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Concept: Internal medicine

674

 To determine whether patient outcomes differ between general internists who graduated from a medical school outside the United States and those who graduated from a US medical school.

Concepts: Pathology, United States, Physician, Neurology, High school, Pediatrics, Medical school, Internal medicine

639

Objectives To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians.Design Observational study.Setting US acute care hospitals.Participants 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists.Main outcome measures 30 day mortality and readmissions and costs of care. Results 736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients' characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients' adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses.Conclusions Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.

Concepts: Medicine, Death, Patient, Hospital, Physician, Doctor-patient relationship, Internal medicine, Residency

183

Readmissions after hospital discharge are common and costly, but prediction models are poor at identifying patients at high risk of readmission. We evaluated the impact of frailty on readmission or death within 30 days after discharge from general internal medicine wards.

Concepts: Patient, Hospital, Physician, Internal medicine

113

For generations, the supply of practicing physicians in the United States has swung from too small to too large and back again. In 2006, alarmed about a growing physician shortage, the Association of American Medical Colleges (AAMC) recommended that medical school enrollments be increased by 30% over the next decade. Now, entering classes are projected to reach 21,434 students by the 2016-2017 academic year, almost a 30% increase over 2002 (see table). Colleges of osteopathic medicine have been growing for the past 20 years, doubling in number from 15 to 30 and increasing enrollments from 6892 students in 1990 to . . .

Concepts: Medicine, Physician, Anatomy, Pediatrics, Medical school, Internal medicine, Doctor of Medicine, Osteopathic medicine in the United States

70

In March 2012, the Society of General Internal Medicine convened the National Commission on Physician Payment Reform to recommend forms of payment that would maximize good clinical outcomes, enhance patient and physician satisfaction and autonomy, and provide cost-effective care. The formation of the commission was spurred by the recognition that the level of spending on health care in the United States is unsustainable, that the return on investment is poor, and that the way physicians are paid drives high medical expenditures. The commission began by examining factors driving the high level of expenditures in the U.S. health care system. It . . .

Concepts: Health care, Health economics, Medicine, United States, Physician, Medical school, Internal medicine, Specialty

66

Membership in medical societies is associated with a number of benefits to members that may include professional education, opportunities to present research, scientific and/or leadership training, networking and others. In this perspective article, the authors address the value that medical specialty society membership and inclusion have in the development of an academic physician’s career and how underrepresentation of women may pose barriers to their career advancement. Because society membership itself is not likely sufficient to support the advancement of academic physicians, this report focuses on one key component of advancement that can also be used as a measure of inclusion in society activities-the representation of women physicians among recipients of recognition awards. Previous reports demonstrated underrepresentation of women physicians among recognition award recipients from two physical medicine and rehabilitation (PM&R) specialty organizations; including examples of zero or near-zero results. This report investigated whether zero or near-zero representation of women physicians among recognition award recipients from medical specialty societies extended beyond the field of PM&R. Examples of the underrepresentation of women physicians, as compared to their presence in the respective field, was found across a range of additional specialties, including dermatology, neurology, anesthesiology, orthopedic surgery, head and neck surgery, and plastic surgery. The authors propose a call for action across the entire spectrum of medical specialty societies to: 1) examine gender diversity and inclusion data through the lens of the organization’s mission, values and culture; 2) transparently report the results to members and other stakeholders including medical schools and academic medical centers; 3) investigate potential causes of less than proportionate representation of women; 4) implement strategies designed to improve inclusion; 5) track outcomes as a means to measure progress and inform future strategies; and 6) publish the results in order to engage community members in conversation about the equitable representation of women.

Concepts: Medicine, Surgery, Physician, Pediatrics, Medical school, Psychiatry, Internal medicine, Specialty

51

Twenty years ago, we described the emergence of a new type of specialist that we called a “hospitalist.”(1) Since then, the number of hospitalists has grown from a few hundred to more than 50,000 (see graph) - making this new field substantially larger than any subspecialty of internal medicine (the largest of which is cardiology, with 22,000 physicians), about the same size as pediatrics (55,000), and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107,000). Approximately 75% of U.S. hospitals, including all highly ranked academic health centers, now have hospitalists. The field’s rapid growth . . .

