lifesciences, Picardia, Venus Medtech, speaker for Abbott. U.L.: research grant to institution from Abbott, Bayer, speaker or consulting honorary from Abbott, Boston Scientific, Bayer; Pfizer, Daiichi-Sankyo. G.Y.H.L.: consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, Anthos. No fees are received personally. National Institute for Health and Care Research (NIHR) Senior Investigator and co-principal investigator of the AFFIRMO project on multi-morbidity in AF, funded from the European Union's Horizon 2020 research and innovation programme under grant agreement no. 899871. J.E.N.-K.: research grants from Abbott, Boston Scientific, Novo Nordic Foundation. J.E.N.-K.: research grants from Abbott, Boston Scientific, Novo Nordic Foundation. E.M.: research grants from Abbott, Biotronik, Boston Scientific, Medtronic, MicroPort, and Zoll. Consultant and speaker fees from Abbott, Abbott, Medtronic, and Zoll. J.E.N.-K.: research grants from Abbott, Boston Scientific, Novo Nordic Foundation. P.O.: speaking honoraria from Bayer, Abbott, Boston Scientific. T.P.: none declared. B.S.: consultant and speaker for Bostin Scientific, Abbott, Medtronic, Biosense Webster. M.S.: none declared. R.B.S. has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation programme under the grant agreement no. 648131, from the European Union's Horizon 2020 research and innovation programme under the grant agreement no. 847770 (AFFECT-EU) and German Center for Cardiovascular Research (DZHK e.V.) (81Z1710103 and 81Z0710114); German Ministry of Research and Education (BMBF 01ZX1408A) and ERACoSysMed3 (031L0239); Wolfgang Seefried project funding German Heart Foundation; lecture fees and advisory board fees from BMS/Pfizer and Novartis outside this work. C.T.: advisory board member of Boston Scientific; proctor for Boston Scientific and Abbott; fees for lectures and travel grants from Boston Scientific and Abbott. A portion of the fees goes to the institute. A.T.: consultant and proctor for Abbott, consultant for Boston Scientific and Pie Medical., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Team-based care models such as the Patient-Centered Medical Home are associated with improved patient health outcomes, better team coordination and collaboration, and increased well-being among health care professionals. Despite these attributes, hindrances to wider adoption remain. In addition, some health care professionals have sought to practice independent of the physician-led health care team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care. In this paper, the American College of Physicians reaffirms the importance of the physician-led health care team and offers policy recommendations on professionalism, payment models, training, licensure, and research to support the expansion of dynamic clinical care teams., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2260.

The relationship of health to rights or human rights is complex. Although many find no right of any kind to health or health care, and others view health care as a right or human right, the American College of Physicians (ACP) instead sees health as a human right . The College, in the ACP Ethics Manual, has long noted the interrelated nature of health and human rights. Health as a human right also has implications for the social and structural determinants of health, including health care. Any rights framework is imperfect, and rights, human rights, and ethical obligations are not synonymous. Individual physicians and the profession have ethical obligations to patients, and these obligations can go beyond matters of rights. Society, too, has responsibilities-the equitable and universal access to appropriate health care is an ethical obligation of a just society. By recognizing health as a human right based in the intrinsic dignity and equality of all patients and supporting the patient-physician relationship and health systems that promote equitable access to appropriate health care, the United States can move closer to respecting, protecting, and fulfilling for all the opportunity for health., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1900.

Physician solicitation of charitable contributions from patients-also known among other things as grateful patient fundraising-raises significant ethical concerns. These include pressure on patients to donate and the effects of this on the patient-physician relationship, potential expectations of donor patients for treatment that is not indicated or preferential care, justice and fairness issues, disclosure and use of confidential patient information for nontreatment purposes, and conflicts of interest. The patient-physician relationship and knowledge of the patient's medical history, clinical status, personal information, and financial circumstances are some of the reasons development and administrative officials might see physicians as strong potential fundraisers. But those are among the reasons grateful patient fundraising is ethically problematic. This American College of Physicians position paper explores these issues and offers guidance., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1691.

