Journal of General Internal Medicine

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities. Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care. This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention. Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study. Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment. Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test. The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests. Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.

BACKGROUND: Hepatitis C virus (HCV) infection is both prevalent and undertreated. OBJECTIVE: To identify barriers to HCV treatment in primary care practice. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: A cohort of 208 HCV-infected patients under the care of a primary care physician (PCP) between December 2001 and April 2004 at a single academically affiliated community health center. MEASUREMENTS: Data were collected from the electronic medical record (EMR), the hospital clinical data repository, and interviews with PCPs. MAIN RESULTS: Our cohort consisted of 208 viremic patients with HCV infection. The mean age was 47.6 (±9.7) years, 56% were male, and 79% were white. Fifty-seven patients (27.4% of the cohort) had undergone HCV treatment. Independent predictors of not being treated included: unmarried status (adjusted odds ratio [aOR] for treatment 0.36, P=.02), female gender (aOR 0.31, P=.01), current alcohol abuse (aOR 0.08, P=.0008), and a higher ratio of no-shows to total visits (aOR 0.005 per change of 1.0 in the ratio of no-shows to total visits, P=.002). The major PCP-identified reasons not to treat included: substance abuse (22.5%), patient preference (16%), psychiatric comorbidity (15%), and a delay in specialist input (12%). For 13% of the untreated patients, no reason was identified. CONCLUSIONS: HCV treatment was infrequent in our cohort of outpatients. Barriers to treatment included patient factors (patient preference, alcohol use, missed appointments), provider factors (reluctance to treat past substance abusers), and system factors (referral-associated delays). Multimodal interventions may be required to increase HCV treatment rates.

Idiopathic hypereosinophilic syndrome is an uncommon leukoproliferative systemic disorder characterized by the overproduction of eosinophils and poor prognosis. A major source of morbidity and mortality of this syndrome is the associated cardiac involvement represented by endocardial thickening and mural thrombi. We report a 64-year-old woman with persistent symptoms of heart failure despite standard medical therapy. Echocardiography revealed reduced left ventricular filling due to a large apical mass; an abnormal diastolic filling pattern was also noticed. Complete blood count revealed remarkable hypereosinophilia. Cardiac magnetic resonance imaging demonstrated an apical thrombus and intense linear enhancement of the endocardium, which were compatible with Löffler endocarditis. Medical therapy, including corticosteroids and anticoagulation, was initiated promptly. The symptoms improved as the peripheral hypereosinophilia resolved in 15 days. The patient was asymptomatic at the 1-year follow-up visit with complete regression of the apical thrombus and no evidence of restrictive cardiomyopathy. We report this case to draw attention to this particularly rare condition with poor prognosis since quick and accurate diagnosis and prompt initiation of therapy may improve symptoms and survival.

Videotapes, through vividly displayed clinical images and teaching interactions, are valuable tools for both learners and teachers. Visual images in combination with verbal instruction have been shown to significantly increase recall and retention. Many clinicians and medical teachers are aware of videotape resources, but have not had a chance to develop their use in medical education. In this paper, we discuss creative applications of videotapes in three major categories: presenting information, triggering discussion, and as a tool for direct self-observation and feedback. Videotapes may be valuable for presenting information in settings of didactic instruction; for triggering discussion during teaching workshops; and for self-observation of patient-doctor interactions and learner-teacher encounters. The article presents learner-centered approaches to review a videotaped clinical encounter in order to enhance value and comfort for the learner and teacher. Sources of tapes include on-site videotaping, published educational tapes and commercial tapes shown in accordance with fair use guidelines, examples of which are referenced. Videotapes add another dimension to traditional sources of physician education.

