It can be difficult for clinicians to stay updated on practice-changing articles.  Synthesis of relevant articles and guideline updates can facilitate staying informed on important new data impacting clinical practice.  The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded.  The New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association, The British Medical Journal (BMJ), the Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 5 practice-changing articles were included, along with a highlight of key guideline updates.

A substantial change in the pattern of influenza infections was noted worldwide1Yum S. Hong K. Sohn S. Kim J. Chun B.C. Trends in viral respiratory infections during COVID-19 pandemic, South Korea.Emerg Infect Dis. 2021; 27: 1685-1688Crossref PubMed Scopus (18) Google Scholar during the COVID-19 pandemic. We sought to describe our experience with seasonal respiratory infections across 60 sites of a major health care system in the Midwest United States. Although timing varies slightly from year to year, seasonal acute respiratory infections, such as influenza A/B, respiratory syncytial virus (RSV), and group A streptococcus (GAS), have predictable months of increased activity. We collected the number of tests performed for influenza A/B, RSV, GAS, and SARS-CoV-2 from November 1, 2018, to March 31, 2020 (ie, the pre-pandemic period) and April 1, 2020, to June 24, 2021 (ie, the pandemic period). During the COVID-19 pandemic, we observed lower rates of influenza A/B than previously reported and discovered substantially decreased positivity rates for RSV and GAS as well.1Yum S. Hong K. Sohn S. Kim J. Chun B.C. Trends in viral respiratory infections during COVID-19 pandemic, South Korea.Emerg Infect Dis. 2021; 27: 1685-1688Crossref PubMed Scopus (18) Google Scholar, 2Soo R.J.J. Chiew C.J. Ma S. Pung R. Lee V. Decreased influenza incidence under COVID-19 control measures, Singapore.Emerg Infect Dis. Aug 2020; 26: 1933-1935Crossref PubMed Scopus (152) Google Scholar, 3Lee H. Lee H. Song K.H. et al.Impact of public health interventions on seasonal influenza activity during the COVID-19 outbreak in Korea.Clin Infect Dis. Jul 1 2021; 73: e132-e140https://doi.org/10.1093/cid/ciaa672Crossref PubMed Scopus (62) Google Scholar, 4Chan K.H. Lee P.W. Chan C.Y. Lam K.B. Ho P.L. Monitoring respiratory infections in covid-19 epidemics.BMJ. May 4 2020; 369: m1628https://doi.org/10.1136/bmj.m1628Crossref PubMed Scopus (26) Google Scholar A total of 1,489,293 tests were performed for influenza A/B, RSV, GAS, and SARS-CoV-2 between November 1, 2018, and June 24, 2021 (Table; Supplemental Figure, available online at http://www.mayoclinicproceedings.org). Our pre-pandemic interval includes 2 typical respiratory seasons with peaks from November through March, during which time 11% of all influenza tests returned positive results, 8% of RSV test results were positive, and 25% of GAS test results were positive. In comparison, during the COVID-19 pandemic, there were only 28 (0.02%) positive influenza results of 139,816 tests, 24 (0.2%) positive RSV results of 11,412 tests, and 5622 (13.2%) positive cases of GAS of 42,485 tests. Even though the overall rate of testing of influenza A/B and RSV was lower during the pandemic, the positivity rate decreased significantly (P<.001), more than would be predicted, and approached zero.TableTests for Acute Respiratory Infections Performed and ResultsPre-pandemic periodaPre-pandemic period: November 1, 2018, to March 31, 2020. (n=350,334)Pandemic periodbPandemic period: April 1, 2020, to June 24, 2021.,cAll P values are <.001. (n=1,138,959)Overall (N=1,489,293)Test performed Influenza A/B20,8438 (59.5)139,816 (12.3)348,254 (23.4) Respiratory syncytial virus37,717 (10.8)11,436 (1.0)49,153 (3.3) Group A streptococcus93,392 (26.7)42,485 (3.7)135,877 (9.1) SARS-CoV-210,787 (3.1)945,222 (83.0)956,009 (64.2)Influenza A/B test results Negative185,311 (88.9)139,788 (100.0)325,099 (93.4) Positive23,127 (11.1)28 (0.0)23,155 (6.6)Respiratory syncytial virus test results Negative34,711 (92.0)11,412 (99.8)46,123 (93.8) Positive3006 (8.0)24 (0.2)3030 (6.2)Group A streptococcus test results Negative70,306 (75.3)36,863 (86.8)107,169 (78.9) Positive23,086 (24.7)5622 (13.2)28,708 (21.1)SARS-CoV-2 test results Negative10,739 (99.6)865,086 (91.5)875,825 (91.6) Positive48 (0.4)80,136 (8.5)80,184 (8.4)Values are reported as number (percentage).a Pre-pandemic period: November 1, 2018, to March 31, 2020.b Pandemic period: April 1, 2020, to June 24, 2021.c All P values are <.001. Open table in a new tab Values are reported as number (percentage). Patients tested for non-COVID viruses during the pandemic tended to be older (median age, 41.7 years; Q1-Q3, 19.9-66.5 years) compared with patients tested during the pre-pandemic period (median age, 28.7 years; Q1-Q3, 7.9-59.4 years; Wilcoxon, P<.001). However, there was no age difference in comparing positive non-COVID test results between the pandemic (median age, 14.6 years; Q1-Q3, 8.3-25.9 years) and the pre-pandemic periods (median age, 12.8 years; Q1-Q3, 6.2-35.5 years, Wilcoxon, P=.466). We also investigated the possibility of viral interference by SARS-CoV-2 on the rate of respiratory viral infections. To assess this, we compared positivity rates of influenza A/B and RSV between patients who had previously tested positive for SARS-CoV-2 and patients who had not tested positive. Only respiratory tests conducted during the pandemic period were included in this subanalysis. To serve as a baseline, we also compared positivity rates among all patients during the pre-pandemic period with patients in the pandemic period who had no previous positive SARS-CoV-2 test results. We found that viral interference did not contribute in decreasing the rates of influenza or RSV. In conclusion, there was a significant decrease observed in the rate of positivity of 3 respiratory illnesses before and during the COVID-19 pandemic. The explanation for the decreased rates of influenza A/B, RSV, and GAS is likely to be multifactorial, and further work will be needed to determine all the elements influencing this change as we navigate future respiratory seasons. Download .pdf (.38 MB) Help with pdf files Supplemental Figure

