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Medical residents do not receive adequate training in screening, brief intervention, and referral to treatment (SBIRT) for alcohol and other drug use disorders. The federally funded Pennsylvania SBIRT Medical and Residency Training program (SMaRT) is an evidence-based curriculum with goals of training residents in SBIRT knowledge and skills and disseminating the curriculum throughout the medical residency programs. The SMaRT program collaborates with 4 hospital systems and 7 residency sites, with a target of 1147 residents to be trained. This brief report describes the design of the SMaRT program curriculum, implementation across settings and programs, and its evaluation methods. (Contains 2 figures and 1 table.)

This article describes the use of a brief needs assessment survey in the development of alcohol and drug screening, brief intervention, and referral to treatment (SBIRT) curricula in 2 health care settings in the San Francisco Bay Area. The samples included university medical center faculty (n = 27) and nonphysician community health and social service providers in a nearby suburban county (n = 21). Informed by curriculum development theory and motivational interviewing strategies, questions regarding clinical and educational priorities, perceived importance and confidence with screening and intervention techniques, and referral resource availability were included. Medical center faculty expressed greater concern about limited appointment time (P = 0.003), adequacy of training (P = 0.025), and provider confidence (P = 0.038) as implementation obstacles and had lower confidence in delivering SBIRT (P = 0.046) and providing treatment referrals (P = 0.054) than community providers. The authors describe their approach to integrating needs assessment results into subsequent curriculum development. Findings highlight potential differences between physician and nonphysician training needs. (Contains 2 tables.)

This article reports on the development and evaluation of a Web-based application that provides instruction and hands-on practice in managing electrolyte and acid-base disorders. Our teaching approach, which focuses on concepts rather than details, encourages quantitative analysis and a logical problem-solving approach. Identifying any dangers to the patient is a vital first step. Concepts such as an "appropriate response" to a given perturbation and the need for electroneutrality in body fluids are used repeatedly. Our Electrolyte Workshop was developed using Flash and followed an iterative design process. Two case-based tutorials were built in this first phase, with one tutorial including an interactive treatment simulation. Users select from a menu of therapies and see the impact of their choices on the patient. Appropriate text messages are displayed, and changes in body compartment sizes, brain size, and plasma sodium concentrations are illustrated via Flash animation. Challenges encountered included a shortage of skilled Flash developers, budgetary constraints, and challenges in communication between the authors and the developers. The application was evaluated via user testing by residents and specialists in internal medicine. Satisfaction was measured with a questionnaire based on the System Usability Scale. The mean System Usability Scale score was 78.4 plus or minus 13.8, indicating a good level of usability. Participants rated the content as being scientifically sound; they liked the teaching approach and felt that concepts were conveyed clearly. They indicated that the application held their interest, that it increased their understanding of hyponatremia, and that they would recommend this learning resource to others. (Contains 4 figures and 8 tables.)

Contradictory data exist regarding optimal methods and instruments for intimate partner violence (IPV) screening in primary care settings. The purpose of this study was to determine the optimal method and screening instrument for IPV among men and women in a primary-care resident clinic. We conducted a cross-sectional study at an urban, academic, internal medicine residency continuity clinic in Connecticut among English or Spanish speaking adult patients. One group of patients ( n = 340) received a self-administered questionnaire (SAQ) containing the partner violence screen (PVS) and the Hurt, Insulted, Threatened or Screamed at Questionnaire (HITS). A second group (n = 126) was screened with PVS and HITS by their primary care providers during face-to-face (FTF) clinical encounters. Multivariable logistic regression models were used to determine the association between IPV prevalence and screening method (SAQ or FTF) after adjusting for socio-demographic effects. The overall IPV prevalence was 17.3% using the SAQ and 9.0% with FTF screening (p = 0.008). Patients receiving the SAQ were more likely to report IPV than those who were screened FTF (adjusted odds ratio [AOR]: 2.6, 95% confidence interval [CI]: 1.2-5.6). This effect persisted for women, who had a higher odds of IPV when screened through a SAQ than when screened FTF (AOR: 3.5, 95% CI: 1.4-8.6). Men did not differ in reporting IPV between methods: 11% with SAQ versus 9.4% FTF (p = 0.69). In internal medicine residency continuity clinics, a SAQ for IPV may result in higher disclosure and completion rates among female patients compared to FTF screening. Unique screening instruments and methods may be needed for men. (Contains 1 figure and 3 tables.)

To compare different scoring algorithms for Pick-N multiple correct answer multiple-choice (MC) exams regarding test reliability, student performance, total item discrimination and item difficulty. Data from six 3rd year medical students' end of term exams in internal medicine from 2005 to 2008 at Munich University were analysed (1,255 students, 180 Pick-N items in total). Scoring Algorithms: Each question scored a maximum of one point. We compared: (a) Dichotomous scoring (DS): One point if all true and no wrong answers were chosen. (b) Partial credit algorithm 1 (PS50): One point for 100% true answers; 0.5 points for 50% or more true answers; zero points for less than 50% true answers. No point deduction for wrong choices. (c) Partial credit algorithm 2 (PS1/m): A fraction of one point depending on the total number of true answers was given for each correct answer identified. No point deduction for wrong choices. Application of partial crediting resulted in psychometric results superior to dichotomous scoring (DS). Algorithms examined resulted in similar psychometric data with PS50 only slightly exceeding PS1/m in higher coefficients of reliability. The Pick-N MC format and its scoring using the PS50 and PS1/m algorithms are suited for undergraduate medical examinations. Partial knowledge should be awarded in Pick-N MC exams.

Objective: Regardless of the outcome of current efforts at healthcare reform, the resources that academic health centers need--to provide care for increasingly complex patient populations, support clinical innovation, grow the clinical enterprise, and carry out their research and teaching missions--are in jeopardy. This article examines the value proposition for psychiatry. Method: The authors describe areas where academic departments of psychiatry have opportunities to help shape the future of academic health centers in a rapidly-changing healthcare environment and share their experience in leadership roles in academic psychiatry and in consulting to academic health center leaders. Results: Many academic health centers are reexamining both their mission and their use of available resources. Some are questioning their ability to sustain traditionally low-margin clinical specialties like internal medicine, pediatrics, and psychiatry, where, all too often, clinical revenues alone are insufficient to cover the full cost of caring for the patients they serve. Conclusion: Academic departments of psychiatry must continually demonstrate their value to the academic health centers' clinical and academic mission.