Concepts: Medicine, Cardiology, Physician, Pediatrics, Medical school, Internal medicine, Specialty, Medical specialties

29

BACKGROUND:: Academic medical institutions have instituted conflict of interest (COI) policies in response to concerns about pharmaceutical industry influence. OBJECTIVE:: To determine whether exposure to COI policies during psychiatry residency training affects psychiatrists' antidepressant prescribing patterns after graduation. RESEARCH DESIGN:: We used 2009 physician-level national administrative prescribing data from IMS Health for 1652 psychiatrists from 162 residency programs. We used difference-in-differences estimation to compare antidepressant prescribing based on graduation before (2001) or after (2008) COI policy adoption across residency program groups with maximally, moderately, and minimally restrictive COI policies. The primary outcomes were shares of psychiatrists' prescribing of heavily promoted, brand reformulated, and brand antidepressants. RESULTS:: Rates of prescribing heavily promoted, brand reformulated, and brand antidepressants in 2009 were lower among post-COI graduates than pre-COI graduates at all levels of COI restrictiveness. However, differences between pre-COI and post-COI graduates' prescribing of heavily promoted medications were larger for maximally restrictive programs than both minimally restrictive programs [-4.3 percentage points; 95% confidence interval (CI), -7.0, -1.6] and moderately restrictive programs (-3.6 percentage points; 95% CI, -6.2, -1.1). The difference in prescribing reformulations was larger for maximally restrictive programs than minimally restrictive programs (-3.0 percentage points; 95% CI, -5.3, -0.7). Results were consistent for prescribing of brand drugs. CONCLUSIONS:: This study provides the first empirical evidence of the effects of COI policies. Our results suggest that COI policies can help inoculate physicians against persuasive aspects of pharmaceutical promotion. Further research should assess whether these policies affect other drug classes and physician specialties similarly.

Concepts: Pharmacology, Medicine, Physician, Pharmaceutical industry, Medical school, Psychiatric medication, Internal medicine, IMS Health

28

BACKGROUND: Fibromyalgia (FM) is a condition characterized by widespread pain and is estimated to affect 0.5-5% of the general population. Historically, it has been classified as a rheumatologic disorder, but patients consult physicians from a variety of specialties in seeking diagnosis and ultimately treatment. Patients report considerable delay in receiving a diagnosis after initial presentation, suggesting diagnosis and management of FM might be a challenge to physicians. METHODS: A questionnaire survey of 1622 physicians in six European countries, Mexico and South Korea was conducted. Specialties surveyed included primary care physicians (PCPs; n=809) and equal numbers of rheumatologists, neurologists, psychiatrists and pain specialists. RESULTS: The sample included experienced doctors, with an expected clinical caseload for their specialty. Most (>80%) had seen a patient with FM in the last 2 years. Overall, 53% of physicians reported difficulty with diagnosing FM, 54% reported their training in FM was inadequate, and 32% considered themselves not knowledgeable about FM. Awareness of American College of Rheumatology classification criteria ranged from 32% for psychiatrists to 83% for rheumatologists. Sixty-four percent agreed patients found it difficult to communicate FM symptoms, and 79% said they needed to spend more time to identify FM. Thirty-eight percent were not confident in recognizing the symptoms of FM, and 48% were not confident in differentiating FM from conditions with similar symptoms. Thirty-seven percent were not confident developing an FM treatment plan, and 37% were not confident managing FM patients long-term. In general, rheumatologists reported least difficulties/greatest confidence, and PCPs and psychiatrists reported greatest difficulties/least confidence. CONCLUSIONS: Diagnosis and managing FM is challenging for physicians, especially PCPs and psychiatrists, but other specialties, including rheumatologists, also express difficulties. Improved training in FM and initiatives to improve patient-doctor communication are needed and may help the management of this condition.

Concepts: Medicine, Patient, Hospital, Rheumatology, Physician, Internal medicine, Specialty, American College of Rheumatology

25

Medicaid is an important federal-state partnership that provides health insurance for more than one fifth of the U.S. population - 73 million low-income people in 2012. The Affordable Care Act will expand Medicaid coverage to millions more. But 30% of office-based physicians do not accept new Medicaid patients, and in some specialties, the rate of nonacceptance is much higher - for example, 40% in orthopedics, 44% in general internal medicine, 45% in dermatology, and 56% in psychiatry.(1) Physicians practicing in higher-income areas are less likely to accept new Medicaid patients.(2) Physicians who do accept new Medicaid patients may use various . . .

Concepts: Health care, Medicine, Health insurance, Hospital, Physician, Medicaid, Internal medicine, Specialty