In the News for the Week of 3-21-06
- Internal medicine holds its own but threat to primary care continues
Clinical news in the headlines
- Annals: Smoking, a middle-aged killer; breast-cancer prevention strategies
- Lifelong treatment may be needed for depressed elderly
- Widely prescribed sleep aid prompts complaints of sleepwalking
- Study finds physician feedback leads to better diabetes control
- Physicians can use CMS practice performance data for MOC credit
- College CEO to address information technology conference
- Blood donors needed at Annual Session 2006
Results from last week’s National Resident Matching Program (NRMP) indicate a stable number of U.S. medical school graduates entering internal medicine residency training programs. However, data from third-year internal medicine residents indicate a continuing trend for those residents to pursue medical subspecialties over primary care.
While the number of U.S. medical students matched to categorical internal medicine training programs was almost the same as last year (2,668 vs. 2,659 in 2005), fewer students are expressing interest in primary care as a career, a March 16 College news release stated. According to Steven E. Weinberger, FACP, the College’s Senior Vice President for Medical Education and Publishing, data from residency questionnaires administered in 2005 found that only 20% of residents graduating this year were planning careers in internal medicine, compared with 54% in 1998.
Overall, 26,715 applicants participated in the Match, more than 15,000 of whom were U.S. seniors, according to a March 16 NRMP news release. The remaining applicants were made up of physicians who have already graduated, osteopathic students and physicians, and non-U.S. medical school graduates.
Internal medicine is the largest specialty in the Match, accounting for almost 22% of available first-year residency positions, and 98% of those positions were filled, said the NRMP release. However, the number of available positions in internal medicine has declined from 4,810 in 2000 to 4,735 this year, and only 56% of those positions were filled by U.S. seniors compared with 59% in 2002.
Other Match highlights included:
There were 50 fewer family practice positions available this year, but the percentage filled increased to 85% from 82% last year.
There was a 7% increase in the number of U.S. medical school graduates entering combined medicine-pediatrics programs.
Otolaryngology, new to the Match this year, filled 98% of its available positions, with 92% of those filled by U.S. seniors.
Interest in obstetrics/gynecology positions increased, with 98% of positions filled compared with 94% in 2002. U.S. seniors filled 72% of those slots, up from 68% in 2002.
Students showed increased interest in “lifestyle” specialties, filling 100% of first-year positions in dermatology (93% by U.S. seniors) and 97% of available positions in anesthesiology (80% by U.S. seniors).
The NRMP press release is online.
The ACP news release is online.
Clinical news in the headlines
The following articles appear in the March 21 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Smoking strongly increases risk of death in middle age. A new study that followed 50,000 people for 25 years found that 41% of the male heavy smokers died during middle age compared to 14% of their non-smoking counterparts. Researchers also found that 26% of female heavy smokers died compared to 9% of the non-smoking women. The study is the largest and longest of smoking habits and consequences that includes both sexes.
The study also found that the longer people delay smoking, the less chance they'll die at a younger age, and that the earlier smokers quit, the greater their benefits for health and longevity.
Study examines cost-effectiveness of six breast-cancer preventive strategies. Researchers using a computer model as well as published information on the costs and benefits of breast-cancer prevention strategies compared six different interventions for disease-free women who carry a single BRCA1 or BRCA2 gene mutation.
The interventions considered were oral contraceptives, which appear to reduce ovarian-cancer risk; tamoxifen, which appears to reduce breast- cancer risk; surgical removal of both ovaries (oophorectomy); surgical removal of both breasts; surgical removal of breasts and ovaries; or no preventive measures (surveillance or watchful waiting).
The decision model found that oophorectomy was the most cost-effective strategy for BRCA1 carriers. For women with the BCRA2 gene mutation, combined preventive oophorectomies and mastectomies were more cost- effective than removing the ovaries alone. Either treatment was less costly and more effective than mastectomy alone, tamoxifen or surveillance.
Elderly patients treated for depression were less likely to suffer a recurrence when they received maintenance therapy with an antidepressant vs. receiving counseling alone, a new study suggests.
In the study, 116 patients age 70 or older who had previously responded to short-term antidepressant treatment were assigned to receive either paroxetine or placebo combined with either monthly psychotherapy or clinical-management sessions for two years.
Among patients taking paroxetine and psychotherapy, 35% suffered a recurrence compared with 68% of those receiving placebo and therapy. The study appears in the March 16 New England Journal of Medicine (NEJM).
The results emphasize that many elderly depressed patients can be maintained for at least two years with a combination of psychotherapy, drugs and case management, said the March 16 New York Times. However, most patients receive only an antidepressant prescription, noted the article, if they are treated at all.
The findings have implications for how physicians treat depression in the elderly, an accompanying NEJM editorial pointed out. The study demonstrates that depression can be chronic even among people with no history of depression, as some patients in the study had their first episode at age 70 or older. The editorial also questions the common practice of stopping antidepressant therapy after six to 12 months.
While patients who fared the best in this study received drugs plus psychotherapy, other non-pharmacologic approaches have also proven effective, the editorial said. For example, exercise and increased social activities can be reasonable first-line treatments for mild-to-moderate depression.