Teaching about diagnosis, treatment, and sequelae of substance use disorders (SUDs) is insufficient in most Internal Medicine residency programs. To address this, the authors developed, implemented, and evaluated a novel and comprehensive SUD curriculum for first year residents (interns) in Internal Medicine, which anchors the ensuing 3-year longitudinal SUD curriculum. This intern curriculum includes didactic and experiential elements and allows skills practice. Topics include local epidemiology of substance abuse, neurobiology of SUDs, and screening, treatment, and referral. The entire curriculum is delivered over 7 hours during a month-long ambulatory rotation. Among 58 interns who have completed a pre-post evaluation of the curriculum, the majority reported an increased sense of responsibility for and confidence in treating patients with SUDs. (Contains 1 table.)

Introduction: Physicians undertake many transitions during the course of a medical career. The purpose of this study was to explore the experiences of physicians who moved to a new community. Methods: A semistructured interview format was used to explore transitional experiences, including reasons for moving; the role of colleagues, learning, and organizational structures; how various mediating factors affected perceptions; and how the experience affected the physicians personally. We used qualitative methods in which data were collected, coded, and analyzed concurrently. Results: 20 physicians from family medicine, internal medicine, and pediatrics described their experiences. Both the professional context and the geographic location affected physicians' perceptions of the move. Both internal and external mediating factors appeared to influence how physicians experienced and adjusted to the move. Physicians who joined functioning units appeared to have fewer problems. The physicians who had more difficulty were physicians who did not come to a specific job, often coming as the result of a spousal move; did not have a professional network in the city; had not sorted out licensure requirements; and were entering community (not institutional) practice. Discussion: This study demonstrates the critical nature of institutional support structures to integrate the newcomer, collegial relationships within the workplace, and the importance of family and friends in mediating the adjustment period. Consideration should be given to structured mentorship or peer-buddy programs and longitudinal educational programs (eg, rounds) that may enable physicians to establish networks and gain practical local knowledge quickly. (Contains 1 figure.)

Introduction: Performance of health care professionals depends on both medical knowledge and the certainty with which they possess it. Conventional continuing medical education interventions assess the correctness of learners' responses but do not determine the degree of confidence with which they hold incorrect information. This study describes the use of confidence-based learning (CBL) in an activity designed to enhance learners' knowledge, confidence in their knowledge, and clinical competence with regard to constipation-predominant IBS (IBS-C), a frequently underdiagnosed and misdiagnosed condition. Methods: The online CBL activity included multiple-choice questions in 2 modules: Burden of Care (BOC; 28 questions) and Patient Scenarios (PS; 9 case-based questions). After formative assessment, targeted feedback was provided, and the learner focused on material with demonstrated knowledge and/or confidence gaps. The process was repeated until 85% of questions were answered correctly and confidently (ie, mastery was attained). Results: Of 275 participants (24% internal medicine, 13% gastroenterology, 32% family medicine, and 31% other), 249 and 167 completed the BOC and PS modules, respectively. Among all participants, 61.8% and 98.2% achieved mastery in the BOC and PS modules, respectively. Baseline mastery levels between specialties were significantly different in the BOC module (p = 0.002); no significant differences were evident between specialties in final mastery levels. Approximately one-third of learners were confident and wrong in topics of epidemiology, defining IBS and constipation, and treatments in the first iteration. No significant difference was observed between specialties for the PS module in either the first or last iterations. Discussion: Learners achieved mastery in topics pertaining to IBS-C regardless of baseline knowledge or specialty. These data indicate that CME activities employing CBL can be used to address knowledge and confidence gaps. (Contains 7 figures and 3 tables.)

Barriers to entering addiction medicine (AM) have led to a persisting workforce shortage. To address this problem, the Chapter of Addiction Medicine (AChAM) was formed in 2001 as a subdivision of the Royal Australasian College of Physicians (RACP). Through consultation, AChAM has identified the scope of practice and offered fellowship to suitable established practitioners. The Chapter successfully applied to the Australian Government for recognition of AM as a medical specialty, which was finalized in November 2009. Specialist reimbursement item numbers were incorporated into that decision process and commence operating in November 2010. AChAM has designed and implemented a training scheme using a model similar to that of the RACP internal medicine training program. This comprises 3 years of basic general medical training post internship followed by 3 years of discipline-specific supervised training. The training is broadly based, with experience in both ambulatory care and inpatient care, and including physical health as well as mental health. Assessment is continuous and competency based. There is no exit examination. The overriding clinical approach rests upon the harm minimization framework consistent with long-established national drug policy in Australia and favors evidence-based treatment. (Contains 1 table.)

Nationwide data were collected concerning inpatient care use and medical expenditure of people with disabilities (N = 937,944) among national health insurance beneficiaries in Taiwan. Data included gender, age, hospitalization frequency and expenditure, healthcare setting and service department, discharge diagnose disease according to the ICD-9-CM coding system which has been used in Taiwan NHI diagnosis system. There were 27.88% of persons with disabilities have been hospitalized for treatments during the year 2005 and it was 3.5 times of the general population (7.95%). The mean of annual inpatient care expenditure was 163,544.21 NTD, and male patients use more inpatient care cost than female patients in people with disabilities. However, the hospitalization rate in female patients is statistical higher than male patients in the study (p less than 0.001). Infectious and parasitic diseases, mental disorders, diseases of the respiratory system, diseases of the circulatory system, injury and poisoning were the top five reasons for hospitalization among the subjects. Our study also found that psychiatry, internal medicine, orthopedic, surgery and neurosurgery are the top five clinical divisions which the cases used more frequently than other clinical departments in hospitalizations. The present study presents the first information of hospitalization care and medical costs in people with disabilities based on a nationwide data analyzes in Taiwan. We suggest the importance of supporting people with disabilities during hospitalizations, following up rehabilitation and there is an urgent need for cost-effective intervention programs for disability prevention, which could be offset against the cost for treating the disabled in the future. (Contains 4 figures and 7 tables.)