Single disciplinary management of patients with vertigo and dizziness is an important challenge for most physicians in China. To assess the impact of a new paradigm of practice (Clinic for Vertigo and Dizziness, CVD) performed by a multidisciplinary team (MDT) on diagnostic spectrum, medical costs, and patient satisfaction. Retrospective before-after study. Sample of 29,793 patients with vertigo/dizziness as primary complaint. Changes in diagnostic spectrum, medical costs, and patient satisfaction before and after the establishment of a CVD based on a 4-year database in three tertiary hospitals in northwestern China. The most common diagnoses of patients with vertigo and dizziness were Meniere’s disease (25.77%), cervical disease (25.00%), cerebral vascular disease (13.96%), vestibular syndrome (10.57%), and other etiologies (6.34%) before the CVD establishment. In contrast, after the CVD establishment, the most common diagnoses were BPPV (23.92%), vestibular migraine (15.83%), Meniere’s disease (14.22%), CSD/PPPD (11.61%), and cerebral vascular diseases (4.45%). Extended implementation of a structured questionnaire for vertigo/dizziness and vestibular-oriented examinations (nystagmus, positional tests, HINTS) at the CVD resulted in a remarkable decline in the utility of CT/MRI and X-ray examination (p < 0.001). Meanwhile, medical costs in patients with vertigo/dizziness dropped by 11.5% (p < 0.001), with a significant improvement in patient satisfaction after the establishment of CVD (p < 0.001). Our study suggested that the MDT paradigm of CVD practice may facilitate the medical management of patients with vertigo/dizziness and improve patient satisfaction.

OBJECTIVE: To improve the quality and specificity of written evaluations by faculty attendings of internal medicine residents during inpatient rotations. DESIGN: Prospective randomized controlled trial. SETTING: Four hospitals: tertiary care university hospital, Veterans’ Administration hospital, and two community hospitals. PARTICIPANTS: Eighty-eight faculty and 157 residents from categorical and primary-care internal medicine residency training programs rotating on inpatient general medicine teams. INTERVENTION: Focused 20-minute educational session on evaluation and feedback, accompanied by 3 by 5 reminder card and diary, given to faculty at the start of their attending month. MEASUREMENTS AND MAIN RESULTS: Primary outcomes: 1) number of written comments from faculty specific to unique, preselected dimensions of competence; 2) number of written comments from faculty describing a specific resident behavior or providing a recommendation; and 3) resident Likert-scale ratings of the quantity and effect of feedback received from faculty. Faculty in the intervention group provided more written comments specific to defined dimensions of competence, a median of three comments per evaluation form versus two in the control group, but when adjusted for clustering by faculty, the difference was not statistically significant (P=.09). Regarding feedback, residents in the intervention group rated the quantity significantly higher (P=.04) and were significantly more likely to make changes in clinical management of patients than residents in the control group (P=.04). CONCLUSIONS: A brief, focused educational intervention delivered to faculty prior to the start of a ward rotation appears to have a modest effect on faculty behavior for written evaluations and promoted higher quality feedback given to house staff.

Financial burden can affect healthcare utilization. Few studies have assessed the short-term associations between material (debt, trouble paying rent) and psychological (worry or distress about affording future healthcare) financial risks, and subsequent outpatient and emergency healthcare use. Worry was defined as concerns about affording future healthcare. Examine whether worry about affording healthcare is associated with healthcare utilization when controlling for material risk and general anxiety Longitudinal observational study Kaiser Permanente members with exchange-based federally subsidized health insurance (n = 450, 45% response rate) Survey measures of financial risks (material difficulty paying for medical care and worry about affording healthcare) and general anxiety. Healthcare use (primary care, urgent care, emergency department, and outpatient specialty visits) in the 6 months following survey completion. Emergency department and primary care visits were not associated with material risk, worry about affording care, or general anxiety in individual and pooled analyses (all 95% confidence intervals (CI) for relative risk (RR) included 1). Although no individual predictor was associated with urgent care use (all 95% CIs for RR included 1), worry about affording prescriptions (relative risk (RR) = 2.01; 95% CI 1.14, 3.55) and general anxiety (RR = 0.38; 95% CI 0.15, 0.95) were significant when included in the same model, suggesting the two confounded each other. Worry about affording healthcare services was associated with fewer specialty care visits (RR = 0.40; 95% CI 0.25, 0.64) even when controlling for material risk and general anxiety, although general anxiety was also associated with more specialty care visits (RR = 1.98; 95% CI, 1.23, 3.18). Screening for both general anxiety and financial worry may assist with specialty care utilization. Identifying these concerns may provide more opportunities to assist patients. Future research should examine interventions to reduce worry about cost of care.