The determination of a patient's death is of considerable medical and ethical significance. Death is a biological concept with social implications. Acting with honesty, transparency, respect, and integrity is critical to trust in the patient-physician relationship, and the profession, in life and in death. Over time, cases about the determination of death have raised questions that need to be addressed. This American College of Physicians position paper addresses current controversies and supports a clarification to the Uniform Determination of Death Act; maintaining the 2 current independent standards of determining death, cardiorespiratory and neurologic; retaining the whole brain death standard; aligning medical testing with the standards; keeping issues about the determination of death separate from organ transplantation; reaffirming the importance and role of the dead donor rule; and engaging in educational efforts for health professionals, patients, and the public on these issues. Physicians should advocate for policies and practices on the determination of death that are consistent with the profession's fundamental and timeless commitment to individual patients and the public., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1361.

The onset of the COVID-19 pandemic revealed significant gaps in the United States' pandemic and public health emergency response system. At the federal level, government responses were undercut by a lack of centralized coordination, inadequately defined responsibilities, and an under-resourced national stockpile. Contradictory and unclear guidance throughout the early months of the pandemic, along with inconsistent funding to public health agencies, also created notable variance in state and local responses. The lack of a coordinated response added pressure to an already overwhelmed health care system, which was forced to resort to rationing care and personal protective equipment, creating moral distress and trauma for health care workers and their patients. Despite these severe shortcomings, the COVID-19 pandemic also highlighted successful policies and approaches, such as Operation Warp Speed, which led to the fastest development and distribution of a vaccine in history. In this position paper, the American College of Physicians (ACP) offers several policy recommendations for enhancing federal, state, and local preparedness for future pandemic and public health emergencies. This policy paper builds on various statements produced by ACP throughout the COVID-19 pandemic, including on the ethical distribution of vaccinations and resources, conditions to resume economic and social activity, and efforts to protect the health and well-being of medical professionals, among others., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-0768.

The United States' public health sector plays a crucial role in preventing illness and promoting health. Public health drove massive gains in life expectancy during the 20th century by supporting vaccination campaigns, promoting motor vehicle safety, and preventing and treating tobacco use. However, public health is underfunded and underappreciated, forcing the field to do more with fewer resources. In this position paper, the American College of Physicians (ACP) updates its 2012 policy recommendations on strengthening the nation's public health infrastructure. ACP calls for effective coordination of public health activities, robust and stable year-to-year funding of public health services, a renewed and well-supported public health workforce, action to address health-related dis- and misinformation, modernized public health data systems, and greater coordination between public health and medical sectors., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-0670.

There has been an exponential growth in the use of telemedicine services to provide clinical care, accelerated by the COVID-19 pandemic. Clinical care delivered via telemedicine has become a major and accepted method of health care delivery for many patients. There is an urgent need to understand quality of care in the telemedicine environment. This American College of Physicians position paper presents 6 recommendations to ensure the appropriate use of performance measures to evaluate quality of clinical care provided in the telemedicine environment., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-0140. All financial and intellectual disclosures of interest were declared, and potential conflicts were discussed and managed. No conflicts were identified. A record of disclosures of interest and management of conflicts is kept for each Performance Measurement Committee meeting and conference call and can be viewed at www.acponline.org/about-acp/who-we-are/leadership/boards-committees-councils/performance-measurement-committee/disclosure-of-interests-and-conflict-of-interest-management-summary-for-performance-measurement.

Patients with multimorbidity increasingly impact healthcare systems, both in primary care and in hospitals. This is particularly true in Internal Medicine. This population associates with higher mortality rates, polypharmacy, hospital readmissions, post-discharge syndrome, anxiety, depression, accelerated age-related functional decline, and development of geriatric syndromes, amongst others. Internists and Hospitalists, in one of their roles as Generalists, are increasingly asked to attend to these patients, both in their own Departments as well as in surgical areas. The management of polypathology and multimorbidity, however, is often complex, and requires specific clinical skills and corresponding experience. In addition, patients' needs, health-care environment, and routines have changed, so emerging and re-emerging specific competences and approaches are required to offer the best coordinated, continuous, and comprehensive integrated care to these populations, to achieve optimal health outcomes and satisfaction of patients, their relatives, and staff. This position paper proposes a set of emerging and re-emerging competences for internal medicine specialists, which are needed to optimally address multimorbidity now and in the future., Competing Interests: Declaration of Competing Interest All authors declare that they have no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, and they declare no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2023 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Improved global access to novel age-appropriate formulations for paediatric subsets, either of new chemical entities or existing drugs, is a priority to ensure that medicines meet the needs of these patients. However, despite regulatory incentives, the introduction to the market of paediatric formulations still lags behind adult products. This is mainly caused by additional complexities associated with the development of acceptable age-appropriate paediatric medicines. This position paper recommends the use of a paediatric Quality Target Product Profile as an efficient tool to facilitate early planning and decision making across all teams involved in paediatric formulation development during the children-centric formulation design for new chemical entities, or to repurpose/reformulate off-patent drugs. Essential key attributes of a paediatric formulation are suggested and described. Moreover, greater collaboration between formulation experts and clinical colleagues, including healthcare professionals, is advocated to lead to safe and effective, age-appropriate medicinal products. Acceptability testing should be a secondary endpoint in paediatric clinical trials to ensure postmarketing adherence is not compromised by a lack of acceptability. Not knowing the indications and the related age groups and potential dosing regimens early enough is still a major hurdle for efficient paediatric formulation development; however, the proposed paediatric Quality Target Product Profile could be a valuable collaborative tool for planning and decision making to expedite paediatric product development, particularly for those with limited experience in developing a paediatric product., (© 2021 British Pharmacological Society.)