The mini-CEX is widely used to rate directly observed resident-patient encounters. Although several studies have explored the reliability of mini-CEX scores, the dimensionality of mini-CEX scores is incompletely understood. Objective: Explore the dimensionality of mini-CEX scores through factor analysis and generalizability analysis. Design: Factor analytic and generalizability study using retrospective data. Participants: Eighty five physician preceptors and 264 internal medicine residents (postgraduate years 1-3). Methods: Preceptors used the six-item mini-CEX to rate directly observed resident-patient encounters in internal medicine resident continuity clinics. We analyzed mini-CEX scores accrued over 4 years using repeated measures analysis of variance to generate a correlation matrix adjusted for multiple observations on individual residents, and then performed factor analysis on this adjusted correlation matrix. We also performed generalizability analyses. Results: Eighty-five preceptors rated 264 residents in 1,414 resident-patient encounters. Common factor analysis of these scores after adjustment for repeated measures revealed a single-factor solution. Cronbach's alpha for this single factor (i.e. all six mini-CEX items) was greater than or equal to 0.86. Sensitivity analyses using principal components and other method variations revealed a similar factor structure. Generalizability studies revealed a reproducibility coefficient of 0.23 (0.70 for 10 raters or encounters). Conclusions: The mini-CEX appears to measure a single global dimension of clinical competence. If educators desire to measure discrete clinical skills, alternative assessment methods may be required. Our approach to factor analysis overcomes the limitation of repeated observations on subjects without discarding data, and may be useful to other researchers attempting factor analysis of datasets in which individuals contribute multiple observations. (Contains 7 tables.)

Systems-based practice (SBP) is rarely taught or evaluated during medical school, yet is one of the required competencies once students enter residency. We believe Texas A&M College of Medicine students learn about systems issues informally, as they care for patients at a free clinic in Temple, TX. The mandatory free clinic rotation is part of the Internal Medicine clerkship and does not include formal instruction in SBP. During 2008-2009, a sample of students (n = 31) on the IMED clerkship's free clinic rotation participated in a program evaluation/study regarding their experiences. Focus groups (M = 5 students/group) were held at the end of each outpatient rotation. Students were asked: "Are you aware of any system issues which can affect either the delivery of or access to care at the free clinic?" Data saturation was reached after six focus groups, when investigators noted a repetition of responses. Based upon investigator consensus opinion, data collection was discontinued. Based upon a content analysis, six themes were identified: "access to specialists, including OB-GYN, was limited; cost containment; lack of resources affects delivery of care; delays in care due to lack of insurance; understanding of larger healthcare system and free clinic role; and delays in tests due to language barriers". Medical students were able to learn about SBP issues during free clinic rotations. Students experienced how SBP issues affected the health care of uninsured individuals. We believe these findings may be transferable to medical schools with mandatory free clinic rotations. (Contains 2 tables.)

Learning theories, which suggest that experienced faculty use collaborative teaching styles, are reflected in qualitative studies of learners in hospital settings. However, little research has used resident focus groups to explore characteristics of successful teachers in outpatient clinics. Therefore, focus group discussions with first through third-year internal medicine residents at a large academic medical center were conducted to better understand residents' perspectives on effective outpatient teaching. A group facilitator solicited residents' reflections, based on their lived experiences, on teaching domains from previous factor analytic studies: interpersonal, clinical-teaching, and efficiency. Researchers coded focus group transcripts and identified themes within the domains. Final themes were determined by consensus. Leading themes were "kindness" and "teacher-learner relationships." Junior residents were sensitive to faculty who were brusque, harsh, and degrading. Senior residents respected faculty who were humble, collaborative, and allowed residents to co-manage teaching encounters. Seniors emphasized the importance of faculty role-modelling and preferentially staffed with experts to "gain wisdom from experience." Overall, residents expressed that effective learning requires grounded teacher-learner relationships. These findings support learning theories and previous factor analytic studies. However, this qualitative study provided insights that could not be gleaned from assessment scores alone.

Oral examinations have become more standardized over recent years. Traditionally a small number of raters were used for this type of examination. Past studies suggested that more raters should improve reliability. We compared the results of a multi-station structured oral examination using two different rater models, those based in a station, (station-specific raters), and those who follow a candidate throughout the entire examination, (candidate-specific raters).Two station-specific and two candidate-specific raters simultaneously evaluated internal medicine residents' performance at each station. No significant differences were found in examination scores. Reliability was higher for the candidate-specific raters. Inter-rater reliability, internal consistency and a study of station inter-correlations suggested that a halo effect may be present for candidates examined by candidate-specific raters. This study suggests that although the model of candidate-specific raters was more reliable than the model of station-specific raters for the overall examination, the presence of a halo effect may influence individual examination outcomes.

Educators must often decide how many points to use in a rating scale. No studies have compared interrater reliability for different-length scales, and few have evaluated accuracy. This study sought to evaluate the interrater reliability and accuracy of mini-clinical evaluation exercise (mini-CEX) scores, comparing the traditional mini-CEX nine-point scale to a five-point scale. Methods: The authors conducted a validity study in an academic internal medicine residency program. Fifty-two program faculty participated. Participants rated videotaped resident-patient encounters using the mini-CEX with both a nine-point scale and a five-point scale. Some cases were scripted to reflect a specific level of competence (unsatisfactory, satisfactory, superior). Outcome measures included mini-CEX scores, accuracy (scores compared to scripted competence level), interrater reliability, and domain intercorrelation. Results: Interviewing, exam, counseling, and overall ratings varied significantly across levels of competence (P less than 0.0001). Nine-point scale scores accurately classified competence more often (391/720 [54%] for overall ratings) than five-point scores (316/723 [44%], P less than 0.0001). Interrater reliability was similar for scores from the nine- and five-point scales (0.43 and 0.40, respectively, for overall ratings). With the exception of correlation between exam and counseling scores using the five-point scale (r = 0.38, P = 0.13), score correlations among all domain combinations were high (r = 0.46-0.89) and statistically significant (P [less than or equal to] 0.015) for both scales. Conclusions: Mini-CEX scores demonstrated modest interrater reliability and accuracy. Although interrater reliability is similar for nine- and five-point scales, nine-point scales appear to provide more accurate scores. This has implications for many educational assessments.

