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In policy and law, regulation of abortion is frequently treated differently from other health services. The safety of abortion is similar to that of other types of office- and clinic-based procedures, and facility requirements should be based on assuring high-quality, safe performance of all such procedures. False concerns for patient safety are being used as a justification for promoting regulations that specifically target abortion. The Project on Facility Guidelines for the Safe Performance of Primary Care and Gynecology Procedures in Offices and Clinics was undertaken by clinicians, consumers, and representatives from accrediting bodies to review the available evidence and guidelines that inform safe delivery of outpatient care. Our overall objective was to develop evidence-informed consensus guidelines to promote health care quality, safety, and accessibility. Our consensus determined that requiring facilities performing office-based procedures, including abortion, to meet standards beyond those currently in effect for all general medical offices and clinics is unjustified based on an analysis of available evidence. No safety concerns were identified.

We and our patients have been aware of the high cost of medications in the United States for decades; however, we are now witnessing a relatively new phenomenon: exponential price increases for some older pharmaceuticals that have been available for years. To assist practitioners in how to respond to the issue of higher priced pharmaceuticals, an interprofessional session was developed and held at CHEST 2016 in Los Angeles. The session proceedings and a few updates are presented here to summarize what pulmonologists; a sarcoidosis expert; a retired executive of a medical society, an executive of a pharmaceutical company and of a pharmacy; and an ethicist advise that we do about the problem. Because the comments presented at the session and in this manuscript represent the opinions of each author, this commentary in essence is a compilation of nine editorials. It does not represent a comprehensive discussion of the field of pricing of drugs. In reflecting upon the answers to the questions posed, and regardless of their sector of health care, all participants stated that they focused on the patient. However, actually providing patient-focused care (ie, the care defined from the patient's perspective) is another matter. To significantly improve patient satisfaction and health-care outcomes, patient-focused care needs to embody the 3 Cs of (1) communication, (2) continuity of care, and (3) concordance of expectations (ie, finding the common ground). Therefore, we discuss how the 3 Cs apply to responses to higher priced pharmaceuticals.

A variety of known etiologic agents can cause diffuse parenchymal lung disease, also referred to as interstitial lung disease. These include inorganic dusts (the pneumoconioses), organic antigens (the cause of hypersensitivity pneumonitis), drugs, and radiation to the thorax. The most common of the disorders classified as pneumoconioses include silicosis, coal worker's pneumoconiosis, asbestosis, and berylliosis. Some of these disorders involve toxicity to, or activation of macrophages, whereas beryllium induces a hypersensitivity reaction that clinically mimics sarcoidosis. Many organic antigens can induce a hypersensitivity pneumonitis, which can have a presentation ranging from an acute illness with transient pulmonary infiltrates to a chronic diffuse parenchymal lung disease. A wide range of drugs are now known to be associated with parenchymal lung disease, with the most important categories being cancer chemotherapeutic agents and a variety of newer biological drugs, but a number of other miscellaneous drugs have also been implicated. Finally, radiation therapy directed to the thorax, most commonly for breast cancer, lung cancer, or Hodgkin disease, can be associated with an acute inflammatory process in the lungs (radiation pneumonitis) or a more chronic fibrotic process (radiation fibrosis).

In the process of exchanging thousands of liters of air each day, the lung is exposed to a multitude of microorganisms and foreign substances transported with the inhaled air. To protect itself against potentially toxic inhaled material, the respiratory system has evolved complex protective mechanisms that can be conceptualized as different groups of components. Each appears to have a distinct role, but a tremendous degree of redundancy and interaction exists among different components. This chapter considers how the lung protects itself against the infectious agents to which it is exposed. Although this chapter focuses on protective mechanisms against infection, defenses against non-infectious substances, especially inhaled particulate material, also are addressed. The major categories of defense mechanisms discussed include (1) physical or anatomic factors relating to deposition and clearance of inhaled material, (2) antimicrobial peptides, (3) phagocytic and inflammatory cells that interact with the inhaled material, and (4) adaptive immune responses, which depend on prior exposure to and recognition of the foreign material. The chapter concentrates on the aspects of the host defense system specific to the lung and then proceeds with a discussion of several ways the system breaks down, resulting in an inability to handle microorganisms and an increased risk for certain types of respiratory tract infection. The chapter concludes by briefly considering how we can activate or augment specific immune responses through immunization, thus enhancing defenses against selected respiratory pathogens.