The incidence of differentiated thyroid cancer (DTC) has been increasing worldwide, mostly, as an increase in the incidental detection of micro papillary thyroid carcinomas (microPTCs), many of which are potentially overtreated, as suggested by the unchanged mortality. Several international guidelines have suggested a less aggressive approach. More recently, it has been shown that active surveillance or minimally invasive treatments (MIT) are good alternatives for the management of these patients. In this context, patient participation in the decision-making process is paramount. The Endocrine Task Force of the European Organisation for Research and Treatment of Cancer (EORTC) has undertaken the task to establish consensus and define its position based on the scientific evidence concerning, 1) the current state of diagnostic and management options in microPTCs, including the current opinion of physicians about shared decision making (SDM), 2) the available evidence concerning patients' needs and the available decision instruments, and 3) to provide practical suggestions for implementation of SDM in this context. To improve SDM and patients' participation, knowledge gaps and research directions were highlighted., Competing Interests: Conflict of interest statement The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The American College of Physicians (ACP) has a long-standing commitment to improving the health of all Americans and opposes any form of discrimination in the delivery of health care services. ACP is committed to working toward fully understanding and supporting the unique needs of the incarcerated population and eliminating health disparities for these persons. In this position paper, ACP offers recommendations to policymakers and administrators to improve the health and well-being of persons incarcerated in adult correctional facilities.

The current data on climate change and environmental degradation are dramatic. The consequences of these changes are already having a significant impact on people's health. Physicians - as advocates of the patients, but also as citizens - have an ethical obligation to be involved in efforts to stop these changes. The European Federation of Internal Medicine (EFIM) strongly encourages the Internal Medicine societies and internists across Europe to play an active role in matters related to climate change and environmental degradation. At a national level, this includes advocating the adoption of measures that reduce greenhouse gas (GHG) emissions and environmental degradation and contributing to policy decisions related to these issues. At a hospital level and in clinical practice, supporting actions by the health sector to reduce its ecological footprint is vital. At the level of EFIM and its associated internal societies, promoting educational activities and developing a toolkit to prepare internists to better care for citizens who suffer from the consequences of climate change. In addition to advocating and implementing effective actions to reduce the ecological footprint of the health industry, recommending the introduction of these themes in scientific programs of Internal Medicine meetings and congresses and the pre- and postgraduate medical training. At a personal level, internists must be active agents in advocating sustainable practices for the environment, increasing the awareness of the community about the health risks of climate change and environmental degradation, and being role models in the adoption of environmentally friendly behaviour., Competing Interests: Declaration of Competing Interest The authors declare they have no conflicts of interest., (Copyright © 2022. Published by Elsevier B.V.)

