Established in 1927 by the American College of Physicians


20 July 2010 Annals of Internal Medicine Tip Sheet

Below is information about two early online releases and two articles being published in the July 6 issue of Annals of Internal Medicine. The information is not intended to substitute for articles as sources of information. Annals of Internal Medicine attribution is required for all coverage. For an embargoed copy of a study, contact Angela Collom at or 215-351-2653.

1. Will Patient Access to Doctor’s Notes Lead to Improved Care?

Researchers Strive to Answer Question Through OpenNotes Pilot Program
This summer, a team of 100 primary care physicians across the country will embark on the “OpenNotes” initiative. OpenNotes will give 25,000 patients the chance to read doctors’ notes on their medical records via a secure Internet portal. The pilot program is designed to determine if access to notes will result in improved doctor-patient communication. For doctors, notes serve as a reminder of the unique characteristics of the patient, their medical history, and their care. For patients, doctors’ notes may help to clarify issues or explain care approaches. The hope is that inviting patients to review their notes could improve their understanding of their health, foster productive communication, stimulate shared decision making, and ultimately lead to better outcomes. However, some fear that patient access to physicians’ notes could have negative consequences, such as confusing or worrying patients. The program will be evaluated primarily through web-based surveys. Researchers believe that if the pilot goes well, OpenNotes could become the standard in years to come. Readers can take a survey to provide their thoughts about OpenNotes at the Annals home page

2. Physician Inattention to Patient Contextual Info May Lead to Medical Errors*

When physicians neglect to incorporate information about factors that could complicate care into a patient care plan, medical errors can occur. Complicating factors can be biomedical, such as other medical conditions, or contextual, meaning social issues such as loss of insurance or inability to read instructions. Researchers explored the frequency and circumstances under which physicians probed patients to identify contextual and biomedical complicating factors and the relationship of identifying them to appropriateness of care. Eight trained actors presented as patients to 111 internal medicine attending physicians. During the medical visits, the actors followed scripts that gave hints to biomedical or contextual complicating factors. The researchers reviewed video-taped visits to judge whether physicians responded to the hints about complicating factors and to see whether patients received appropriate care. The researchers judged care as appropriate in 73 percent of uncomplicated, 38 percent of biomedically complicated, 22 percent of contextually complicated, and only 9 percent of dually complicated encounters.
*See for a video that explains how the researchers used standardized patients in their exploration of physician behavior when patients do not present with a straightforward medical problem.

3. Assisted Interventions Can Lead to Better End of Life Care for the Homeless

Few interventions have focused on improving end-of-life (EOL) care for vulnerable populations, including the homeless. Researchers conducted a prospective, single-blind, randomized trial to compare two EOL care interventions for the homeless – individual counseling and assistance in filling out advance directive forms, or a self-guided intervention with advance directive forms and written educational materials. Two hundred and sixty-two homeless persons were randomly assigned to either assisted or self-guided EOL planning. Individual counseling and assistance with filling out advance directive forms significantly increased completion of advance care planning compared with a self-guided completion (38 percent versus 13 percent), showing that adequate support can increase homeless persons’ participation in EOL planning.

4. Technology May Contribute to the Growing Problem of Plagiarism in Medical Residency Applications

While anecdotal reports suggest that some medical residency applications essays contain plagiarized content, there has been no systematic investigation of these claims. Researchers sought to determine the prevalence of plagiarism in a large cohort of residency application essays. The researchers used a computer program to analyze 4,975 residency applications at a single large academic medical center. They found evidence of plagiarism in approximately one in 20 essays, with essays of non-U.S. applicants more likely to demonstrate evidence of plagiarism. The authors implicate the Internet as a contributing factor. Besides making vast amounts of material available for “cut and paste,” evidence shows that students view copying from the Internet as an acceptable practice and not true plagiarism. According to the author of an accompanying editorial, medical residency applications need to change with the times. She writes: “If the integrity of the personal statement is increasingly polluted by Internet samples or hired consultants, perhaps the personal statement is ill-suited to this era and best left to history.”