Annals of internal medicine
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There has been considerable change in the practice of internal medicine in the past quarter century, including the rise of specialization, increasing time pressure, the hospitalist movement, and the rapidly changing responsibilities of internists in inpatient and outpatient settings. Training programs have not adequately responded to these trends, and there is a consensus that the residency education system urgently needs redesign.
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The American College of Physicians supports the need for reform throughout the continuum of training in internal medicine. Today's internists must have the necessary knowledge, skills, and attitudes to meet the challenges of an expanding body of medical knowledge and a rapidly evolving system of health care delivery. Suggested priorities for undergraduate medical education include redesigning curricular experiences to afford students earlier and more exposure to career opportunities in internal medicine, improving ambulatory education, exposing students to outstanding faculty role models in internal medicine, and incorporating educational experiences during the fourth year that optimize its value and relevance to the student's future career plans in internal medicine. ⋯ The ambulatory component of training requires substantial reform in its structure, sites, content, and timing. Team-based models should be used both for patient care and for flexibility in design of residency training. Better faculty models must be developed that build on the concept of a "core faculty," improve the rewards for teaching faculty, and provide appropriate faculty development focusing on a necessary set of educator competencies.
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Randomized Controlled Trial
Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous?
Because coronary perfusion occurs mainly during diastole, patients with coronary artery disease (CAD) could be at increased risk for coronary events if diastolic pressure falls below critical levels. ⋯ The risk for the primary outcome, all-cause death, and MI, but not stroke, progressively increased with low diastolic blood pressure. Excessive reduction in diastolic pressure should be avoided in patients with CAD who are being treated for hypertension.