Indigenous peoples in the United States experience many health disparities and barriers to accessing health care services. In addition, Indigenous communities experience poor social drivers of health, including disproportionately high rates of food insecurity, violence, and poverty, among others. These challenges are unsurprising, given historical societal discrimination toward Indigenous peoples and government policies of violence, forced relocation with loss of ancestral home, and erasure of cultures and traditions. Indigenous peoples have displayed resilience that has sustained their communities through these hardships. Through treaties between the federal government and Indigenous nations, the federal government has assumed a trust responsibility to provide for the health and well-being of Indigenous populations through the direct provision of health care services and financial support of tribally operated health systems. However, despite serving a population that has endured substantial historical trauma and subsequent health issues, federal programs serving Indigenous peoples receive inadequate federal funding and substantially fewer resources compared with other federal health care programs. Access to care is further challenged by geographic isolation and health care workforce vacancies. Given the history of Indigenous peoples in the United States and their treatment by the federal government and society, the American College of Physicians (ACP) asserts the federal government must faithfully execute its trust responsibility through increased funding and resources directed toward Indigenous communities and the undertaking of concerted policy efforts to support the health and well-being of Indigenous people. ACP believes that these efforts must be community-driven, Indigenous-led, and culturally appropriate and accepted, and center values of respect and self-determination.

Environmental health refers to the health effects associated with environmental factors, such as air pollution, water contamination, and climate change. Environmental hazards are associated with poor outcomes in common diseases, including diabetes and heart disease. In this position paper, the American College of Physicians (ACP) seeks to inform physicians about environmental health and offers policymakers recommendations to reduce the adverse health consequences of climate change, improve air and water quality, reduce exposure to toxic substances, and address environmental injustice. ACP affirms that all communities, including people of color, people with low income, and marginalized populations, deserve to live in a healthy environment.

This American College of Physicians position paper aims to inform ethical decision making for the integration of precision medicine and genetic testing into clinical care. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and can also inform how health care systems, professional schools, and residency programs integrate genomics into educational and clinical settings. Addressing the challenges of precision medicine and genetic testing will guide ethical and responsible implementation to improve health outcomes.

The number of Americans aged 65 years or older is expected to increase in the coming decades. Because the risk for disability increases with age, more persons will need long-term services and supports (LTSS) to help with bathing, eating, dressing, and other everyday tasks. Long-term services and supports are delivered in nursing homes, assisted living facilities, the person's home, and other settings. However, the LTSS sector faces several challenges, including keeping patients and staff safe during the COVID-19 pandemic, workforce shortages, quality problems, and fragmented coverage options. In this position paper, the American College of Physicians offers policy recommendations on LTSS coverage, financing, workforce, safety and quality, and emergency preparedness and calls on policymakers and other stakeholders to reform and improve the LTSS sector so that care is high quality, accessible, equitable, and affordable.

Food insecurity functions as a social driver of health, directly negatively impacting health status and outcomes, which can further negatively impact employment and income and increase medical expenditures-all of which exacerbates food insecurity. Progress in meaningfully reducing the food-insecurity rate has stalled in recent years. Although rates have decreased since their peak during the Great Recession, these gains have been reversed by the economic implications of the COVID-19 pandemic. As the federal government is the largest provider of food assistance, there is much potential in better leveraging nutrition assistance programs like the Supplemental Nutrition Assistance Program (SNAP) and the Child Nutrition Programs to increase access to healthful foods and improve public health. However, these programs face many funding challenges and internal shortcomings that create uncertainties and prevent maximal effect. Physicians and other medical professionals also have a role in improving nutritional health by screening for food insecurity and serving as connectors between patients, community organizations, and government services. Governments and payers must support these efforts by providing sufficient resources to practices to fulfill this role. In this position paper, the American College of Physicians (ACP) offers several policy recommendations to strengthen the federal food-insecurity response and empower physicians and other medical professionals to better address those social drivers of health occurring beyond the office doors.

Spinal dysraphism (SD) or spina bifida (SB) is a congenital deformity that results from embryonic neural tube closure failure during fetal development. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section. This paper aims to evaluate the role of the physical and rehabilitation medicine (PRM) physician and PRM practice for children and adults with spinal dysraphism. A systematic literature review and a consensus procedure involved all European countries delegates represented in the UEMS PRM section through a Delphi process. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The professional role of the PRM physician requires specific expertise in the treatment of patients with SD to plan, lead and monitor the rehabilitation process in an interdisciplinary setting and to participate in the assessment of the needs of these patients in the transitional phase from childhood to adulthood, with particular attention to the activity limitation and participation restriction.