Chapter 29 describes the management of the two broad classes of respiratory failure – hypoxemic respiratory failure and hypercapnic respiratory failure. The goals of each are described in terms of the principles of support and the desired targets for gas exchange. The available types of mechanical ventilation are presented, focusing on pressure support ventilation and pressure-controlled ventilation as the major modes of pressure-limited ventilation, and assist-control ventilation and synchronized intermittent mandatory ventilation as the major modes of volume-cycled ventilation. Positive end-expiratory pressure is explained as a technique to avoid alveolar closure during expiration, increase functional residual capacity, reduce the amount of shunting, and improve oxygenation. When ventilated patients are sufficiently stable, a daily trial of spontaneous breathing is used to assess the patient's ability to be maintained off ventilatory support. The technique of noninvasive ventilation as an alternative to intubation and ventilation through an endotracheal tube is described, along with the clinical scenarios where it may be most applicable. Complications associated with intubation, with endotracheal or tracheostomy tubes, and with use of a mechanical ventilator are described as the major categories of complications associated with intubation and mechanical ventilation. Options for chronic ventilatory support in the home setting are presented, focusing primarily on home noninvasive ventilation. In selected patients with severe lung disease of various etiologies, lung transplantation may be an option, although it does replace the underlying disease with the potential complications of infection and rejection following transplantation.

Chapter 11 covers a wide range of diffuse parenchymal or interstitial lung diseases without a known etiologic agent triggering the disease. Idiopathic pulmonary fibrosis (IPF), a generally progressive disease with a relatively poor prognosis, is the most common entity within a broader category of idiopathic interstitial pneumonias. Also classified as an idiopathic interstitial pneumonia is nonspecific interstitial pneumonia (NSIP), which is commonly associated with underlying systemic rheumatic disease but can also be idiopathic. Two other entities within this category are desquamative interstitial pneumonia (DIP) and respiratory bronchiolitis-interstitial lung disease (RB-ILD), which are likely related and notable for a strong association with smoking. Rounding out the category of idiopathic interstitial pneumonias are two other disorders, cryptogenic organizing pneumonia (COP) and acute interstitial pneumonia (AIP). Sarcoidosis, a systemic granulomatous disease of unknown etiology, most commonly affects the lungs and/or intrathoracic lymph nodes, and is notable for a variable prognosis and the potential for therapeutic suppression of disease with corticosteroids. The chapter concludes by summarizing what is known about the pathogenesis and clinical aspects of several miscellaneous disorders involving the pulmonary parenchyma. These include pulmonary Langerhans cell histiocytosis (also called eosinophilic granuloma of the lung), lymphangioleiomyomatosis, Goodpasture syndrome, granulomatosis with polyangiitis, chronic eosinophilic pneumonia, and pulmonary alveolar proteinosis.

The lungs do not act in isolation, but rather are part of an integrated system that also involves the central nervous system (CNS), which controls the action of the muscles of respiration, and the appropriate response of the respiratory muscles to the signals they receive from the CNS. The respiratory generator, located in the medulla, also receives input from the cerebral cortex and higher levels of the brainstem, as well as feedback from central and peripheral chemoreceptors that is targeted to maintaining stable and acceptable levels of Po 2 and Pco 2 . This chapter provides an overview of the neural, muscular, and chest wall contributions to respiration. The anatomy of ventilatory control is presented, followed by a description of input that the control system receives from chemoreceptors as well as receptors from the lungs and chest wall. The action of the diaphragm, the main muscle of respiration, is described, including the importance of the zone of apposition and diaphragm length. This presentation of the anatomy and physiology of ventilatory control and the respiratory pump forms the background information for understanding the disorders of ventilatory control and disorders of the respiratory pump that will be presented in Chapters 18 and 19, respectively.

