Faculty Bibliography

Language barriers may contribute to the under-detection of depression in Latinos and Asians. A total of 782 English, Spanish, and Chinese-speaking primary care patients were enrolled in a randomized controlled trial. Language discordant patients were randomized to Remote Simultaneous Medical Interpreting (RSMI) or usual and customary (U&C) interpreting. The Beck Depression Inventory-Fast Screen (BDI-FS) was administered. Patients were tracked for 1 year. A total of 462 patients completed the BDI-FS. Thirty-three percent had a positive (>/=4) screen. Twenty-seven percent of BDI-FS positive patients were diagnosed with depression. Among BDI-FS positive patients, Chinese-speakers were less likely to be diagnosed compared with English speakers (31% vs. 10%, P < 0.05). There was a trend towards greater diagnosis with RSMI (27% detection with RSMI vs. 20% U&C, P = 0.41). The diagnosis of depression among BDI-FS positive patients in our population was low, particularly among Chinese-speakers. RSMI could be an important part of a multi-faceted approach to improving the detection of depression

Over 22 million US residents are limited English proficient. Hospitals often call upon untrained persons to interpret. There is a dearth of information on errors in medical interpreting and their impact upon cancer education. We conducted an experimental study of standardized medical interpreting training on interpreting errors in the cancer encounter, by comparing trained and untrained interpreters, using identical content. Nine interpreted cancer encounters with identical scripts were recorded and transcribed. Using an 'Error Analysis Tool,' a bilingual linguist and two bilingual medical providers scored the transcripts for interpreting errors made, including their potential clinical severity. Trained interpreters were 70% less likely to have clinical errors than untrained ones. The likelihood of medical error increased with the length of the concept and decreased with the precision of vocabulary. It is important to train medical interpreters and to ensure their availability in cancer education encounters to minimize the risk for errors

BACKGROUND: Hypertension is the major risk factor for cardiovascular (CV) disease such as myocardial infarction (MI) and stroke. This risk is well known to extend into the perioperative period. Although most perioperative hypertension can be managed with the patient's outpatient regimen, there are situations in which oral medications cannot be administered and parenteral medications become necessary. They include postoperative nil per os status, severe pancreatitis, and mechanical ventilation. This article reviews the management of perioperative hypertensive urgency with parenteral medications. METHODS: A PubMed search was conducted by cross-referencing the terms 'perioperative hypertension,' 'hypertensive urgency,' 'hypertensive emergency,' 'parenteral anti-hypertensive,' and 'medication.' The search was limited to English-language articles published between 1970 and 2008. Subsequent PubMed searches were performed to clarify data from the initial search. RESULTS: As patients with hypertensive urgency are not at great risk for target-organ damage (TOD), continuous infusions that require intensive care unit (ICU) monitoring and intraarterial catheters seem to be unnecessary and a possible misuse of resources. CONCLUSIONS: When oral therapy cannot be administered, patients with hypertensive urgency can have their blood pressure (BP) reduced with hydralazine, enalaprilat, metoprolol, or labetalol. Due to the scarcity of comparative trials looking at clinically significant outcomes, the medication should be chosen based on comorbidity, efficacy, toxicity, and cost

BACKGROUND: The second best conduit for coronary artery bypass graft surgery (CABG) is unclear. We sought to determine if the use of a second arterial conduit, the radial artery (RA), would improve long-term survival after CABG using the left internal thoracic artery (LITA) and saphenous vein (SV). METHODS: We compared the 14-year outcomes in propensity-matched patients undergoing isolated, primary CABG using the LITA, RA, and SV versus CABG using the LITA and only SV. In all, 826 patients from each group had similar propensity-matched demographics and multiple variables. The primary endpoint was all-cause mortality obtained using the Social Security Death Index. RESULTS: Perioperative outcomes including in hospital mortality (0.1% for the RA patients and 0.2% for the SV patients) were similar. Kaplan-Meier survival at 1, 5, and 10 years was 98.3%, 93.9%, and 83.1% for the RA group versus 97.2%, 88.7%, and 74.3% for the SV group (log rank, p = 0.0011). Cox proportional hazards models showed a lower all-cause mortality in the RA group (hazard ratio 0.72, confidence interval: 0.56 to 0.92, p = 0.0084). Ten-year survivals showed a 52% increased mortality for the SV patients (25.7%) versus the RA patients (16.9%; p = 0.0011). For symptomatic patients, RA patency was 80.7%, which was not different than the LITA patency rate of 86.4% but was superior to the SV patency rate of 46.7% (p < 0.001). CONCLUSIONS: Using the LITA, SV, and a RA conduit for CABG results in significantly improved long-term survival compared with using the LITA and SV. The use of two arterial conduits offers a clear and lasting survival advantage, likely due to the improved patency of RA grafts. We conclude that RA conduits should be more widely utilized during CABG