Socioeconomic factors remain one of the most clinically significant contributors to health outcomes in this country, yet the current fee-for-service payment structure incentivizes volume and does not address such factors. The American College of Physicians proposes specific policy recommendations on reforming payment programs, including those designed to treat underserved patient populations, to better address value in health care and achieve greater equity. The proposal advocates that population-based prospective payment models, including hybrid models that combine fee-for-service with prospective payments, not only have the potential to achieve high-value care but can also be designed in such a way as to adjust for the social drivers that impact health outcomes. The need to recognize health care disparities and inequities in the implementation of the Quality Payment Program in particular and risk scoring in general and the need for social policies to improve access to health information technology are further examples of policy prescriptions that can advance equity. Evidence-based services and programs in Medicare Part B that are shown to preserve the Medicare trust fund through savings in Part A should be able to be scored as offsets for the cost of those new programs. The approach of building a health care system that is smarter about how dollars are spent to make people healthier must shift to one with a clear intention of decreasing health inequities and addressing social drivers of health.

The primary intention of any scientific work is to share the gained knowledge and to contribute to the knowledge and progress in the scientific domain. The wide range of journals and conferences, each with specific submission requirements, can be difficult to navigate, especially for young scientists without extensive experience. But a suitable publication strategy can be helpful, especially at the beginning of a scientific career. Using the annual conference of the German Association for Medical Informatics, Biometry and Epidemiology (GMDS) e.V. as an example, this editorial highlights fundamental differences, advantages and disadvantages, as well as assistance in selecting the right form of submission.

Suicide is a major global public health issue, and in recent years, there has been increasing recognition of the problem of physician suicide. This American College of Physicians policy paper examines, from the perspective of ethics, the issues that arise when individuals and institutions respond to physician suicides and when they engage in broader efforts aimed at physician suicide prevention. Emphasizing the medical profession as a unique moral community characterized by ethical and professional commitments of service to patients, each other, and society, this paper offers guidance regarding physician suicide and the role of a healing community. The response to an individual physician suicide should be characterized by respect and concern for those who are grieving, the creation of a supportive environment for suicide loss survivors, and careful communication about the event. Because suicide is a complex problem, actions aimed at preventing suicide must occur at the individual, interpersonal, community, and societal levels. The medical community has an obligation to foster a culture that supports education, screening, and access to mental health treatment, beginning at the earliest stages of medical training., (© 2021. Society of General Internal Medicine.)

Most anticancer molecules are administered in body-size-based dosing schedules, bringing up unsolved issues regarding pharmacokinetic data in heavy patients. The worldwide spread of obesity has not been matched by improved methods and strategies for tailored drug dosage in this population. The weight or body surface area (BSA)-based approaches may fail to fully reflect the complexity of the anthropometric features besides obesity in cancer patients suffering from sarcopenia. Likewise, there is a lack of pharmacokinetic data on obese patients for the majority of chemotherapeutic agents as well as for new target drugs and immunotherapy. Therefore, although the available findings point to the role of dose intensity in cancer treatment, and support full weight-based dosing, empirical dose capping often occurs in clinical practice in order to avoid toxicity. Thus a panel of experts of the Associazione Italiana Oncologia Medica (AIOM), Associazione Medici Diabetologi (AMD), Società Italiana Endocrinologia (SIE), and Società Italiana Farmacologia (SIF), provides here a consensus statement for appropriate cytotoxic chemotherapy and new biological cancer drug dosing in obese patients., Competing Interests: Disclosure NS has served as consultant for Celgene and Isheo. GB has served as consultant for Roche, Servier, Celgene, Ipsen, Sanofi, Merck Serono. All other authors have declared no conflicts of interest., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Pancreatic cancer (PC) is a common cause of cancer-related death, due to difficulties in detecting early-stage disease, to its aggressive behaviour, and to poor response to systemic therapy. Therefore, developing strategies for early diagnosis of resectable PC is critical for improving survival. Diabetes mellitus is another major public health problem worldwide. Furthermore, diabetes can represent both a risk factor and a consequence of PC: nowadays, the relationship between these two diseases is considered a high priority for research. New-onset diabetes can be an early manifestation of PC, especially in a thin adult without a family history of diabetes. However, even if targeted screening for patients at higher risk of PC could be a promising approach, this is not recommended in asymptomatic adults with new-onset diabetes, due to the much higher incidence of hyperglycaemia than PC and to the lack of a safe and affordable PC screening test. Prompted by a well-established and productive multidisciplinary cooperation, the Italian Association of Medical Oncology (AIOM), the Italian Medical Diabetologists Association (AMD), the Italian Society of Endocrinology (SIE), and the Italian Society of Pharmacology (SIF) here review available evidence on the mechanisms linking diabetes and PC, addressing the feasibility of screening for early PC in patients with diabetes, and sharing a set of update statements with the aim of providing a state-of-the-art overview and a decision aid tool for daily clinical practice., Competing Interests: Disclosure SA has served as a consultant for Menarini. GB has served as consultant for Roche, Servier, Celgene, Ipsen, Sanofi, Merck Serono. NS has served as a consultant for Merck Sharp & Dohme, Roche, Isheo, Iquvia. All other authors have declared no conflicts of interest., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