Chapter 6 reviews the common problem of chronic obstructive pulmonary disease (COPD). The various factors contributing to the etiology and pathogenesis of smoking are described, focusing on smoking and the protease-antiprotease hypothesis, but also considering environmental and indoor pollution, infection, and genetic factors. The pathologic features of chronic bronchitis and emphysema are detailed, including the contribution of small airways disease and the distinction between centrilobular and panacinar emphysema. The pathophysiology of airflow obstruction in COPD is explained, with consideration of factors that affect, as well as the effects of, airway resistance and loss of elastic recoil. Various factors potentially contributing to hypoxemia and hypercapnia are described, noting the importance of ventilation-perfusion mismatch. Newer concepts of COPD phenotypes are considered, as well as the factors that can lead to pulmonary hypertension in some patients. Treatment of COPD focuses on the use and roles of β 2 -agonists, anticholinergic agents, inhaled and systemic corticosteroids, antibiotics, and PDE-4 inhibitors. Lung volume reduction surgery and lung transplantation are considered as treatment options in selected individuals with severe disease, and the roles of pulmonary rehabilitation and long-term oxygen therapy are reviewed.

Chapter 12 reviews the anatomy and physiology of the pulmonary vasculature. In contrast to the systemic arteries, which carry blood from the left ventricle to the rest of the body, the pulmonary arteries, which carry blood from the right ventricle into the lungs, are relatively low-pressure, thin-walled vessels. Under normal circumstances, the mean pressure within the main pulmonary arteries is approximately 15 mm Hg, roughly one-sixth of the pressure in the aorta. Pulmonary hemodynamics are measured clinically by means of a balloon-tipped catheter inserted in a large systemic vein and advanced to a wedged position in the pulmonary vasculature. Geographic matching of ventilation and perfusion in the lung is essential for appropriate oxygen exchange and is accomplished in large part via hypoxic pulmonary vasoconstriction, by which blood flow in the lungs is preferentially routed to well ventilated alveoli. The pulmonary capillary endothelium also has important metabolic functions, such as the conversion of angiotensin I to angiotensin II.

Chapter 20 addresses the etiologic and pathologic aspects of lung cancer—the most common cause of cancer and cancer-related death worldwide. Risk factors, including smoking, occupational exposures and genetic predisposition, are explained. Concepts of the underlying pathogenesis of lung cancer are discussed, including the potential importance of proto-oncogenes and tumor suppressor genes. Detailed descriptions of the anatomic and pathological patterns of four major categories of lung cancer, squamous cell carcinoma, small cell carcinoma, adenocarcinoma, and large cell carcinoma, are examined.

Academic Health Centers are evolving to larger and more complex Academic Health Systems (AHS), reflecting financial stresses requiring them to become nimble, efficient, and patient (consumer) and faculty (employee) focused. The evolving AHS organization includes many positive attributes: unity of purpose, structural integration, collaboration and teamwork, alignment of goals with resource allocation, and increased financial success. The organization, leadership, and business acumen of the AHS influence directly opportunities for Departments of Medicine. Just as leadership capabilities of the AHS affect its future success, the same is true for departmental leadership. The Department of Medicine is no longer a quasi- autonomous entity, and the chairperson is no longer an independent decision-maker. Departments of Medicine will be most successful if they maintain internal unity and cohesion by not fragmenting along specialty lines. Departments with larger endowments or those with public financial support have more flexibility when investing in the academic missions. The chairpersons of the future should serve as change agents while simultaneously adopting a “servant leadership” model. Chairpersons with executive and team building skills, and business acumen and experience, are more likely to succeed in managing productive and lean departments. Quality of patient care and service delivery enhance the department’s effectiveness and credibility and assure access to additional financial resources to subsidize the academic missions. Moreover, the drive for excellence, high performance and growth will fuel financial solvency.

Deaths and injuries related to firearms constitute a major public health problem in the United States. In response to firearm violence and other firearm-related injuries and deaths, an interdisciplinary, interprofessional group of leaders of 8 national health professional organizations and the American Bar Association, representing the official policy positions of their organizations, advocate a series of measures aimed at reducing the health and public health consequences of firearms. The specific recommendations include universal background checks of gun purchasers, elimination of physician "gag laws," restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths. The health professional organizations also advocate for improved access to mental health services and avoidance of stigmatization of persons with mental and substance use disorders through blanket reporting laws. The American Bar Association, acting through its Standing Committee on Gun Violence, confirms that none of these recommendations conflict with the Second Amendment or previous rulings of the U.S. Supreme Court.