It can be challenging to identify new evidence that may shift clinical practice within internal medicine. Synthesis of relevant articles and guideline updates can facilitate staying informed of these changes. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 8 practice-changing articles were included.

In a time of rapidly shifting evidence-based medicine, it is challenging to stay informed of research that modifies clinical practice. To enhance knowledge of practice-changing literature, a group of 7 internists reviewed titles and abstracts in 7 internal medicine journals with the highest impact factors and relevance to outpatient general internal medicine. Coronavirus disease-19 research was purposely excluded to highlight practice changes beyond the pandemic. New England Journal of Medicine (NEJM), The Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine were reviewed. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on relevance to outpatient internal medicine, impact on practice, and strength of evidence. Clusters of articles pertaining to the same topic were considered together. In total, 7 practice-changing articles were included.

Clinicians are challenged to stay informed of new and changing medical literature. To facilitate knowledge updates and synthesis of practice-changing information, a group of 6 internists reviewed the titles and abstracts in the 7 outpatient general internal medicine journals with the highest impact factors and relevance to outpatient internal medicine physicians: New England Journal of Medicine (NEJM), Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertaining to the same topic were considered together. In total, 7 practice-changing articles were included.

The coronavirus disease 2019 (COVID-19) pandemic has created a need and opportunity for telemedicine consultations. The risk of disease transmission to patients without COVID-19 and to health care workers has stimulated health care institutions to identify new ways to track and follow-up individuals with potential or proven COVID-19. Herein, we describe systems used to provide care to patients in the Mayo Clinic Health System – Southeast Minnesota region. Mayo Clinic has instituted a centralized nurse hotline for screening all Mayo Clinic patients who call and describe possible COVID-19 symptoms to determine whether they meet current guidelines for a polymerase chain reaction test (via nasopharyngeal swab) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). After this screening, which is offered across all Mayo sites, patients in the Southeast Minnesota region are offered a pilot program for a virtual appointment with a health care professional, via either telephone or videoconference, to address their active symptoms while they wait for their swab test results. Approximately one-third to one-half of patients elect a virtual provider evaluation. Video visits are conducted via the Patient Online Services portal, which allows patients to log into their video appointment from their calendar and connect with the provider through a highly secure interface. Virtual appointments are divided into 2 categories. The first category comprises patients with simple acute concerns aged 18 months to 75 years, and the second category comprises patients with more complex or multiple concerns and patients outside that age range. The first group of patients is scheduled by using centralized virtual visit calendars for same-day appointments with advanced practice providers, predominantly drawn from providers previously assigned to Mayo Clinic Express Care clinics. The second group of patients, who have more complex or serious concerns, are scheduled for virtual visits on the calendar of their primary care provider, allowing them to benefit from the increased opportunity for continuity of care. Video visits are preferred to telephone visits because they allow for better interaction and data gathering. In 75% of cases, the virtual provider is able to resolve the patient's concerns; 25% of patients continue on to additional in-person appointments. If imaging studies, laboratory testing, or in-person appointments are needed to complete the diagnostic evaluation, the patient is offered an appointment in local COVID-19 comprehensive care centers, which have been established with additional safety procedures and environmental protection to safely care for patients with possible COVID-19 who are awaiting test results and persons with active COVID-19 who require in-person care. From March 25, 2020, through May 1, 2020, 1759 virtual visits were performed for Mayo Clinic patients in the Southeast Minnesota region. Positive SARS-CoV-2 polymerase chain reaction results are reported via a group in-basket in electronic health records to the general internal medicine (GIM)/infectious diseases COVID-19 Frontline Care Team. A physician from the COVID-19 Frontline Care Team initially contacts patients to assess their symptom severity and to determine their risk of developing severe COVID-19. This visit occurs virtually via either telephone or videoconference across all Mayo Clinic sites in the Midwest. Patients then receive remote monitoring from a GIM nursing team using both virtual visits and telephone calls for symptom updates. General internal medicine has also established processes to connect with staff in other specialties to optimize care delivery for patients actively infected with SARS-CoV-2. The intensity of remote monitoring is driven mainly by the risk of a patient developing a serious case of COVID-19, with higher-risk patients being more intensively monitored. Mayo Clinic provides patients at highest risk with a cellular-enabled tablet telehealth system and monitors for blood pressure, heart rate, temperature, weight, and oxygen saturation, as well as 24-hour nursing support and nursing follow-up twice daily. Patients at lower risk are sent a thermometer and pulse oximeter by overnight mail and are encouraged to report their vital signs and symptoms twice daily via messages sent through their patient portal account, which are reviewed by the remote monitoring nursing teams. An alert is generated whenever vital signs or symptoms change beyond predefined thresholds. On the basis of these alerts, the nursing team can contact patients and escalate care, as necessary. By using remote monitoring, by June 10, 2020, we had kept 2000 symptomatic patients in the Midwest with positive COVID-19 test results at home under self-isolation while we provided remote medical care and monitoring of vital signs and symptoms to allow the early identification of decompensation. Decompensation often begins with hypoxia and hypotension, which are readily identified using the remote monitoring system. By triaging patients to the emergency department or a dedicated local COVID-19 comprehensive care center, we have been able to funnel these patients to areas that are appropriately equipped for patients with COVID-19, thereby decreasing the risk of disease transmission. A similar process exists for patients with COVID-19 being discharged from the hospital. All inpatients with a diagnosis of COVID-19 are assessed by the infectious diseases team and risk stratified for remote patient monitoring after discharge. Within 48 hours of discharge, the team from GIM reassesses the patients and makes recommendations for duration of isolation. During the COVID-19 pandemic, the GIM team has also assisted in the evaluation of patients being seen for nonurgent medical care who had symptoms concerning for possible COVID-19 infection. The GIM team conducts a virtual visit during which they review records, assess infection risk, and make recommendations regarding the need for testing. This effort helps minimize infection risk to staff by eliminating unnecessary in-person visits for patients who may have COVID-19. Virtual care models have been highly successful in meeting the needs of persons with possible COVID-19 and those with positive COVID-19 test results. Virtual visits have been widely accepted by patients and represent a key component of providing timely and safe health care during this pandemic.

INTRODUCTION:Learners may subconsciously change their behavior once they know they are being observed, and this Hawthorne effect should be considered when designing assessments of learner behavior. While there is a growing body of literature to suggest direct observation is the ideal standard for formative assessment, the best method to directly observe learners is unknown. We explored scheduled and unscheduled methods of direct observation among internal medicine residents in the outpatient continuity clinic to advance the understanding of both observation methods.METHODS:We conducted a thematic analysis of faculty and internal medicine residents in an outpatient clinic setting. A semi-structured interview guide for focus group sessions was created. Focus groups were used to explore the internal medicine resident and core teaching faculty perceptions of the scheduled and unscheduled direct observation methods in the outpatient clinc. An experienced qualitative research interviewer external to the internal medicine residency was moderating the sessions. Eight peer focus groups were held. Abstraction of themes from focus group transcripts identified resident and faculty perceptions of the different observation methods.RESULTS:Focus groups had 14 resident participants and 14 faculty participants. Unscheduled observations were felt to be more authentic than scheduled observations since residents perceived their behavior to be unmodified. Unscheduled observations allowed for increased numbers of observations per resident, which permitted more frequent formative assessments. Residents and faculty preferred remote video observation compared to in-room observation. Participants found direct observation a useful learning tool for high-yield, specific feedback.CONCLUSIONS:Unscheduled remote direct observation captures authentic clinical encounters while minimizing learner behavior modification. An unscheduled observation approach results in more frequent formative assessment and therefore in more instances of valuable feedback compared to scheduled observations. These findings can help guide the best practice approaches to direct clinical observation in order to enhance residents learning and experience.

The expansive scope of general internal medicine makes it difficult to identify practice-changing medical literature. Clinical updates can be facilitated by synthesizing relevant articles and implications for practice. Six internal medicine physicians reviewed the titles and abstracts in the 7 general internal medicine clinical outpatient journals with the highest impact factor and relevance to the internal medicine outpatient physician: New England Journal of Medicine (NEJM), Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA-Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus on articles based on clinical relevance to outpatient Internal Medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 7 practice-changing articles were included.

Clinicians are challenged to identify new practice-changing articles in the medical literature. To identify the practice-changing articles published in 2017 most relevant to outpatient general internal medicine, 5 internists reviewed the following sources: 1) titles and abstracts from internal medicine journals with the 7 highest impact factors, including New England Journal of Medicine, Lancet, Journal of the American Medical Association, British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine; 2) synopses and syntheses of individual studies, including collections in the American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine; 3) databases of synthesis, including Evidence Updates and the Cochrane Library. Inclusion criteria were perceived clinical relevance to outpatient general medicine, potential for practice change, and strength of evidence. This process yielded 140 articles. Clusters of important articles around one topic were considered as a single-candidate series. A modified Delphi method was utilized by the 5 authors to reach consensus on 7 topics to highlight and appraise from the 2017 literature.

Entrustable professional activities (EPAs) have been developed to assess resident physicians with respect to Accreditation Council for Graduate Medical Education (ACGME) competencies and milestones. Although the feasibility of using EPAs has been reported, we are unaware of previous validation studies on EPAs and potential associations between EPA quality scores and characteristics of educational programs. Our aim was to validate an instrument for assessing the quality of EPAs for assessment of internal medicine residents, and to examine associations between EPA quality scores and features of rotations. This was a prospective content validation study to design an instrument to measure the quality of EPAs that were written for assessing internal medicine residents. Residency leadership at Mayo Clinic, Rochester participated in this study. This included the Program Director, Associate program directors and individual rotation directors. The authors reviewed salient literature. Items were developed to reflect domains of EPAs useful for assessment. The instrument underwent further testing and refinement. Each participating rotation director created EPAs that they felt would be meaningful to assess learner performance in their area. These 229 EPAs were then assessed with the QUEPA instrument to rate the quality of each EPA. Performance characteristics of the QUEPA are reported. Quality ratings of EPAs were compared to the primary ACGME competency, inpatient versus outpatient setting and specialty type. QUEPA tool scores demonstrated excellent reliability (ICC range 0.72 to 0.94). Higher ratings were given to inpatient versus outpatient (3.88, 3.66; p = 0.03) focused EPAs. Medical knowledge EPAs scored significantly lower than EPAs assessing other competencies (3.34, 4.00; p < 0.0001). The QUEPA tool is supported by good validity evidence and may help in rating the quality of EPAs developed by individual programs. Programs should take care when writing EPAs for the outpatient setting or to assess medical knowledge, as these tended to be rated lower.

Identifying new practice-changing articles is challenging. To determine the 2015 practice-changing articles most relevant to outpatient general internal medicine, 3 internists independently reviewed the titles and abstracts of original articles, synopses of single studies and syntheses, and databases of syntheses. For original articles, internal medicine journals with the 7 highest impact factors were reviewed: New England Journal of Medicine, Lancet, Journal of the American Medical Association (JAMA), British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine. For synopses of single studies and syntheses, collections in American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine were reviewed. For databases of synthesis, Evidence Updates and the Cochrane Library were reviewed. More than 100 articles were identified. Criteria for inclusion were as follows: clinical relevance, potential for practice change, and strength of evidence. Clusters of important articles around one topic were considered as a single-candidate series. The 5 authors used a modified Delphi method to reach consensus on inclusion of 7 topics for in-depth appraisal.

PurposeTo determine U.S. internal medicine (IM) residents' knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments.MethodThe authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age-sex-race-illness standardized measure of hospital days and inpatient physician visits by Medicare recipients).ResultsOf 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they "share estimated costs of tests and treatments with patients"; 15,549 of 17,626 (88.2%) agreed that they "incorporate patients' values and concerns into clinical decisions." Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital's care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors.ConclusionsU.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents' competency in providing value-based care.

Mayo Clinic Proceedings began publishing Residents' Clinic articles in 1995. The purpose of Residents' Clinics is for internal medicine residents to describe—through narratives, multiple choice questions (MCQs), and explanations of the MCQ answers—the evaluation of patients who are managed by internists with respect to diagnosis, treatment, and prognosis. The traditional focus of Residents' Clinics is to enhance readers' reasoning skills and medical knowledge of diseases that occur in adults. Other journals that publish similar articles on knowledge and clinical reasoning are New England Journal of Medicine and JAMA.1Geller B.J. Stone R.M. Merola J.F. Levy B.D. Loscalzo J. A man with fever, cough, and rash.N Engl J Med. 2015; 373: 74-80Crossref PubMed Scopus (4) Google Scholar, 2Huang W. Molitch M.E. Enlarged thymus in a patient with dyspnea and weight loss.JAMA. 2015; 313: 2174-2175Crossref PubMed Scopus (2) Google Scholar However, it is noteworthy that physicians' expertise in managing patients extends beyond acquiring and displaying medical knowledge. In 2001, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcomes Project, which required that residents demonstrate proficiency in the following six competencies: (1) patient care, (2) medical knowledge, (3) systems-based practice, (4) practice-based learning and improvement, (5) professionalism, and (6) interpersonal and communication skills.3Swing S.R. The ACGME Outcome Project: retrospective and prospective.Med Teach. 2007; 29: 648-654Crossref PubMed Scopus (572) Google Scholar, 4Malik M.U. Diaz Voss Varela D.A. Stewart C.M. et al.Barriers to implementing the ACGME Outcome Project: a systematic review of program director surveys.J Grad Med Educ. 2012; 4: 425-433Crossref PubMed Google Scholar Assessing resident performance in these competencies is challenging,5Jones Jr., M.D. Rosenberg A.A. Gilhooly J.T. Carraccio C.L. Perspective: competencies, outcomes, and controversy—linking professional activities to competencies to improve resident education and practice.Acad Med. 2011; 86: 161-165Crossref PubMed Scopus (68) Google Scholar so in 2009, the ACGME and the American Board of Internal Medicine introduced subcompetencies6Internal Medicine Milestone Group. The Internal Medicine Milestones Project: A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Accreditation Council for Graduate Medical Education website. http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf. Published July 2015. Accessed July 31, 2015.Google Scholar—also called reporting milestones—under the Next Accreditation System (NAS).4Malik M.U. Diaz Voss Varela D.A. Stewart C.M. et al.Barriers to implementing the ACGME Outcome Project: a systematic review of program director surveys.J Grad Med Educ. 2012; 4: 425-433Crossref PubMed Google Scholar, 7Nasca T.J. Philibert I. Brigham T. Flynn T.C. The next GME accreditation system—rationale and benefits.N Engl J Med. 2012; 366: 1051-1056Crossref PubMed Scopus (1052) Google Scholar Reporting milestones provide the advantages of behavior-specific anchors and an ability to gauge residents' progress over time (Table).TableAccreditation Council for Graduate Medical Education Competencies and Reporting MilestonesaEach milestone is rated on a 9-point scale with descriptive anchors, ranging from “critical deficiencies” to “ready for unsupervised practice” to “aspirational.” For more information, see the Accreditation Council for Graduate Medical Education's and American Board of Internal Medicine's Internal Medicine Milestones Project.6CompetencyReporting milestoneDescriptionPatient carePC1Gathers and synthesizes essential and accurate information to define a patient's clinical problemPC2Develops and achieves comprehensive management plan for each patientPC3Manages patients with progressive responsibility and independencePC4Skill in performing proceduresPC5Requests and provides consultative careMedical knowledgeMK1Clinical knowledgeMK2Knowledge of diagnostic testing and proceduresSystems-based practiceSBP1Works effectively within an interprofessional teamSBP2Recognizes system error and advocates for improvementSBP3Identifies forces that impact the cost of health care and advocates for and practices cost-effective careSBP4Transitions patients effectively within and across health delivery systemsPractice-based learning and improvementPBLI1Monitors practice with a goal for improvementPBLI2Learns and improves via performance auditPBLI3Learns and improves via feedbackPBLI4Learns and improves at the point of careProfessionalismPROF1Has professional and respectful interactions with patients, caregivers, and members of the professional teamPROF2Accepts responsibility and follows through on tasksPROF3Responds to each patient's characteristics and needsPROF4Exhibits integrity and ethical behavior in professional conductInterpersonal and communication skillsICS1Communicates effectively with patients and caregiversICS2Communicates effectively in interprofessional teamsICS3Appropriate utilization and completion of health recordsa Each milestone is rated on a 9-point scale with descriptive anchors, ranging from “critical deficiencies” to “ready for unsupervised practice” to “aspirational.” For more information, see the Accreditation Council for Graduate Medical Education's and American Board of Internal Medicine's Internal Medicine Milestones Project.6Internal Medicine Milestone Group. The Internal Medicine Milestones Project: A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Accreditation Council for Graduate Medical Education website. http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineMilestones.pdf. Published July 2015. Accessed July 31, 2015.Google Scholar Open table in a new tab With multiple competencies and subcompetencies, why would there be such emphasis on the competency of medical knowledge in graduate medical education? There are several reasons. First, assessment drives learning.8Wood T. Assessment not only drives learning, it may also help learning.Med Educ. 2009; 43: 5-6Crossref PubMed Scopus (89) Google Scholar In other words, people are strongly motivated to understand information that is required for high-stakes assessments. The medical knowledge certification examination, which internists must pass every 10 years in order to maintain board certification, is one such motivation for continuous learning. Second, board pass rates are a key metric for determining the quality of residency training programs.9Wolfsthal S.D. Beasley B.W. Kopelman R. Stickley W. Gabryel T. Kahn M.J. Membership Survey and Scientific Data Committee, the Association of Program Directors of Internal MedicineBenchmarks of support in internal medicine residency training programs.Acad Med. 2002; 77: 50-56Crossref PubMed Scopus (12) Google Scholar Third, competencies like professionalism and communication are more challenging to objectively measure than medical knowledge, so they may be understressed. The ACGME and NAS milestones-based assessments require that residents exhibit a wide range of competencies that transcend awareness of diseases to include caring for the whole patient within the contexts of physician-patient relationships, medical teams, and the health care system. Therefore, residents should be encouraged to think broadly about their clinical experiences when writing Residents' Clinic contributions. This issue of the Proceedings includes a Residents' Clinic article by Vatterott et al10Vatterott P.C. Schouten W.M. Wittich C.M. 75-Year-old man with fever, cough, myalgias and pruritis.Mayo Clin Proc. 2015; 90: 1694-1698Abstract Full Text Full Text PDF Scopus (2) Google Scholar regarding a patient with an unfortunate outcome that occurred in the setting of several widely recognized cognitive errors.11Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them.Acad Med. 2003; 78: 775-780Crossref PubMed Scopus (954) Google Scholar, 12Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making.N Engl J Med. 2013; 368: 2445-2448Crossref PubMed Scopus (299) Google Scholar, 13Kahneman D. Thinking Fast and Slow. Farrar, Straus and Giroux, New York, NY2011Google Scholar Reflecting on one's mistakes in clinical reasoning is consistent with the ACGME's definition of practice-based learning and improvement, which underscores the importance of improving patient care through constant self-evaluation.14Accreditation Council for Graduate Medical Education. Outcomes Project. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/430_CompetencyDefinitions_RO_ED_10182007.pdf. Accessed October 19, 2015.Google Scholar This case also illustrates transformative learning,15Cranton P. Understanding and Promoting Transformative Learning: A Guide for Educators of Adults.2nd ed. Jossey-Bass, San Francisco, CA2006Google Scholar which is growth of awareness through changing one's worldview. Transformative learning requires a disorienting dilemma such as a cognitive error, reflecting on the dilemma to expose areas for improvement, and then addressing limitations by acquiring new knowledge, skills, or attitudes. In fact, transformative learning has been identified as a link between practice-based learning and improvement and large-scale improvements in the health care system.16Wittich C.M. Reed D.A. McDonald F.S. Varkey P. Beckman T.J. Perspective: transformative learning; a framework using critical reflection to link the improvement competencies in graduate medical education.Acad Med. 2010; 85: 1790-1793Crossref PubMed Scopus (33) Google Scholar Furthermore, learning from errors reaffirms the culture of transparency in modern training programs and the systems audit approach to discussing medical errors at morbidity and mortality conferences.17Szostek J.H. Wieland M.L. Loertscher L.L. et al.A systems approach to morbidity and mortality conference.Am J Med. 2010; 123: 663-668Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar The Residents' Clinic article by Vatterott et al10Vatterott P.C. Schouten W.M. Wittich C.M. 75-Year-old man with fever, cough, myalgias and pruritis.Mayo Clin Proc. 2015; 90: 1694-1698Abstract Full Text Full Text PDF Scopus (2) Google Scholar marks a substantial departure from previous Residents' Clinics over the past 20 years, which have included MCQs that address only the medical knowledge and patient care competencies. This new approach reveals the complex abilities required of internists, which would also include systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. Ultimately, the article by Vatterott et al should align Residents' Clinics with the milestones-based objectives of the ACGME and NAS in this era of competency-based education. Looking forward, we anticipate that most Residents' Clinic articles will continue to focus mainly on patient cases that represent the medical knowledge and patient care competencies. Nonetheless, we will broaden the scope of Residents' Clinics by considering manuscripts that demonstrate, in a compelling fashion, any of the ACGME competencies. Examples could include clinical scenarios that show methods for effective physician-patient communication, improving health care systems, or resolving ethical dilemmas. 75-Year-Old Man With Fever, Cough, Myalgias, and PruritusMayo Clinic ProceedingsVol. 90Issue 12PreviewA 75-year-old man presented to the emergency department (ED) with a 5-day history of fever, cough, nasal congestion, sore throat, myalgias, headache, loose stools, and diffuse pruritus. His medical history was notable for coronary artery bypass graft surgery several years previously, hypertension, hyperlipidemia, chronic kidney disease, acid reflux, alcohol abuse, and gout. He had taken acetaminophen with modest improvement in his fever, myalgias, and headache. He was a lifelong nonsmoker. The patient had no sick contacts or recent travel history. Full-Text PDF