The Internal Medicine In-Training Examination (ITE) is administered during residency training in the United States as a self-assessment and program assessment tool. Performance on this exam correlates with outcome on the American Board of Internal Medicine Certifying examination. Internal Medicine Program Directors use the United States Medical Licensing Examination (USMLE) to make decisions in recruitment of potential applicants. This study was done to determine a correlation of USMLE Steps 1, 2 and 3 results with ITE scores in each level of Internal Medicine training. A retrospective review of all residents graduating from an Internal Medicine program from 1999 to 2006 was done. Subjects included had data for all USMLE Steps and ITE during all years of training. Thirty-one subjects were included in the study. Correlations of USMLE Steps 1, 2 and 3 were done with ITE scores (percent correct) in each year of training. Pearson's correlation coefficient (r) was determined for each pairing and a t test to determine statistical significance of the correlation was done. Statistical significance was defined as "P" value less than 0.05. The "r" values for USMLE Step 1 and ITE percent correct in PGY I, II and III were 0.46, 0.55 and 0.51 respectively. Corresponding "r" values for USMLE Step 2 and ITE percent correct were 0.79, 0.70 and 0.72; for USMLE Step 3 these values were 0.51, 0.37 and 0.51 respectively for each training year. USMLE scores are correlated with ITE scores. This correlation was strongest for USMLE Step 2.

Background: Adaptation to learning styles has been proposed to enhance learning. Objective: We hypothesized that learners with sensing learning style would perform better using a problem-first instructional method while intuitive learners would do better using an information-first method. Design: Randomized, controlled, crossover trial. Setting: Resident ambulatory clinics. Participants: 123 internal medicine residents. Interventions: Four Web-based modules in ambulatory internal medicine were developed in both "didactic" (information first, followed by patient problem and questions) and "problem" (case and questions first, followed by information) format. Measurements: Knowledge posttest, format preference, learning style (Index of Learning Styles). Results: Knowledge scores were similar between the didactic (mean [plus or minus] standard error, 83.0 [plus or minus] 0.8) and problem (82.3 [plus or minus] 0.8) formats (p = 0.42; 95% confidence interval [CI] for difference, -2.3 to 0.9). There was no difference between formats in regression slopes of knowledge scores on sensing-intuitive scores (p = 0.63) or in analysis of knowledge scores by styles classification (sensing 82.5 [plus or minus] 1.0, intermediate 83.7 [plus or minus] 1.2, intuitive 81.0 [plus or minus] 1.5; p = 0.37 for main effect, p = 0.59 for interaction with format). Format preference was neutral (3.2 [plus or minus] 0.2 [1 strongly prefers didactic, 6 strongly prefers problem], p = .12), and there was no association between learning styles and preference (p = 0.44). Formats were similar in time to complete modules (43.7 [plus or minus] 2.2 vs 43.2 [plus or minus] 2.2 minutes, p = 0.72). Conclusions: Starting instruction with a problem (versus employing problems later on) may not improve learning outcomes. Sensing and intuitive learners perform similarly following problem-first and didactic-first instruction. Results may apply to other instructional media.

The aim of this study was to assess the effect of physiotherapy on ventilator dependency and lengths of intensive care unit (ICU) stay. Patients were divided into two groups. The control group, which received standard nursing care, was a retrospective chart review. The data of control patients who were not receiving physiotherapy were obtained from the hospital records. The intervention group was prospectively taken into the chest physiotherapy program. This study was planned on mechanically ventilated patients who were admitted to a six-bed multidisciplinary internal medicine intensive care unit of the university hospital. A total of 510 patients who were hospitalised in the ICU were included in the study. Demographics, diagnostic profiles, co-existing chronic diseases, respiratory parameters on admission, patient's overall severity by Acute Physiology and Chronic Health Evaluation II score, patient outcome, duration of stay in ICU, duration of ventilator support, and complications were assessed. The extubation time and length of ICU stay were compared between the two groups. Control patients had a longer period of ventilator dependency than the intervention patients and this difference was statistically significant (P less than 0.05). It was noted that the resulting length of stay in the ICU was significantly lower in the intervention group than in the control group (P less than 0.05). Although the patients had similar diagnoses and physical features, the length of stay in the ICU was significantly lower in the intervention group. The results show that physiotherapy has a great impact on ventilatory dependency and length of stay in the ICU.

Rates of screening, brief intervention, and referral to treatment (SBIRT) for alcohol and drug use by physicians remain low, despite evidence of efficacy. Motivational enhancement therapy (MET) may be a promising means to help physicians resolve ambivalence about intervening with alcohol and drug users and take advantage of educational opportunities. In the present study, 9 internal medicine residents received brief MET prior to standard education in SBIRT. Residents' self-reported SBIRT attitudes and behaviors were measured before the intervention and at a 5-week follow-up point. Changes in SBIRT attitudes and behaviors all occurred in the expected direction, although, due to the small sample size, none reached statistical significance. Results suggest that MET may enhance educational opportunities and lead to changes in SBIRT behavior.

A concern on the level of anatomy knowledge reached after a problem-based learning curriculum has been documented in the literature. Spatial anatomy, arguably the highest level in anatomy knowledge, has been related to spatial abilities. Our first objective was to test the hypothesis that residents are interested in a course of applied anatomy after a problem-based learning curriculum. Our second objective was to test the hypothesis that the interest of residents is driven by innate higher spatial abilities. Fifty-nine residents were invited to take an elective applied anatomy course in a prospective study. Spatial abilities were measured with a redrawn Vandenberg and Kuse Mental Rotations Test in two (MRT A) and three (MRT C) dimensions. A need for a greater knowledge in anatomy was expressed by 25 residents after a problem-based learning curriculum. MRT A and C scores obtained by those choosing (n = 25) and not choosing (n = 34) applied anatomy was not different (P = 0.46 and P = 0.38, respectively). Percentage of residents in each residency program choosing applied anatomy was different [23 vs. 31 vs. 100 vs. 100% in Family Medicine, Internal Medicine, Surgery, and Anesthesia, respectively; P less than 0.0001]. The interest of residents in applied anatomy was not driven by innate higher spatial abilities. Our applied anatomy course was chosen by many residents because of training needs rather than innate spatial abilities. Future research will need to assess the relationship of individual differences in spatial abilities to learning spatial anatomy. (Contains 4 tables and 1 figure.)