Physician decision making is partially responsible for the roughly 30% of U.S. healthcare expenditures that are wasted annually on low-value care. In response to both the widespread public demand for higher-quality care and the cost crisis, payers are transitioning toward value-based payment models whereby physicians are rewarded for high-value, cost-conscious care. Furthermore, to target physicians in training to practice with cost awareness, the Accreditation Council for Graduate Medical Education has created both individual objective milestones and institutional requirements to incorporate quality improvement and cost awareness into fellowship training. Subsequently, some professional medical societies have initiated high-value care educational campaigns, but the overwhelming majority target either medical students or residents in training. Currently, there are few resources available to help guide subspecialty fellowship programs to successfully design durable high-value care curricula. The resource-intensive nature of pulmonary and critical care medicine offers unique opportunities for the specialty to lead in modeling and teaching high-value care. To ensure that fellows graduate with the capability to practice high-value care, we recommend that fellowship programs focus on four major educational domains. These include fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. In doing so, pulmonary and critical care educators can strive to train future physicians who are prepared to provide care that is both high quality and informed by cost awareness.

In recent years, the Maintenance of Certification (MOC) program of the American Board of Internal Medicine has generated substantial controversy. Lipner and colleagues' study demonstrates that allo...

We and our patients have been aware of the high cost of medications in the United States for decades; however, we are now witnessing a relatively new phenomenon: exponential price increases for some older pharmaceuticals that have been available for years. To assist practitioners in how to respond to the issue of higher priced pharmaceuticals, an interprofessional session was developed and held at CHEST 2016 in Los Angeles. The session proceedings and a few updates are presented here to summarize what pulmonologists; a sarcoidosis expert; a retired executive of a medical society, an executive of a pharmaceutical company and of a pharmacy; and an ethicist advise that we do about the problem. Because the comments presented at the session and in this manuscript represent the opinions of each author, this commentary in essence is a compilation of nine editorials. It does not represent a comprehensive discussion of the field of pricing of drugs. In reflecting upon the answers to the questions posed, and regardless of their sector of health care, all participants stated that they focused on the patient. However, actually providing patient-focused care (ie, the care defined from the patient's perspective) is another matter. To significantly improve patient satisfaction and health-care outcomes, patient-focused care needs to embody the 3 Cs of (1) communication, (2) continuity of care, and (3) concordance of expectations (ie, finding the common ground). Therefore, we discuss how the 3 Cs apply to responses to higher priced pharmaceuticals.

In this position paper, the American College of Physicians (ACP) examines the rationale for patient and family partnership in care and reviews outcomes associated with this concept, including greater adherence to care plans, improved satisfaction, and lower costs. The paper also explores and acknowledges challenges associated with implementing patient- and family-centered models of care. On the basis of a comprehensive literature review and a multistakeholder vetting process, the ACP's Patient Partnership in Healthcare Committee developed a set of principles that form the foundation for authentic patient and family partnership in care. The principles position patients in their rightful place at the center of care while acknowledging the importance of partnership between the care team and patient in improving health care and reducing harm. The principles state that patients and families should be treated with dignity and respect, be active partners in all aspects of their care, contribute to the development and improvement of health care systems, and be partners in the education of health care professionals. This paper also recommends ways to implement these principles in daily practice.