The findings also suggest that periodic evaluation is critical for elderly patients who have recovered from an episode of major depression, said the editorial. Even if they do not need lifelong treatment with antidepressants, they should receive ongoing follow-up care.
The New York Times is online.
A widely used sleep aid has sparked concerns about sleepwalking and other unusual behaviors among people prescribed the drug.
Cases of sleepwalking related to use of zolpidem tartrate (Sanofi-Aventis’s Ambien) have been reported in medical journals and by sleep experts, said the March 14 Washington Post. Some patients also have reported evidence of nocturnal eating after taking the drug, the article said, and of having no memory of those incidents when they awake.
The drug, which accounted for more than 24 million prescriptions in 2004, has prompted more sleepwalking reports to the FDA than all other sleep medications combined, said the Washington Post. In addition, five cases were reported in a 2002 edition of the journal Sleep Medicine while researchers at the Minnesota Regional Sleep Disorders Center reported 19 cases at a medical conference last year.
The drug’s label acknowledges somnambulism as a rare but potential side effect, along with other potential central nervous system effects, that have been reported in fewer than one in 1,000 patients, said the article. Zolpidem tartrate is among a group of newer sleep aids that are considered safer and less addictive than older drugs, the Washington Post reported, adding that the FDA did not raise questions about the side effects before approving the drug in 1993.
The FDA adverse event report databases show that 207 somnambulism reports were made between 1997 and June 2005, said the Washington Post. Most physicians reporting the episodes listed the cause as unknown but 48 linked them to zolpidem tartrate. By comparison, there were 18 reports filed about benzodiazepines, an older class of sleep aids that includes six drugs.
The Washington Post is online.
Physicians given computerized feedback on how well they managed diabetic patients’ blood glucose levels were more likely to prescribe appropriate therapy, a new study found.
In the three-year study, researchers randomly assigned 345 internal medicine residents treating mostly African-American patients to usual care or groups that received computerized reminders and/or feedback regarding blood glucose management in diabetics. Whenever glucose levels exceeded 150 mg/dL, physicians were assessed as to whether they “did nothing,” “did anything” or “did enough” (to meet recommendations).
At baseline, 35% of physicians fell into the “did anything” group while 21% were characterized as “did enough.” But after three years, 52% of those who received feedback every two weeks “did anything” and 30% “did enough.” The results appear in the March 13 Archives of Internal Medicine.
Since HbA1c levels in diabetes patients have been rising in the U.S., physicians may be failing to intensify therapy when indicated, the authors noted. The findings indicate that individualized feedback given to physicians can lead to reduced HbA1c levels and improvements in overall outcomes for diabetics.
The Archives of Internal Medicine abstract is online.
ACP and the ABIM announced last week that physicians enrolled in ABIM's maintenance of certification program can now use CMS performance data to receive credit toward meeting ABIM's practice performance self-assessment requirement.
The CMS performance data would be provided to physicians participating in the agency's Physician Voluntary Reporting Program, a voluntary quality-improvement reporting program that targets conditions like diabetes, congestive heart failure and coronary artery disease. The CMS, which launched the program at the beginning of this year, should begin sending feedback to participating physicians later this spring.
Recertification candidates typically fulfill that requirement by entering clinical data from patient records into an ABIM practice improvement module (PIM). The ABIM's self-directed practice improvement module will now allow candidates to enter clinical results provided by the CMS, eliminating the need for physicians to review patient records.
"ACP is pleased to see CMS and ABIM working together to increase the value and reduce the burden that internists face, as they respond to multiple requests for data that describe their practice results," said John Tooker, FACP, the College's Executive Vice President and Chief Executive Officer, in the release.
Internists who complete the PIM receive credit toward maintenance of certification as well as continuing medical education credits.
More information is online.
For more information on the CMS program, see "CMS initiative paves way for physician pay-for-reporting," in the January-February ACP Observer.
John Tooker, FACP, ACP's Executive Vice President and Chief Executive Officer, will be a key speaker at the third annual conference of eHealth Initiative (eHI), to be held in Washington April 10-11.
Dr. Tooker, who will give opening remarks as well as lead a discussion on health information exchange, will join the slate of national health information technology experts presenting at the "Connecting Communities Learning Forum and Exhibition." The program will also feature sessions with pioneering state, regional and community collaborators on lessons learned, best practices and practical insights into health information technology, including organizational, clinical, financial, legal and technical factors. eHealth is one of the country's leading organizations working to improve health care quality, safety and efficiency through the use of information technology.
The conference will bring hundreds of public and private sector leaders from around the country to Capitol Hill. Registrants will learn how to apply a number of recently released practical tools and guides designed to immediately support information technology implementation and use.
Registration is open. Further information is online.
The American Red Cross will hold a blood drive during Annual Session 2006 in Philadelphia.
The event, endorsed by ACP's Council of Associates and the Volunteerism Subcommittee, will be held in Hall D of the Pennsylvania Convention Center from 9:30 a.m.-3:30 p.m., Friday, April 7.
Please sign up online or onsite at the drive.
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Copyright 2006 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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