The environment in which physicians practice and patients receive care continues to change. Increasing employment of physicians, changing practice models, new regulatory requirements, and market dynamics all affect medical practice; some changes may also place greater emphasis on the business of medicine. Fundamental ethical principles and professional values about the patient-physician relationship, the primacy of patient welfare over self-interest, and the role of medicine as a moral community and learned profession need to be applied to the changing environment, and physicians must consider the effect the practice environment has on their ethical and professional responsibilities. Recognizing that all health care delivery arrangements come with advantages, disadvantages, and salient questions for ethics and professionalism, this American College of Physicians policy paper examines the ethical implications of issues that are particularly relevant today, including incentives in the shift to value-based care, physician contract clauses that affect care, private equity ownership, clinical priority setting, and physician leadership. Physicians should take the lead in helping to ensure that relationships and practices are structured to explicitly recognize and support the commitments of the physician and the profession of medicine to patients and patient care.

Introduction: Timely, complete and accurate patient data is needed in care decisions along the continuum of care. To access patient data from other organizations, there are three types of regional health information exchange systems (RHIS) in use In Finland. Some regions use multiple RHISs while others do not have a RHIS available. The recently introduced National Patient Data Repository (Kanta) is increasingly used for health information exchange (HIE)., Objectives: The purpose of this study was to assess usage of paper, RHISs and Kanta by context in 2017; evolution of paper use over the years; and predictors of paper use in 2017 among Finnish physicians for HIE system development., Methods: Data from national electronic health record (EHR) usage and user experience surveys were taken from 2010 (prior to ePrescription system implementation), 2014 (prior to implementation of Kanta) and 2017 (Kanta was in full use in the public sector and in large private organizations). The web-based surveys were targeted to all physicians engaged in clinical work in Finland., Results: Kanta was the most frequently used means of HIE in 2017. Paper use had reduced significantly from 2010 to 2014. The trend continued in 2017. Still, up to half of the physicians reported using paper daily or weekly in 2017. There were great variations in paper use by healthcare sector, available RHIS type and EHR system used. In multivariable analysis (with all other variables constant), predictors of more frequent use of paper than electronic means for HIE were: private sector or hospital, access to Master Patient Index RHIS (type 1), multiple RHIS (type 4) or no RHIS (type 5), two particular EHR systems, older age, less experience, operative, psychiatric or diagnostic specialties, and male gender., Conclusions: Usability of HIE systems including EHRs as access points to HIE need to be improved to facilitate usage of electronic HIE. Usage ensures more timely and complete patient data for safe, coordinated care. Specialty-specific needs and requirements call for more user participation in HIE design. Especially older professionals need training to better exploit HIS for HIE., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The growing insights in the next-generation immunotherapy and the state-of-the-art advancement in targeted-agents significantly improved clinical outcome of cancer patients by pointing towards a unexplored Achilles' heel. Novel toxicity profiles have been uncovered, representing unmet medical needs. Thus, a panel of expert provide comprehensive pharmacological and clinical evidence, to provide a patient-tailored approach to metabolic adverse events associated with novel anti-cancer treatments. Prompted by the need of a multidisciplinary cooperation, a working group of Associazione Italiana Oncologia Medica (AIOM), Associazione Medici Diabetologi (AMD) and Società Italiana Farmacologia (SIF) examined the available literature data. The identification of patient risk profile and the characterization of metabolic effects of novel anti-tumour drugs is clearly a clinical challenge that can be addressed by a multidisciplinary clinical approach. Therefore, this review pinpoints the relevance of the challenging profiling of the patient suffering from dysmetabolic conditions induced by the novel therapeutics in medical oncology., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

In 2019, the Board of Trustees of the American Association of Orthodontists asked a panel of medical and dental experts in sleep medicine and dental sleep medicine to create a document designed to offer guidance to practicing orthodontists on the suggested role of the specialty of orthodontics in the management of obstructive sleep apnea hypopnea syndrome. The present article aimed to provide interpretation of this White Paper, and to further help Chinese orthodontist to understand it.