Internal medicine ambulatory training redesign, including recommendations to increase ambulatory training, is a focus of national discussion. Residents' and program directors' perceptions about ambulatory training models are unknown.To describe internal medicine residents' and program directors' perceptions regarding ambulatory training duration, alternative ambulatory training models, and factors important for ambulatory education.National cohort study.Internal medicine residents (N = 14,941) and program directors (N = 222) who completed the 2007 Internal Medicine In-Training Examination (IM-ITE) Residents Questionnaire or Program Directors Survey, representing 389 US residency programs.A total of 58.4% of program directors and 43.7% of residents preferred one-third or more training time in outpatient settings. Resident preferences for one-third or more outpatient training increased with higher levels of training (48.3% PGY3), female sex (52.7%), primary care program enrollment (64.8%), and anticipated outpatient-focused career, such as geriatrics. Most program directors (77.3%) and residents (58.4%) preferred training models containing weekly clinic. Although residents and program directors reported problems with competing inpatient-outpatient responsibilities (74.9% and 88.1%, respectively) and felt that absence of conflict with inpatient responsibilities is important for good outpatient training (69.4% and 74.2%, respectively), only 41.6% of residents and 22.7% of program directors supported models eliminating ambulatory sessions during inpatient rotations.Residents' and program directors' preferences for outpatient training differ from recommendations for increased ambulatory training. Discordance was observed between reported problems with conflicting inpatient-outpatient responsibilities and preferences for models maintaining longitudinal clinic during inpatient rotations. Further study regarding benefits and barriers of ambulatory redesign is needed.

A 57-year-old man presented to the emergency department with a 2-week history of progressive dyspnea on exertion, edema of the legs, a nonproductive cough, and scant hemoptysis. He also reported occasional passage of bright red blood from his rectum and intermittent nausea and vomiting during the previous 4 days.

Purpose To describe internal medicine residents' opinions regarding the optimal duration of internal medicine residency training, and to assess whether these opinions are associated with specific career interests. Method A national cohort study was conducted during the 2005 Internal Medicine In-Training Examination (IM-ITE), which involved 382 of 388 (98.5%) U.S. internal medicine programs. A sample of 14,579 residents enrolled in three-year categorical or primary care training programs in the United States reported their opinions regarding optimal residency training duration on the IM-ITE 2005 Residents Questionnaire. Reported optimal training duration was assessed by postgraduate training year, sex, medical school location, program type, and reported career plan. Results Among the residents surveyed, 78.1% reported a three-year optimal length of internal medicine residency training, 15.3% preferred a two-year training duration, and 6.7% preferred a four-year duration. Residents planning careers in general medicine, hospital medicine, and subspecialty fields all preferred a three-year training duration (83.8%, 82.6%, and 75.9%, respectively). Residents planning subspecialty careers were more likely than those planning general or hospital medicine careers to prefer a two-year program (18.7% versus 7.4% and 8.3%). Residents planning generalist or hospitalist careers were more likely to favor a four-year program (8.9% and 9.1%, respectively) compared with residents planning subspecialty careers (5.4%). Conclusions Most internal medicine residents endorse a three-year optimal duration of internal medicine residency training. This perspective should be considered in further national discussions regarding the optimal duration of internal medicine training.

A 36-year-old pregnant woman at 21 weeks' gestation presented with a 4-week history of a dry, nonproductive cough. She said she had no fever, chills, dyspnea, chest pain, or weight loss. She had no new pets, environmental exposures, or sick contacts.

A 21-year-old man presented to the emergency department after 2 days of pain in the right lower abdominal quadrant. The pain was dull and nonradiating, and it had increased in intensity during those 2 days. It was not worsened by food intake and was unrelated to bowel movements. He also noted that for the past month he had had exertional dyspnea with a cough productive of scanty yellow sputum.

To determine whether specific occupations and industries may be associated with sarcoidosis.A Case Control Etiologic Study of Sarcoidosis (ACCESS) obtained occupational and environmental histories on 706 newly diagnosed sarcoidosis cases and matched controls. We used Standard Industrial Classification (SIC) and Standard Occupational Classification (SOC) to assess occupational contributions to sarcoidosis risk.Univariable analysis identified elevated risk of sarcoidosis for workers with industrial organic dust exposures, especially in Caucasian workers. Workers for suppliers of building materials, hardware, and gardening materials were at an increased risk of sarcoidosis as were educators. Work providing childcare was negatively associated with sarcoidosis risk. Jobs with metal dust or metal fume exposures were negatively associated with sarcoidosis risk, especially in Caucasian workers.In this study, we found that exposures in particular occupational settings may contribute to sarcoidosis risk.