Context: Past research has documented rural physician and health care professional shortages. Purpose: Rural hospital chief executive officers' (CEOs') reported shortages of health professionals and perceptions about recruiting and retention are compared in Illinois and Arkansas. Methods: A survey, previously developed and sent to 28 CEOs in Illinois, was mailed to 110 CEOs in Arkansas. Only responses from rural CEOs are presented (Arkansas n = 39 and Illinois n = 22). Findings: Physician shortages were reported by 51 CEOs (83.6%). Most reported physician shortages in Arkansas were for family medicine, internal medicine, cardiology, obstetrics-gynecology, general surgery, and psychiatry. Most reported physician shortages in Illinois were for family medicine, obstetrics-gynecology, orthopedic surgery, internal medicine, cardiology, and general surgery. Additionally, registered nurses and pharmacists were the top 2 allied health professions shortages. Multivariate analysis (factor and discriminant analyses) examined community attributes associated with ease of recruiting physicians. Six factors were identified and assessed as to their importance in influencing ease of recruitment, with the state included in the model. Three factors were identified as discriminating whether or not physician recruitment was easy: community supportive for family, community cooperates and perceives a good future, and community attractiveness. Conclusions: Similarities in shortages and attributes influencing recruitment in both states suggest that efforts and policies in health professions workforce development can be generalized between regions. This study further reinforces some important known issues concerning retention and recruitment, such as the importance of identifying providers whose preferences are matched to the characteristics and lifestyle of a given area.

Introduction: Diplomates in the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program satisfy the self-evaluation of medical knowledge requirement by completing open-book multiple-choice exams. However, this method remains unlikely to affect practice change and often covers content areas not relevant to diplomates' practices. We developed and evaluated an Internet-based point of care (POC) learning portfolio to serve as an alternative. Methods: Participants enter information about their clinical questions, including characteristics, information pursuit, application, and practice change. After documenting 20 questions, they reflect upon a summary report and write commitment-to-change statements about their learning strategies. They can link to help screens and medical information resources. We report on the beta test evaluation of the module, completed by 23 internists and 4 internal medicine residents. Results: Participants found the instructions clear and navigated the module without difficulty. The majority preferred the POC portfolio to multiple-choice examinations, citing greater relevance to their practice, guidance in expanding their palette of information resources, opportunity to reflect on their learning needs, and credit for self-directed learning related to their patients. Participants entered a total of 543 clinical questions, of which 250 (46%) resulted in a planned practice change. After completing the module, 14 of 27 (52%) participants committed to at least 1 change in their POC learning strategies. Discussion: Internists found the portfolio valuable, preferred it to multiple-choice examinations, often changed their practice after pursuing clinical questions, and productively reflected on their learning strategies. The ABIM will offer this portfolio as an elective option in MOC. (Contains 5 tables.)

Narrative writing has been used to promote reflection and increased self-awareness among physicians. The purpose of this study was to determine the impact of prompted narrative writing on reflection. Thirty-two interns at 9 internal medicine residency programs participated in a year-long qualitative study about personal growth beginning in July of 2002. Interns wrote narratives every 8 weeks. At study completion, interns wrote a final narrative describing the affect that being in the study had on them. Responses were reviewed and organized into domains. Writing throughout the year resulted in reflection and encouraged interns to reconsider their core values and priorities. Some found that the exercise promoted greater self-awareness and provided an emotional outlet. Writing about difficult experiences coupled with reflection motivated some interns to want to improve. Prompted narrative writing led to reflection among interns and promoted self-awareness. Educators may consider incorporating narrative writing into residency education.

Background: Previous studies have suggested an association between reasoning strategies and diagnostic success, but the influence on this relationship of variables such as question format and task difficulty, has not been studied. Our objective was to study the association between question format, task difficulty, reasoning strategies and diagnostic success. Methods: Study participants were 13 Internal Medicine residents at the University of Calgary. Each was given eight problem-solving questions in four clinical presentations and were randomized to groups that differed only in the question format, such that a question presented as short answer (SA) to the first group was presented as extended matching (EM) to the second group. There were equal numbers of SA/EM questions and straightforward/difficult tasks. Participants performed think-aloud during diagnostic reasoning. Data were analyzed using multiple logistic regression. Results: Question format was associated with reasoning strategies; hypothetico-deductive reasoning being used more frequently on EM questions and scheme-inductive reasoning on SA questions. For SA question, non-analytic reasoning alone was used more frequently to answer straightforward cases than difficult cases, whereas for EM questions no such association was observed. EM format and straightforward task increased the odds of diagnostic success, whereas hypothetico-deductive reasoning was associated with reduced odds of success. Conclusions: Question format and task difficulty both influence diagnostic reasoning strategies and studies that examine the effect of reasoning strategies on diagnostic success should control for these effects. Further studies are needed to investigate the effect of reasoning strategies on performance of different groups of learners.

Background: Medical knowledge is essential for appropriate patient care; however, the accuracy of internal medicine (IM) residents' assessment of their medical knowledge is unknown. Methods: IM residents predicted their overall percentile performance 1 week (on average) before and after taking the in-training exam (ITE), an objective and well accepted method to assess medical knowledge to study resident assessment accuracy. Ordinary least squares regression was used to study the association between the absolute accuracy of their predictions of their percentile performance on the ITE examination and their actual percentile performance. Results: Ninety-three percent of our 28 residents participated. Residents were highly inaccurate in predicting their percentile performance. Only 31% had ITE scores that were within 10 points of their predictions. On average, most residents were pessimistic about their overall percentile performance with 18 (69%) underestimating their performance. Having just taken the examination and previous experience with the examination did not improve predictions of percentile performance. Conclusion: IM residents did not accurately predict their own level of medical knowledge. Taking the examination and experience with previous exams does not appear to improve the ability of these IM residents to predict their performance. Residents need to be taught to rely on the results of standardized examinations such as the ITE to best assess their overall medical knowledge. The factors important for accurate self-assessment of medical knowledge in individual clinical situations remain unexplored.

Studies examining medical teams indicate that exposure to the terminally ill often has detrimental effects on their physical and emotional well-being. However, recent theoretical developments suggest that this exposure might also have positive implications. The current study sought to examine 2 positive outcomes, meaning in life and personal growth, among physicians and nurses working with hospitalized children and exposed to different levels of patient mortality. In addition, the contribution of level of secondary traumatization and the personal resources of professional self-esteem and optimism were examined. The sample consisted of 58 physicians and 66 nurses working in pediatric hemato-oncology, pediatric intensive care units, and pediatric internal medicine wards in Israel. The findings indicate that a higher level of exposure to patient death, higher optimism, and professional self-esteem, and lower secondary traumatization predicted the sense of meaning in life, whereas occupation, as well as higher professional self-esteem and higher level of secondary traumatization, especially among lower professional self-esteem individuals, predicted a higher experience of personal growth. In addition, nurses reported higher levels of professional self-esteem, secondary traumatization, and personal growth than physicians. The theoretical and practical implications of the results are discussed. (Contains 4 tables.)