Background/objectives: The growing interest of medical community about sarcopenia resulted in the production of several clinical practice guidelines (CPGs), with an unavoidable variability in terms of the overall quality of those publications. Our aim is to evaluate the quality of CPGs on sarcopenia using the AGREE II instrument., Subjects/methods: We performed an online literature search for sarcopenia CPGs using different databases. Four independent reviewers evaluated the quality of CPGs using the AGREE II instrument. To classify the quality of each guideline, we defined specific thresholds of final score: high-quality if five or more domains scored >60%; average-quality if three or four domains scored >60%; low-quality if ≤2 domains scored >60%., Results: Our literature search yielded 315 articles, and after applying exclusion criteria our final analysis included 19 CPGs. The overall quality of CPGs was remarkable, as 13/19 (68.4%) were considered of "high-quality" CPGs, with more than four domains reached a score higher than 60%. "Scope and Purpose" and "Clarity of Presentations" had the best domain results (78.4% and 73.8%, respectively), while the two domains with the lowest scores were "Rigor of Development" and "Applicability" (61.5% and 58.7%, respectively). Interobserver variability ranged between moderate (0.624) and fair (0.275)., Conclusions: Our study showed that the overall quality of CPGs about sarcopenia was noteworthy, as more than two-third of paper obtained a "high-quality" score. The domain "applicability" had the lowest score, suggesting that emphasis should be put on possible strategies for helping other doctors to implement guideline recommendations in clinical practice.

William Osler combined many excellent characteristics of a clinical educator being a scientific scholar, a motivational speaker and writer and a proficient physician. As we celebrate his life a century on, many of his educational ideals are as pertinent today as they were in those Victorian times. Osler's contributions to modern medicine go beyond his legacy of quotable aphorisms to a doctor, educator and leader whose proponent use of bedside teaching, careful clinical methods, and clinicopathological correlation was a great inspiration for students and junior doctors. He was also a great advocate of patient-centred care-listening to and closely observing his patients, an important message for modern medicine as the reliance on investigations strains modern healthcare systems. This review of Osler's contribution to medical education summarises his development as an educator and provides reflection on his influences to modern clinical education., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

The Canadian physician Sir William Osler is a key figure in the history of modern medicine. He encouraged lifelong learning for doctors, starting with bedside teaching. Contemporary with Old World figures such as Pasteur in Paris and Virchow in Berlin, he played a major role in raising awareness among clinicians of the importance of the scientific basis for the practice of medicine. He championed a rational approach to treatment and did much to encourage avoidance of 'unnecessary drugging' by prescribers. He is credited with playing a key role in improving education of medical students and postgraduate education of doctors, with important benefits for the care of hospital patients. He also had a major influence on his medical colleagues through founding and leading medical societies. A century on from his death in December 1919, his specific contributions and how he achieved them are not well known. The aim of this article is to consider the evidence that Osler was an influential medical leader and to reflect on the extent to which the achievements which resulted from his leadership are relevant to modern clinical medicine. Questions of interest include his leadership style, what made for his success as a leader, his medical achievements both in North America and in England, his own insight into leadership and how he was viewed by his peers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

If Sir William Osler were alive and practising as one of our contemporary colleagues, would he be viewed as a role model by medical trainees and other physicians? Recently published literature has sought to define clinical excellence; this characterisation of physician performance establishes a context in which role models in medicine can be appraised. Building on this framework, we present rich anecdotes and quotes from Sir William Osler himself, his colleagues, and his students to consider whether Osler would have been regarded as a role model for clinical excellence today. This paper illustrates convincingly that William Osler indeed personified clinical excellence and would have been appreciated as a consummate role model if he were alive and on a medical school's faculty today. However, a century has passed since his death, and he is not sufficiently visible today to serve as a role model to modern medical trainees and physicians. Moreover, we speculate that Osler himself would not have wanted to be a role model for today's trainees, as he emphasised that medicine is best learned from teachers at the bedside-a place where he cannot be. Reanimating Osler through rich stories and inspiring quotes, and translating his example of clinical excellence into modern clinical practice, can remind us all to carry Oslerian virtues with us in our professional work., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Under the rapid advances of digital technology, traditional paper-based forms of reading and writing are steadily giving way to digital-based literacies, in theory as well as in application. Drawing on a study of literacy in a medical workplace context, this article examines critically the shift toward computer-mediated textual practices. While a considerable body of research has investigated benefits and issues associated with digital literacy tools in medicine, we consider the affordances of paper-based practices. Our analysis of verbal interaction and textual artifacts drawn from a qualitative study of oncology visits indicates that the uses of pen and paper are advantageous for both doctor and patient. Specifically, they allow doctors to process and package information in ways that are favorable to their personal modus operandi, and they enable patients to participate in the medical visit and take an active role in managing their medical treatment. Understanding the affordances of paper-based literacy provides insights for refining digital tools as well as for motivating the design of possible hybrid forms and digital-analog intersections that can best support medical practices.