Past research suggests that environmental factors may be associated with sarcoidosis risk. We conducted a case control study to test a priori hypotheses that environmental and occupational exposures are associated with sarcoidosis. Ten centers recruited 706 newly diagnosed patients with sarcoidosis and an equal number of age-, race-, and sex-matched control subjects. Interviewers administered questionnaires containing questions regarding occupational and nonoccupational exposures that we assessed in univariable and multivariable analyses. We observed positive associations between sarcoidosis and specific occupations (e.g., agricultural employment, odds ratio [OR] 1.46, confidence interval [CI] 1.13-1.89), exposures (e.g., insecticides at work, OR 1.52, CI 1.14-2.04, and work environments with mold/mildew exposures [environments with possible exposures to microbial bioaerosols], OR 1.61, CI 1.13-2.31). A history of ever smoking cigarettes was less frequent among cases than control subjects (OR 0.62, CI 0.50-0.77). In multivariable modeling, we observed elevated ORs for work in areas with musty odors (OR 1.62, CI 1.24-2.11) and with occupational exposure to insecticides (OR 1.61, CI 1.13-2.28), and a decreased OR related to ever smoking cigarettes (OR 0.65, CI 0.51-0.82). The study did not identify a single, predominant cause of sarcoidosis. We identified several exposures associated with sarcoidosis risk, including insecticides, agricultural employment, and microbial bioaerosols.

A 60-year-old woman with a history of seronegative rheumatoid arthritis presented to the emergency department with a 10-day history of worsening dyspnea on exertion, nonproductive cough, and fever ...

A 33-year-old man presented for evaluation of hemoptysis. He had been in his usual state of health until the day of presentation, when he had a transient cough productive of one tablespoon (approximately 15 ml) of bright red blood. He did not have associated chest pain or dyspnea. He reported that he had not had recent weight loss, fever, illness, or trauma and that he did not have a history of bleeding.

In this Sounding Board article, the leaders of major medical specialties make the case that government has no place in making laws that direct patient–physician relationships.

The American College of Physicians celebrates its 100th anniversary in 2015. This commentary highlights 3 leading issues for internal medicine and for the College as it enters its second century an...

A 17-year-old boy awakes with left-sided pleuritic chest pain. He also notes mild dyspnea during track-and-field practice. Over the ensuing months, symptoms progress to dyspnea when he is at rest, accompanied by three-pillow orthopnea.

Viewing every patient as a potential lawsuit is bad for patients, practice, and the health care system.

Health care professionals in pulmonary, critical care, and sleep medicine play key roles as teachers for learners of all levels in both clinical care and scientific investigation. Teaching excellence requires training in principles of adult learning and the acquisition and practice of key professional skills including assessment and feedback techniques, curriculum development, and strategies for effective teaching across venues ranging from the bedside to the lecture hall. Those interested in pursuing teaching as the focus of their academic career and basis for promotion should invest in professional development as a teacher and educator. Professional development activities include obtaining additional training as a teacher in dedicated medical education fellowships or serving as a peer observer or being observed by a fellow teacher. Numerous additional options for training as a teacher and educator are now available including resource repositories, continuing medical education courses, and online training modules. Those with an interest in medical education research may benefit from enrollment in masters or other advanced degree programs focused on the qualitative and quantitative methods and other key research skills. Aspiring clinician-educators should also seek out opportunities to participate in a community of medical educators locally, regionally, nationally, and internationally. At each of these levels, there exist opportunities to contribute to course or program design, development, and evaluation. Finally, for those interested in promotion as an academic clinician-educator, there are increasing requirements to produce academic scholarship ranging from curricular materials to journal articles focused on education and education research.

More than a century has elapsed since the initial description of sarcoidosis, but critical aspects of the disorder remain poorly understood. Information obtained from epidemiologic observations and basic laboratory research suggests that the disease may represent an immunologic response to an exogenous agent in a genetically susceptible individual. However, a definitive etiologic role for any specific exogenous agent has never been proved, and a “candidate gene” underlying a predisposition to sarcoidosis has not yet been identified. This review presents an historical framework for considering available evidence regarding a transmissible agent in sarcoidosis and host susceptibility to the disease.