The research reported in this article examined attitudes toward the care of the elderly between and among medical students and residents in training. Data were collected with a 16-item attitude questionnaire. Participants were medical students in their introduction period (prior to clinical experience) and residents of the Department of Internal Medicine, Faculty of Medicine at Siriraj Hospital to answer. There was no difference in the attitudes toward the care for the elderly between medical students and residents. Prior exposure to the elderly may have an influence on attitudes toward the care of the elderly. The geriatric curriculum should be developed to correct misunderstandings and improve the attitudes of the students and residents. (Contains 1 table.)

Objective: To determine the degree to which the medical humanities have been integrated into the fields of internal medicine and psychiatry, the authors assessed the presence of medical humanities articles in selected psychiatry and internal medicine journals from 1950 to 2000. Methods: The journals searched were the three highest-ranking psychiatry and internal medicine journals on the Institute for Scientific Information's Impact Factor rankings that were published in English and aimed at a clinical audience. Operationalized criteria defining the medical humanities allowed the percentage of text in the selected journals constituting medical humanities to be quantified. Journals were hand searched at 10-year intervals from 1950 to 2000. Mixed effects models were used to describe the change in medical humanities over time. Results: The percentage of text within psychiatry journals meeting the criteria for medical humanities declined from a peak of 17% in 1970 to a low of 2% in 2000, while the percentage of humanities articles in internal medicine journals roughly doubled from 5% to 11% over the same time period. A linear model increasing over time best fit the medical humanities in the internal medicine journals, while a cubic model decreasing over time best fit the psychiatry humanities data. Humanities articles in medical journals had a greater breadth and diversity than those in psychiatry journals. Conclusion: Medical humanities publications dramatically decreased over time in psychiatry journals while they more than doubled in internal medicine journals. These data suggest the need for further empirical research and discussion of the potential roles of the humanities in psychiatry.

Background: Quality measurement and improvement in practice are requirements for Maintenance of Certification by the American Board of Medical Specialties boards and a component of many pay for performance programs. Objective: To describe the development of the American Board of Internal Medicine (ABIM) Practice Improvement Module (PIM[superscript SM]) and the average performance of ABIM diplomates who have completed the Preventive Cardiology PIM[superscript SM]. Design: Observational study of self-administered practice quality improvement. Setting: Office practices through the United States. Participants: A total of 179 cardiologists and general internists completing requirements for ABIM Maintenance of Certification from 2004 through 2005. Measurements: Physicians self-audited at least 25 charts to obtain performance measures, patient demographics, and coronary heart disease risk factors. At least 25 patients completed surveys regarding their experience of care in the physician's practice. Physicians completed a self-assessment survey detailing the presence of various practice systems. Results: The mean rate for systolic blood pressure control was 48%, for diastolic blood pressure 84%, and for low-density lipoprotein (LDL) cholesterol at goal 65%. Of patients 61% rated the quality of care as excellent and 58% rated the practices excellent at encouraging questions and answering them clearly. More than 85% of patients reported "no problem" obtaining a prescription refill, scheduling an appointment, reaching someone in the practice with a question, or obtaining lab results. Targets for improvement were increasing the rates for LDL cholesterol or systolic blood pressure at goal, improving patients' physical activity, patient education, and accuracy of risk assessment. Improvement strategies included implementing chart forms, patient education, or care management processes. Limitations: Patients and charts were selected by physicians reporting their performance for the purpose of MOC. Conclusions: The Preventive Cardiology PIM[superscript SM] successfully provides a self-assessment of practice performance and provides guidance in helping physicians initiate a cycle of quality improvement in their practices. (Contains 1 figure and 4 tables.)

Introduction: There is a strong need for high-quality continuing medical education (CME) in Germany. To maintain a medical license, physicians are required to participate in regular training. Although evidence suggests that compared to lectures interactive methods can impart sustainable knowledge and a high degree of satisfaction, few interactive CME courses are offered. Methods: We designed an interactive, team-based CME concept and launched it in a series of seminars on internal medicine. The group work was designed using team-based learning. Pre- and postcourse knowledge tests with an electronic voting system and paper questionnaires (Likert scale 1-6) were used to evaluate knowledge, motivation, and expectations of the participants (n = 159). Results: Participants rated the interactivity and team-based discussion (mean: 4.57, SD: 1.41) of the CME seminars as highly important reasons to participate and stated that the CME course was very instructional (mean: 5.16, SD: 0.84) and the case discussions enhanced their learning (mean: 5.46, SD: 0.75). The majority of participants stated that their expectations were met. The participants enhanced their outcome from a mean of 47.2% right answers prior to the course to 70.3% in the postcourse test ( p less than 0.001). Discussion: An interactive, case-based design of a CME course following the team-based learning concept leads to a significant gain in the participants' knowledge with an identified preknowledge level. Participants' expectations seemed fulfilled by a CME course design, which combines small group discussions in the lecture hall with didactic lectures and intensive discussion. (Contains 3 tables and 1 figure.)

Objective: A high percentage of suicide victims have seen a primary care physician in the months before committing suicide. Thus, primary care physicians may play an important role in suicide prevention. Method: The authors mailed a survey to directors of training programs in family practice, internal medicine, and pediatrics, and 50.5% responded. Data obtained were analyzed with WebStat. Results: Training directors reported deficiencies in training in suicide and depression. Notably, less than half of the internal medicine and pediatrics training directors who replied reported that teaching about suicide was adequate. The majority of them indicated a need for standardized curricular materials on suicide and depression. Conclusions: Experts could provide standardized curricula to primary care residencies in the recognition and management of suicide and depression. More robust training about these vital mental health concerns in primary care could reduce morbidity and mortality.

