Journal of general internal medicine
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After five decades of growth that has included advances in medical education and health care delivery, value cohesion, and integration of diversity, we propose an overarching mission for academic general internal medicine to lead excellence, change, and innovation in clinical care, education, and research. General internal medicine aims to achieve health care delivery that is comprehensive, technologically advanced and individualized; instills trust within a culture of respect; is efficient in the use of time, people, and resources; is organized and financed to achieve optimal health outcomes; maximizes equity; and continually learns and adapts. This mission of health care transformation has implications for the clinical, educational, and research activities of divisions of general internal medicine over the next several decades.
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The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice. ⋯ The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.
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Clinical practice guidelines aim to improve the health of patients by guiding individual care in clinical settings. Many guidelines specifically about health promotion or primary disease prevention are beginning to support informed patient choice, and suggest that clinicians and patients engage in shared discussions to determine how best to tailor guidelines to individuals. However, guidelines generally do not address how to translate evidence from the population to the individual in clinical practice, or how to engage patients in these discussions. ⋯ SDM can be used even in situations with strong evidence for benefits at the level of the population, by helping patients and clinicians prioritize behaviors during time-pressured medical encounters. Involving patients in discussions could lead to improved health through better adherence to chosen options, reduced practice variation about preference-sensitive options, and improved care more broadly. However, more research is needed to determine the impact of this approach on outcomes such as morbidity and mortality.
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Little is known about the healthcare experiences of adults on the autism spectrum. Moreover, autistic adults have rarely been included as partners in autism research. ⋯ A CBPR approach may facilitate the inclusion of people with disabilities in research by increasing researchers' ability to create accessible data collection instruments. Autistic adults who use the Internet report experiencing significant healthcare disparities. Efforts are needed to improve the healthcare of autistic individuals, including individuals who may be potentially perceived as having fewer disability-related needs.
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Telemedicine can facilitate communication between primary care clinicians and specialists. Generalists who use telemedicine for consultation (teleconsultation) may be able to practice more independently and reduce the number of formal referrals to specialists. In the United States, a federally funded human immunodeficiency virus (HIV) teleconsultation service (HIV Warmline) offers clinicians live telephone access to HIV specialists; however, its impact on clinicians' self-perceived clinical competence and referral rates has not been studied. ⋯ Primary care clinicians who called the HIV Warmline reported increased confidence in their HIV care and less need to refer patients to specialists. Teleconsultation may be a powerful tool to help consolidate HIV care in the primary care setting, and could be adapted for use with a variety of other medical conditions. The direct impact of teleconsultation on actual referral rates, quality of care and clinical outcomes needs to be studied.