The regulations for ability to drive with cerebrovascular diseases in the German Driving License Regulations (Fahrerlaubnisverordnung, FeV) and German Guidelines for the Evaluation of Driving Ability of the Federal Highway Research Institute (BASt) are not up to date with the current medical knowledge and are not consistent with comparable regulations regarding cardiovascular diseases. This is particularly true for the assessment of future risks for a sudden loss of control during driving. The present position paper of six medical and neuropsychological societies in Germany presents the current conditions for the assessment of driving ability of patients a cerebrovascular diesease and recommends an estimation of the ability to drive founded on the current state of scientific knowledge. It addresses the following: 1. Physical and mental functional limitations and the possibilities for compensation, which if necessary enable a fitness to drive under conditions or within limits, including the importance of behavioral or personality changes and cognitive deficiencies that interfere with safety. 2. The potential danger due to a sudden loss of control as a result of a transient ischemic attack (TIA) new stroke event, or another cardiovascular event while driving. A summary in the form of a table provides physicians and expert assessors with assistance for the most important cerebrovascular diseases.

Doctors in Star Trek are vital and central characters, often crucial in helping their captains to reach command decisions. They are also interdisciplinarians, performing not only medical tasks but also any form of work related to all fields of biology. Furthermore, these doctors also carry out any required research that pertains to the biological sciences. It is perhaps this unique blend of skills, combined with a fundamental orientation towards humanism and compassion, that leads to their default position, de facto, if not de jure, as the crew's ethics officers, a role that they embrace with as much dedication and zeal as the former Soviet communist political officers/commissars (the Zampolit) did theirs. This paper will show that from the very inception of Star Trek, doctors strictly adhered to deontological tenets which lead them to actively influence command decisions that pertain not only to health, but also to any ethical decisions that may have to be taken by Starfleet officers. This portrayal of future doctors signals the wishes of contemporary audiences: that future doctors remain humane, compassionate and ethical guardian angels, and not only superb medics., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Artificial intelligence and machine learning technologies have a variety of applications throughout the provision of health care, such as clinical documentation, diagnostic image processing, and clinical decision support. This position paper describes the American College of Physicians' (ACP) foundational positions and recommendations regarding the use of these technologies in the provision of health care. The foundation of these positions are principles in the ACP Ethics Manual. Internal medicine physicians are increasingly interacting with systems that implement artificial intelligence (AI) and machine learning (ML) technologies. Some physicians and health care systems are even developing their own AI models, both within and outside of electronic health record (EHR) systems. These technologies have various applications throughout the provision of health care, such as clinical documentation, diagnostic image processing, and clinical decision support. With the growing availability of vast amounts of patient data and unprecedented levels of clinician burnout, the proliferation of these technologies is cautiously welcomed by some physicians. Others think it presents challenges to the patient–physician relationship and the professional integrity of physicians. These dispositions are understandable, given the "black box" nature of some AI models, for which specifications and development methods can be closely guarded or proprietary, along with the relative lagging or absence of appropriate regulatory scrutiny and validation. This American College of Physicians (ACP) position paper describes the College's foundational positions and recommendations regarding the use of AI- and ML-enabled tools and systems in the provision of health care. Many of the College's positions and recommendations, such as those related to patient-centeredness, privacy, and transparency, are founded on principles in the ACP Ethics Manual. They are also derived from considerations for the clinical safety and effectiveness of the tools as well as their potential consequences regarding health disparities. The College calls for more research on the clinical and ethical implications of these technologies and their effects on patient health and well-being. [ABSTRACT FROM AUTHOR]