Tackling the Problem of Ambulatory Faculty Recruitment in Undergraduate Medical Education: An AAIM Position Paper

Historically, training within internal medicine has offered a comprehensive and deep understanding of adult medical issues, with a particular emphasis on critical thinking as well as diagnosis and management of complex medical disease. However, as hospital admissions decline and length of stay shortens, it is not possible to learn the breadth of internal medicine on the basis of inpatient service alone. The management of diseases in the inpatient setting and in the outpatient setting is significantly different. For example, management of diabetes mellitus, heart failure, and chronic obstructive pulmonary disease are very distinctive in inpatient versus outpatient settings. Some conditions, such as asthma and human immunodeficiency virus, are no longer seen frequently enough in the inpatient setting to guarantee learning opportunities. The ability to see the course of illness over time as well as appreciate the relational aspects of care and prevention of complications requires ambulatory training. The Liason Committee on Medical Education and the Accreditation Council for Graduate Medical Education endorse ambulatory training for these reasons. Despite the need for robust ambulatory education, internal medicine educators face well-documented difficulties in recruiting ambulatory training sites for both students and residents

Improving COPD Care at the University of North Carolina Internal Medicine Outpatient Clinic

The Global Initiative for Chronic Obstructive Lung Disease has encouraged symptom assessment for all chronic obstructive pulmonary disease (COPD) patients and pulmonary rehabilitation for COPD patients with high symptom burden and risk of exacerbations. Pulmonary rehabilitation has been shown to improve their symptoms, quality of life, and exercise tolerance and to reduce readmissions and mortality in patients with a recent exacerbation (≤4 weeks from prior hospitalization). However, many patients never have the opportunity to take advantage of pulmonary rehabilitation because systematic ways of assessing symptoms, identifying symptomatic patients, and referring those who would benefit from pulmonary rehabilitation are lacking. In the University of North Carolina general medicine clinic, symptom assessment and pulmonary rehabilitation referrals were not done prior to this effort. The project’s primary goal was to systematically screen for dyspnea symptoms during all COPD patient encounters, with secondary goals of improving rates of screening for hypoxia, referrals to pulmonary rehabilitation in symptomatic patients, and documentation in the electronic health record

Aligning Medical Student Curriculum with Practice Quality Goals: Impacts on Quality Metrics and Practice Capacity for Students

The practice of medicine occurs primarily in the ambulatory environment where providers have many competing demands, including health record documentation and patient volume expectations. Subsequently, medical student education has not been a priority for providers, health systems, or community practices. Yet, accrediting and professional organizations, such as the Association of American Medical Colleges, American Academy of Family Physicians, Ambulatory Pediatric Association, Society of General Internal Medicine, and the Liaison Committee on Medical Education, recommend education in ambulatory settings

The State of Ambulatory Undergraduate Internal Medicine Medical Education: Results of the 2016 Clerkship Directors in Internal Medicine Annual Survey

Ambulatory care is qualitatively different and valuable to the health system. Given the shifts in health care that prioritize ambulatory care, internal medicine educators see benefits to learning in this environment. Internal medicine education teaches the skills necessary for managing complex patients, including those with multiple illnesses, medications, and social needs, all of which are encountered in the practice of ambulatory internal medicine

Students Adding Value: Improving Patient Care Measures While Learning Valuable Population Health Skills

Medical students are potential resources for ambulatory primary care practices if learning goals can align with clinical needs. The authors introduced a quality improvement (QI) curriculum in the ambulatory clinical rotation that matched student learning expectations with practice needs. In 2016-2017, 128 students were assigned to academic, university affiliated, community health, and private practices. Student project measures were matched with appropriate outcome measures on monthly practice dashboards. Binomial mixed effects models were used to model QI measures. For university collaborative practices with student involvement, the estimated odds of a patient being screened for breast cancer in March 2017 was approximately 2 times greater than in 2016. This odds ratio was 36.2% greater than the comparable odds ratio for collaborative practices without student involvement (95% confidence interval = 22.7% to 51.2% greater). When student curriculum and assignments align with practice needs, practice metrics improve and students contribute to improvements in real-world settings