OBJECTIVE: Communication skills are crucial for high-risk behavior screening and counseling. Practicing physicians have limited opportunities to improve these skills. This paper assesses the impact of a continuing medical education (CME) program for Student Health Center clinicians that targeted communication skills, screening practices and patient satisfaction. METHODS: Program evaluation included pre- and post-objective structured clinical examinations (OSCE's), chart review, and provider and patient satisfaction surveys. Data were analyzed using paired t-tests and ranked sum tests. RESULTS: OSCE scores (n=15) revealed significant improvements in communication skills overall (p=0.004) and within specific domains (data gathering: p=0.003; rapport building: p=0.01; patient education: p=0.02), but no change in case-specific knowledge (p=0.1). Participants (n=14) reported high satisfaction with program methods (mean=4.6/5) and content (mean=4.7/5), 70% planning to alter their clinical practice. Chart audits (pre=96, post=103) showed increased screening for smoking (RR 1.65, p=0.03), depressed mood (RR 1.40, p=0.04), anhedonia (RR 1.47, p=0.01), sexual activity (RR 1.73, p=0.002) and drinking (RR 1.77, p=0.04). Sampling of satisfaction among participants' patients (pre n=689, post n=383) detected no increase in already high baseline satisfaction. CONCLUSION: This curriculum improved clinicians' relevant skills and screening behavior. PRACTICE IMPLICATIONS: Skills-oriented CME can improve clinicians' communication skills and screening and counseling practices

To establish guidelines for more effectively incorporating part-time faculty into departments of internal medicine, a task force was convened in early 2007 by the Association of Specialty Professors. The task force used informal surveys, current literature, and consensus building among members of the Alliance for Academic Internal Medicine to produce a consensus statement and a series of recommendations. The task force agreed that part-time faculty could enrich a department of medicine, enhance workforce flexibility, and provide high-quality research, patient care, and education in a cost-effective manner. The task force provided a series of detailed steps for operationalizing part-time practice; to do so, key issues were addressed, such as fixed costs, malpractice insurance, space, cross-coverage, mentoring, career development, productivity targets, and flexible scheduling. Recommendations included (1) increasing respect for work-family balance, (2) allowing flexible time as well as part-time employment, (3) directly addressing negative perceptions about part-time faculty, (4) developing policies to allow flexibility in academic advancement, (5) considering part-time faculty as candidates for leadership positions, (6) encouraging granting agencies, including the National Institutes of Health and Veterans Administration, to consider part-time faculty as eligible for research career development awards, and (7) supporting future research in "best practices" for incorporating part-time faculty into academic departments of medicine.

AIMS/OBJECTIVE:Long QT syndrome (LQTS), a potentially fatal disorder, has to be distinguished from non-fatal conditions. Our aim was to investigate whether history-taking can be used in identifying patients likely to have LQTS. METHODS AND RESULTS/RESULTS:We compared the characteristics of a group of LQTS patients with syncope patients presenting at the emergency department (ED) and vasovagal patients younger than 40 years of age. Thirty-two LQTS patients were included. We included 113 patients at the ED and 69 vasovagal patients. Family history of syncope, sudden cardiac death, or cardiovascular disease was found more often in LQTS patients. Palpitations were the only symptom reported more often in this group. Syncope while supine, during emotional stress and associated with exercise was also more common among LQTS. Standing as a trigger was found more often in ED and vasovagal patients. CONCLUSION/CONCLUSIONS:We conclude that a family history for syncope and sudden cardiac death, palpitations as a symptom, supine syncope, syncope associated with exercise, and emotional stress place patients at higher risk for LQTS. These findings should alert physicians to the potentially life-threatening illness of LQTS, and act accordingly by obtaining an electrocardiogram and paying specific attention to the QT interval.

BACKGROUND:Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care. OBJECTIVE:To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care. DESIGN/METHODS:Cross-sectional analysis. SETTING/METHODS:119 ambulatory clinics in New York, New York, and in the upper Midwest. PARTICIPANTS/METHODS:422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure. MEASUREMENTS/METHODS:Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits). RESULTS:More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors. LIMITATION/CONCLUSIONS:The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician. CONCLUSION/CONCLUSIONS:Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.