Retaining interest in caring for underserved patients among future medicine subspecialists: Underserved Medicine and Public Health (UMPH) program.

BACKGROUND: Accessing subspecialty care is hard for underserved patients in the U.S. Published curricula in underserved medicine for Internal Medicine residents target future-primary care physicians, with unknown impact on future medicine subspecialists. METHODS: The aim was to retain interest in caring for underserved patients among Internal Medicine residents who plan for subspecialist careers at an urban university hospital. The two-year Underserved Medicine and Public Health (UMPH) program features community-based clinics, evening seminars, reflection assignments and practicum projects for 3–7 Internal Medicine residents per year. All may apply regardless of anticipated career plans after residency. Seven years of graduates were surveyed. Data were analyzed using descriptive statistics. RESULTS: According to respondents, UMPH provided a meaningful forum to discuss important issues in underserved medicine, fostered interest in treating underserved populations and provided a sense of belonging to a community of providers committed to underserved medicine. After residency, 48% of UMPH graduates pursued subspecialty training and 34% practiced hospitalist medicine. 65% of respondents disagreed that “UMPH made me more likely to practice primary care” and 59% agreed “UMPH should target residents pursuing subpecialty careers.” CONCLUSIONS: A curriculum in underserved medicine can retain interest in caring for underserved patients among future-medicine subspecialists. Lessons learned include [1] building relationships with local community health centers and community-practicing physicians was important for success and [2] thoughtful scheduling promoted high resident attendance at program events and avoided detracting from other activities required during residency for subspecialist career paths. We hope Internal Medicine residency programs consider training in underserved medicine for all trainees. Future work should investigate sustainability, whether training results in improved subspecialty access, and whether subspecialists face unique barriers caring for underserved patients. Future curricula should include advocacy skills to target systemic barriers

Public health training in internal medicine residency programs: a national survey

BACKGROUND: The IOM recommends public health training for all physicians. Data characterizing such training of internal medicine (IM) residents are lacking. PURPOSE: To describe the current state of public health education at IM residency programs, characterize programs offering public health education, and quantify interest in expanding training opportunities. METHODS: IM residency program directors from the 380 Accreditation Council for Graduate Medical Education-accredited residency programs in the U.S were invited to participate in a cross-sectional survey. Responses were received from 127 programs (33%). Data were collected July-December 2012 and analyzed in January 2013. Participants were queried on domestic public health training offered, perceived resident interest in and satisfaction with this training, and interest in expanding training. RESULTS: Eighty-four respondents (66%) provide some form of public health training, but structure and content vary widely. In many programs offering public health training, few residents (\u3c10%) receive it. Although 93 programs (73%) integrate public health into core curricula, only three topics were common to a majority of these programs. Sixty-six respondents (52%) offer clinical training at community-based health centers. Most residency program directors (90%) are very or somewhat interested in expanding their public health training. CONCLUSIONS: This study characterizes the structures and content of public health training across IM residency programs. The wide range highlights the diverse definition of public health training used by IM residency program directors and lack of universal public health competencies required for IM physicians. Opportunities exist for collaboration among residency programs and between IM and public health educators to share best practices

Nighttime resident supervision and education: results of a national survey of internal medicine residency program directors

Over the past several years, the Accreditation Council for Graduate Medical Education (ACGME) has issued new restrictions on resident duty hours while calling for increased supervision to ensure patient safety. To meet these requirements, some hospitals have hired overnight in-house hospitalist physicians, also called nocturnists, while others have continued a traditional model wherein a resident in-house can access a supervisor at home by phone as needed. This study examines the current state of internal medicine resident supervision and teaching at night.Christopher Bruti (Rush University Medical Center), Mathhew Tuck (Veterans Affairs Medical Center), Rebecca Harrison (Oregon Health and Science University School of Medicine), Dustin Smith (Atlanta VA Medical Center), Michael Kisielewski (Alliance for Academic Internal Medicine), Jillian S. Catalanotti (The George Washington University School of Medicine and Health Sciences), Alfred Burger (Icahn School of Medicine)Includes bibliographical reference

Will She Recover? A Prolonged Hospitalization for a Comatose Female with Neuropsychiatric Lupus

25 year old African-American woman was brought into the ED by EMS after she was found unresponsive in her apartment. Police found the patient to be unconscious and unable to be aroused, lying in feces and urine, with no witnesses or medical history available. In the ED, physical exam showed an obtunded female with GCS of 6T. Neurological exam revealed a left eye gaze with horizontal nystagmus, absent Babinski reflex, 3+ reflexes in upper extremity, and 4+ reflexes in lower extremity bilaterally. CT head did not demonstrate acute hemorrhage or masses. The patient was intubated to protect her and admitted to the ICU. She was started on empiric therapy for seizure with levetiracetam and for meningoencephalitis with ceftriaxone, vancomycin, and acyclovir. Lumbar puncture revealed no infection, and urine drug screen was normal. Brain MRI showed diffusion along the posterior frontal, parietal and temporal cortices bilaterally with diffuse pachymeningeal enhancement concerning for an autoimmune process. Using the regional online health information exchange, we discovered that the patient had been diagnosed with SLE at a nearby hospital, two weeks prior to this admission. She had been started on steroids and hydroxychloroquine, and was discharged with plans for rheumatology follow-up. However, she missed that appointment, and medication compliance was unknown. Labs revealed a mixed lupus and Sjogren’s picture, with evidence of renal and hematologic involvement of her SLE. This patient was treated with levetiracetam, lacosamide, and pregabalin for seizures, and diagnostic EEG was performed. She was also started on pulse dose steroids and cyclophosphamide for SLE. Her neurologic status remained unimproved and her ICU course was marked by multiple complications, including massive hemoptysis at her tracheostomy site, prolonged seizures, and anoxia. Her chance of recovery was believed to be very poor given intensity of her condition. She was transferred to the medical floor on day 26 after passing tracheostomy collar trial, but she continued to have no purposeful movements. Over the next two months, she slowly regained neurological function in her extremities, and was discharged to inpatient rehabilitation on oral prednisone and lacosamide. She returned home, and in the rheumatology clinic one month after discharge, had regained full neurological function. She began her third dose of cyclophosphamide and was continued on her seizure medications, and returned to work. She continues to follow with rheumatology and neurology. SLE affects the neurological system by affecting inflammatory, vasculitic, thromboembolic, and meningeal pathways through a series of complex mechanisms. As a result, patient may experience a range of symptoms including stroke, seizures, cognitive dysfunction, and headaches. Risk factors for neuropsychiatric SLE include the presence of antiphospholipid antibodies, nephritis, young age, and African American ethnicity. Recognizing neuropsychiatric manifestations of SLE are important as management involves treating both the neurological symptoms and the underlying SLE. Symptoms of neuropsychiatric SLE should be evaluated and treated just as in patients without lupus. Our patient presented with a likely seizure, and was treated empirically for seizure. Lupus patients with stroke should be treated as any other stroke patients. Airway, breathing, and circulation should always be assessed first when a patient presents with severe neurological symptoms. Once the patient has been stabilized and started on appropriate neurological treatments, SLE treatments such as pulse dose steroids should be initiated to help recover from the underlying disease. Neurological symptoms may persist longer in SLE patients, leading to a long and difficult hospital course. Our patient was initially thought to have a very low chance of regaining neurological function. Despite these concerns, she recovered fully after 68 hospital days and an additional 16 days in inpatient rehab. Because neuropsychiatric symptoms of SLE are often indistinguishable from non-SLE neurological symptoms, diagnosis can be difficult, requiring strong clinical suspicion and accurate medical history