A National Survey of Undergraduate Clinical Education in Internal Medicine

BACKGROUND: In the present milieu of rapid innovation in undergraduate medical education at US medical schools, the current structure and composition of clinical education in Internal Medicine (IM) is not clear. OBJECTIVE: To describe the current composition of undergraduate clinical education structure in IM. DESIGN: National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred twenty-nine clerkship directors at all Liaison Committee on Medical Education accredited US medical schools with CDIM membership as of September 1, 2017. MAIN MEASURES: IM core clerkship and post-core clerkship structure descriptions, including duration, educational models, inpatient experiences, ambulatory experiences, and requirements. KEY RESULTS: The survey response rate was 83% (107/ 129). The majority of schools utilized one core IM clerkshipmodel (67%) and continued to use a traditional block model for a majority of their students (84%). Overall 26% employed a Longitudinal Integrated Clerkship model and 14% employed a shared block model for some students. The mean inpatient duration was 7.0 ± 1.7 weeks (range 3–11 weeks) and 94% of clerkships stipulated that students spend some inpatient time on general medicine. IM-specific ambulatory experiences were not required for students in 65% of IM core clerkship models. Overall 75% of schools did not require an advanced IM clinical experience after the core clerkship; however, 66% of schools reported a high percentage of students (> 40%) electing to take an IM sub-internship. About half of schools (48%) did not require overnight call or night float during the clinical IM sub-internship. CONCLUSIONS: Although there are diverse core IM clerkship models, the majority of IM core clerkships are still traditional block models. The mean inpatient duration is 7 weeks and 65% of IM core clerkship models did not require IM-specific ambulatory education

Global Retinoblastoma Presentation and Analysis by National Income Level.

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]). Conclusions and Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs

Measurement of associated Z plus charm production in proton-proton collisions at root s=8TeV

A study of the associated production of a Z boson and a charm quark jet (Z + c), and a comparison to production with a b quark jet (Z + b), in pp collisions at a centre-of-mass energy of 8 TeV are presented. The analysis uses a data sample corresponding to an integrated luminosity of 19.7 fb(-1), collected with the CMS detector at the CERN LHC. The Z boson candidates are identified through their decays into pairs of electrons or muons. Jets originating from heavy flavour quarks are identified using semileptonic decays of c or b flavoured hadrons and hadronic decays of charm hadrons. The measurements are performed in the kinematic region with two leptons with pT(l) > 20 GeV, vertical bar eta(l)vertical bar 25 GeV and vertical bar eta(jet)vertical bar Z + c + X) B(Z -> l(+)l(-)) = 8.8 +/- 0.5 (stat)+/- 0.6 (syst) pb. The ratio of the Z+c and Z+b production cross sections is measured to be sigma(pp -> Z+c+X)/sigma (pp -> Z+b+X) = 2.0 +/- 0.2 (stat)+/- 0.2 (syst). The Z+c production cross section and the cross section ratio are also measured as a function of the transverse momentum of theZ boson and of the heavy flavour jet. The measurements are compared with theoretical predictions.Peer reviewe

Measurement of the underlying event activity in inclusive Z boson production in proton-proton collisions at root s=13 TeV

This paper presents a measurement of the underlying event activity in proton-proton collisions at a center-of-mass energy of 13TeV, performed using inclusive Z boson production events collected with the CMS experiment at the LHC. The analyzed data correspond to an integrated luminosity of 2.1 fb(-1). The underlying event activity is quantified in terms of the charged particle multiplicity, as well as of the scalar sum of the charged particles' transverse momenta in different topological regions defined with respect to the Z boson direction. The distributions are unfolded to the stable particle level and compared with predictions from various Monte Carlo event generators, as well as with similar CDF and CMS measurements at center-of-mass energies of 1.96 and 7TeV respectively.Peer reviewe

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens