Faculty Bibliography

BACKGROUND: Difficult patient encounters in the primary care office are frequent and are associated with physician burnout. However, their relationship to patient care outcomes is not known. OBJECTIVE: To determine the effect of difficult encounters on patient health outcomes and the role of physician dissatisfaction and burnout as mediators of this effect. DESIGN: A total of 422 physicians were sorted into 3 clusters based on perceived frequency of difficult patient encounters in their practices. Patient charts were audited to assess the quality of hypertension and diabetes management and preventive care based on national guidelines. Summary measures of quality and errors were compared among the 3 physician clusters. RESULTS: Of the 1384 patients, 359 were cared for by high-cluster physicians (those who had a high frequency of difficult encounters), 871 by medium-cluster physicians, and 154 by low-cluster physicians. Dissatisfaction and burnout were higher among physicians reporting higher frequencies of difficult encounters. However, quality of patient care and management errors were similar across all 3 groups. CONCLUSIONS: Physician perception of frequent difficult encounters was not associated with worse patient care quality or more medical errors. Future studies should investigate whether other patient outcomes, including acute care and patient satisfaction, are affected by difficult encounters.

Objectives. We have described and evaluated the impact of a unique fellowship program designed to train postdoctoral, physician fellows in research at the interface of medicine and public health. Methods. We developed a rigorous curriculum in public health content and research methods and fostered linkages with research mentors and local public health agencies. Didactic training provided the foundation for fellows' mentored research initiatives, which addressed real-world challenges in advancing the health status of vulnerable urban populations. Results. Two multidisciplinary cohorts (6 per cohort) completed this 2-year degree-granting program and engaged in diverse public health research initiatives on topics such as improving pediatric care outcomes through health literacy interventions, reducing hospital readmission rates among urban poor with multiple comorbidities, increasing cancer screening uptake, and broadening the reach of addiction screening and intervention. The majority of fellows (10/12) published their fellowship work and currently have a career focused in public health-related research or practice (9/12). Conclusions. A fellowship training program can prepare physician investigators for research careers that bridge the divide between medicine and public health. (Am J Public Health. Published online ahead of print May 17, 2012: e1-e7. doi:10.2105/AJPH.2011.300486).

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): To determine how adding a non-clinical member to primary care teams can improve hypertension and smoking cessation outcomes in Veteran Affairs New York Harbor Healthcare System's (VA NYHHS) implementation of the VA's Patient Centered Medical Home (PCMH) model, known as Patient Aligned Care Teams (PACT). OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): As part of the Program for Research on Outcomes of VA Education (PROVE) study, we sought to define a toolkit of panel management strategies that Panel Management Assistants (PMAs) will use to improve outcomes in smoking cessation and hypertension across patient panels. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENTVS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): Coincident with the nation-wide implementation of PACT across the VA system, PROVE explores the incremental impact of panel management and clinical microsystem education on hypertension and smoking outcomes. Two-thirds of randomly selected PACT teams in ambulatory care clinics at the Brooklyn and Manhattan campuses of the VA NYHHS had a PMA added to the team. Based on literature review and qualitative interviews of clinicians and key stakeholders at VA NYHHS, we developed a core toolkit of strategies utilizing clinical databases to target subsets of smokers and hypertensive patients that could benefit from specialized panel management interventions outside of the patient visit, such as identifying smokers who have not recently received tobacco cessation medications. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICH WILL BE USED TOEVALUATE PROGRAM/INTERVENTION): Prior to PROVE's intervention, we determined baseline rates of hypertension (uncontrolled and controlled) and smoking for all PACT panels. To assess PROVE's effectiveness of integrating panel management strategies by PACT teams, we will survey providers and nurses at baseline, 6 and 12 months to me!

To establish and sustain the high-performing health care system envisioned in the Affordable Care Act (ACA), current provisions in the law to strengthen the primary care workforce must be funded, implemented, and tested. However, the United States is heading towards a severe primary care workforce bottleneck due to ballooning demand and vanishing supply. Demand will be fueled by the "silver tsunami" of 80 million Americans retiring over the next 20 years and the expanded insurance coverage for 32 million Americans in the ACA. The primary care workforce is declining because of decreased production and accelerated attrition. To mitigate the looming primary care bottleneck, even bolder policies will be needed to attract, train, and sustain a sufficient number of primary care professionals. General internists must continue their vital leadership in this effort.

BACKGROUND: The United States faces a shortage of primary care physicians and declining number of medical students choosing primary care careers. METHODS: We conducted a secondary analysis of 2 similar national surveys of senior medical students from 1990 and 2007 that addressed student characteristics, specialties chosen, clerkship experiences, perceptions of internal medicine (IM) compared with other specialties, and influential aspects of IM. We compared responses from 1990 and 2007 by analyzing a merged data set of identical items from the 2 surveys (65% of the items). RESULTS: The total sample of 2421 students comprised 1244 at 16 schools in 1990 (response rate, 75%) and 1177 at 11 schools in 2007 (82%). In 2007, there were more women (52% vs 37%, P < .001) and more educational debt (mean, $101 000 vs $63 000, P < .001). Similar proportions of students planned IM careers (23% vs 24%), although plans to practice general IM dropped from 9% to 2% (P < .001). The appeal of primary care as an influence toward IM declined from 57% to 33% (P < .001). More 2007 students reported high satisfaction with the IM clerkship (78% vs 38%, P < .001). Both cohorts thought that workload and stress are greater in IM than in other fields. Students in 2007 felt that opportunities for meaningful work in IM were greater than did students in 1990 (58% vs 42%, P < .001). CONCLUSIONS: More students in 2007 than in 1990 viewed IM as a potentially meaningful career. However, the 2007 students had higher debt, more negative perceptions of workload and stress in IM, and less career interest in general IM. To rebuild the generalist physician workforce, improving students' experience of IM in medical school is no longer sufficient. Bolder reform will be required to improve the educational pipeline, practice, and payment of generalist IM physicians

PURPOSE: Medical students' career choices affect health care. To understand how to increase the number of students who choose careers in internal medicine (IM), students who seriously considered IM but chose another field ('Switchers') and those who rejected IM ('Never Considered') were compared with those who chose IM ('Choosers'). METHOD: Fourth-year medical students from 11 U.S. institutions were surveyed about demographics, medical school educational experiences, and aspects of the specialty of IM. Univariate analysis and multivariate logistic regression models examined associations between student characteristics and classification as Switchers, Choosers, and Never Considered. RESULTS: A total of 1,177 students completed the survey (82% response rate). There were 274 (23%) Choosers, 398 (34%) Switchers, and 499 (43%) Never Considered. The authors' models explained over 80% of variance in these three career choice classification groups. For most responses, an increasingly favorable gradient from Never Considered to Choosers was observed. Multivariate analysis revealed six items that were associated with higher probability of choosing IM: types of patients internists see, timing of career decision, interest groups, intellectual challenge, satisfaction among internists, and the core IM clerkship. CONCLUSIONS: Several potentially modifiable educational experiences and aspects of IM distinguished Switchers from the other two groups. The percentage of variance explained by group suggests that these findings identify important underpinnings of career decisions. These items also suggest ways that educational experiences and aspects of the specialty could be redesigned by academicians and policy makers to improve the attractiveness of IM careers