Self-regulation in medicine depends on accurate self-assessment. The purpose of the present study was to examine the discrepancy between self and peer assessments for a group of specialist physicians from internal medicine (IM), pediatrics, and psychiatry clinical domains (i.e., patient management, clinical assessment, professional development, and communication). Data from 304 psychiatrists, pediatricians and internal medicine specialists were used. Each physician had data from an identical self and 8 peer (38 item/4 clinical domains assessment). A total of 2306 peer assessments were available. Physicians were classified into quartiles based on mean assessment peer data and compared with self-assessment data. The analyses showed that self and peer assessment profiles were consistent across specialties and domains. Physicians assessed in the lowest and highest quartiles (i.e., less than 25th and greater than 75th) by colleagues tended to rate themselves 30-40 percentile ranks higher and lower than peers, respectively. This study suggests that practicing physicians are inaccurate in assessing their own performance. These data suggest that systems to provide practicing physicians with regular and routine feedback may be appropriate if we are to ensure physicians are able to accurately assess themselves in a profession in which self-regulation is predicated upon the assumption that physicians know their capabilities and limitations.

Within academic medical centers, psychiatry, pediatrics, and certain other specialties of internal medicine carry a disproportionate responsibility for teaching but are least able to support teaching and research through clinical income. This article reviews the educational, research and clinical missions of an academic psychiatry department and the major challenges facing chairs as they seek to lead their departments. Though the leadership role that the chair plays in psychiatric education, research, and clinical services can be tremendously satisfying, it is also true that being a chair in these times has much in common with "middle management" in other corporate structures.

Interdisciplinary health care training is advocated by numerous government and philanthropic organizations. Educators in the health professions are increasingly offering training in interdisciplinary health care in a variety of contexts, including ambulatory settings. This paper describes a three-year program to teach skills in interdisciplinary care to learners from internal medicine, social work, pharmacy, and nursing in a geriatrics clinic at a major academic institution in the United States. Framed in a critical review of existing evidence for the effectiveness of interdisciplinary training and health care and expert recommendations, specific recommendations are made to educators interested in interdisciplinary training in ambulatory settings. (Contains 1 table.)

The authors describe the development and administration of a substance use attitudes questionnaire to social work students and clinicians, physician assistant students and practitioners, and medical interns. The general purpose for the Attitudes Survey was to collect baseline data regarding past training, current attitudes, beliefs, practices, and knowledge regarding SUD across multiple disciplines. The field survey questionnaire, modeled on D'Onofrio's, was administered to 276 Physician Assistant students and clinicians, Internal Medicine interns, Masters of Social Work students and clinicians working in treatment settings in Houston, Texas.

Introduction: The American Board of Internal Medicine (ABIM) recognized that certification and recertification must be based on an assessment of performance in practice as well as an examination of medical knowledge. Physician self-assessment of practice performance is proposed as one method that certification boards may use to evaluate competence in practice-based learning and improvement and systems-based practice. Methods: Sixteen practicing general internists and endocrinologists with 10-year time-limited certification participated in a beta test of the ABIM's diabetes practice improvement module (PIM) as part of their recertification program. A PIM consists of a self-directed medical record audit, practice system survey, and patient survey. A quality improvement education specialist from the Connecticut Quality Improvement Organization provided on-site and distance consultation on quality improvement methods and tools. An independent audit assessed the reliability of physician self-audit. Qualitative interviews were conducted at 2 time points to assess for physician satisfaction and behavioral change in quality improvement. Results: Fourteen physicians completed the diabetes PIM. All but 1 physician found the medical record audit to provide important information about the practice. Of the 11 physicians who completed a follow-up interview, 10 stated that the quality improvement education specialist helped improve their practice. Discussion: Self-assessment using the ABIM diabetes PIM as part of recertification provides valuable practice information and can lead to meaningful behavioral change by physicians. Collaboration with an educator in quality improvement appears to facilitate the effects of the practice improvement module. Future work should investigate the effect on patient outcomes.

Knowledge-translation interventions and interprofessional education and collaboration interventions all aim at improving health care processes and outcomes. Knowledge-translation interventions attempt to increase evidence-based practice by a single professional group and thus may fail to take into account barriers from difficulties in interprofessional relations. Interprofessional education and collaboration interventions aim to improve interprofessional relations, which may in turn facilitate the work of knowledge translation and thus evidence-based practice. We summarize systematic review work on the effects of interventions for interprofessional education and collaboration. The current evidence base contains mainly descriptive studies of these interventions. Knowledge is limited regarding the impact on care and outcomes and the extent to which the interventions increase the practice of evidence-based care. Rigorous multimethod research studies are needed to develop and strengthen the current evidence base in this field. We describe a Health Canada-funded randomized trial in which quantitative and qualitative data will be gathered in 20 general internal medicine units located at 5 Toronto, Ontario, teaching hospitals. The project examines the impact of interprofessional education and collaboration interventions on interprofessional relationships, health care processes (including evidence-based practice), and patient outcomes. Routes are suggested by which interprofessional education and collaboration interventions might affect knowledge translation and evidence-based practice.

Context: Rural elderly patients are faced with numerous challenges in accessing care. Additional strains to access may be occurring given recent market pressures, which would have significant impact on this vulnerable population. Purpose: This study focused on the practice patterns and future plans of rural Florida physicians who routinely see elderly patients. Additionally, we examine those who provide services to a high volume of Medicare (HVM) patients. Methods: A self-administered mailed survey was sent to rural physicians who identified themselves as practicing family medicine, internal medicine, psychiatry, general surgery, a surgical specialty, or a medical specialty. Questions examined changes in services offered by all rural physicians and among them, the HVM physicians. Impact of the professional liability insurance situation, satisfaction with current practice, and future practice plans on changes in service availability was also examined. Results: Overall, 539 physicians responded for a participation rate of 42.7%. Two hundred eighty eight (54.9%) of all physicians in the study indicated a decrease or elimination of patient services in the last year. HVM physicians, compared to low volume of Medicare providers, were significantly more likely to decrease or eliminate services overall (66% vs 45%, P = 0.001). Mental health services (47% vs 18%, P = 0.001), vaccine administration (39% vs 16%, P = 0.008), and Pap smears (41% vs 13%, P = 0.008) were more likely to be eliminated among the HVM physicians. HVM physicians were also significantly more likely to be somewhat or very dissatisfied (40% vs 23%, P = 0.012) with their practice. Conclusions: Physicians in rural Florida report dissatisfaction with their practice and are decreasing or eliminating services that are important to the elderly. Given the aging population and increasing need for health care services, these trends raise concern about the ability for these patients to receive necessary care.