The practice of outpatient general internal medicine requires a diverse and evolving knowledge base. General internists must identify practice-changing shifts in the literature and reflect on their impact. Accordingly, we conducted a review of practice-changing articles published in outpatient general internal medicine in 2014. To identify high-quality, clinically relevant publications, we reviewed all titles and abstracts published in the following primary data sources in 2014: New England Journal of Medicine, Journal of the American Medical Association (JAMA), Annals of Internal Medicine, JAMA Internal Medicine, and the Cochrane Database of Systematic Reviews. All 2014 primary data summaries from Journal Watch-General Internal Medicine and ACP JournalWise also were reviewed. The authors used a modified Delphi method to reach consensus on inclusion of 8 articles using the following criteria: clinical relevance to outpatient internal medicine, potential for practice change, and strength of evidence. Clusters of important articles around one clinical question were considered as a single-candidate series. The article merits were debated until consensus was reached on the final 8, spanning a variety of topics commonly encountered in outpatient general internal medicine.

Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents' advance care planning (ACP) practices and improve residents' ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.

presents to the clinic for evaluation of headaches, which she de-scribes as pulsatile and throbbing, usually unilateral but involving different sides of the head at different times, and severe, causing her to miss work. They usually last between 12 and 24 hours and are asso-ciated with nausea but no vomiting and no changes in vision. They are worse around the time of her menses, have been occurring about twice a month for the past 6 months, and respond to ibuprofen. She thought they were caused by chronic seasonal allergies and sinusitis and has tried antihistamines and nasal irrigation without success. They are not affected by body position, they are not explosive, and they are not brought on by the Valsalva ma-neuver. She reports no other neurologic or systemic symptoms. A detailed neurologic examination shows no deficits. However, the patient is concerned, as one of her friends was recently diagnosed with cancer. She requests imaging to “make sure there is no can-cer.” Would it be appropriate to order imaging at this time?