Objectives: To assess the incidents of patient-initiated assault (PIA) against clinical clerks during the first six months of clinical clerkship. To characterise the assaults with respect to service, location, clerk gender, patient gender. To examine the students' perceptions of the reporting process for PIA. Methods: A brief email survey was sent to all third year medical students after six months of clinical clerkship experience. Students were asked to describe assault experiences including: location, service, patient gender and injuries sustained. Results: Six students reported experiencing physical assault in the first six months of clerkship. Assaults occurred on psychiatry (4) and internal medicine (2) services. Two of the assaults took place during consultations in the emergency department. All students reported having pre-clerkship training in management of violent situations. No students were aware of PIA reporting protocols for their hospital. Conclusions: Clinical clerks are at risk of PIA during their training. Students experiencing PIA feel that current levels of pre-clerkship training do not adequately inform them of the resources available after such an incident. These findings underline the need for PIA programs in the undergraduate curriculum including pre-clerkship training and clear, institution-wide reporting guidelines.

We have set out to investigate an approach to improve patients' ability to self-manage chronic illness. For effective health care in chronic disease, we believe patients need to work in partnership with their doctor; patient-centred consultations are one way to achieve this. This report describes our experience of training specialists in gastroenterology to consult in a patient-centred style as part of a complex self-management intervention in a randomized controlled trial (RCT) involving 700 patients with established inflammatory bowel disease (IBD) attending outpatient clinics. The training session aimed to provide specialists from nine randomly selected intervention sites with the basic skills to carry out the intervention. The training lasted 2 hours, and included background on the research and intervention, a demonstration video, role-play, and video-feedback training. The main findings of the RCT are presented (service use, enablement and satisfaction), and discussed in the light of the views of consultants and patients on the experience of putting the training into practice. The findings of our study confirm and highlight the value of training in patient-centred communication and its potential for promoting self-management effects; the training proved effective in enabling consultants in gastroenterology to establish guided self-management in patients with IBD.

Researchers in the Department of Bioengineering at Rice University are developing a new approach for fighting cancer, based on nanoshells that can both detect and destroy cancerous cells. The aim is to locate the cells, and be able to make a rational choice about whether they need to be destroyed and if possible they should immediately be sent for treatment.

Utilization of objective structured clinical examinations (OSCEs) for final assessment of medical students in Internal Medicine requires a representative sample of OSCE stations. The reliability and generalizability of OSCE scores provides validity evidence for OSCE scores and supports its contribution to the final clinical grade of medical students. The objective of this study was to perform item analysis using OSCE stations as the unit of analysis and evaluate the extent to which OSCE score reliability can be improved using item analysis data. OSCE scores from eight cohorts of fourth-year medical students (n = 435) in a 6-year undergraduate program were analyzed. Generalizability (G) coefficients of OSCE scores were computed for each cohort. Item analysis was performed by considering each OSCE station as an item and computing the corrected item-total correlation. OSCE stations which negatively impacted the reliability were deleted and the G-coefficient was recalculated. The G-coefficients of OSCE scores from the eight cohorts ranged from 0.48 to 0.80 (median 0.62). The median number of OSCE stations that negatively impacted the G-coefficient was 3.5 (out of a median of 25 total stations). When the "problem stations" were deleted, the median G-coefficient across eight cohorts increased to 0.62--0.72. In conclusion, item analysis of OSCE stations is useful and should be performed to improve the reliability of total OSCE scores. Problem stations can then be identified and improved.

Clinicians routinely report fewer features in a case than they subsequently agree are present. The authors report studies that assess the effect of considering a more comprehensive description than physicians usually offer. These comprehensive descriptions were generated from photographs of dermatology and internal medicine and were complete and accurate. Groups of clinicians of varying expertise were asked to offer a diagnosis based solely on the comprehensive verbal description. This initial exercise decreased the subsequent diagnostic acumen of experienced participants with the photographs relative to a group that initially diagnosed from the photographs. Reasons that the initial consideration of a list of features, all of which are present in the photograph, would decrease diagnostic accuracy are discussed.

Objective: To compare the effects of active and didactic teaching strategies on learning- and process-oriented outcomes. Design: Controlled trial. Setting: After-hours residents' teaching session. Participants: Family and Community Medicine, Internal Medicine, and Pediatrics residents at two academic medical institutions. Interventions: We randomly assigned residents to two groups. One group received a didactic lecture on effective use of diagnostic tests; during this session, the teacher spent a full hour delivering content. The other group received the same content in a session structured to foster resident-to-resident interactions. In the latter session, the teacher spent only 30 minutes directly delivering content to residents. Measures and Main Results: We measured residents' knowledge about and attitudes toward the session content before, immediately after, and one month after each session. We measured residents' perceptions of engagement and session value immediately after each session. We employed blinded observers who used a structured instrument to observe residents' activities during each session. Both teaching methods led to improvements in residents' scores on both knowledge and attitude assessments. The amount of improvement was not statistically different between groups. Residents in the active learning session perceived themselves, and were observed to be, more engaged with the session content and each other than residents in the didactic session. Residents in the didactic session perceived greater educational value from the session compared to residents in the active session. Conclusions: We reduced the amount of time spent in teacher-driven content delivery by 50 percent and covered the same amount of content with no detrimental effects on knowledge acquisition or attitude enhancement. Teaching strategies that foster learner-to-learner interactions will lead to more active engagement among learners, however, these learners may value the session less. Further research is needed to explore learner perceptions of the teaching process and other outcomes of active learning in medical education.

Surveyed directors of internal medicine (IM) and family practice (FP) residency programs regarding the format, content, and quantity of psychosocial training in their programs, their opinions on topics related to such training, and program demographics. Found considerable variation in content and time devoted to psychosocial training within and between program types, with FP programs generally requiring more training. (EV)

Reviews the rationale for including prevention in the clinical medicine clerkship. Summarizes current guidelines, presents examples of curricula in several medical schools, and proposes a future direction that stresses integrating teaching preventive medicine into internal medicine clerkships and across the entire four-year medical curriculum. (DB)

A study of 99 international graduate medical students in an internal medicine program compared performance on two standardized English-language-proficiency tests with three measures of success: patient satisfaction; faculty and colleague evaluations; and scores on an objective test of medical knowledge. Patient satisfaction and faculty/colleague evaluations were found related to English language skills. (Author/MSE)