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This American College of Physicians position paper aims to inform ethical decision making surrounding participation in short-term global health clinical care experiences. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and should inform how institutions, organizations, and others structure short-term global health experiences. The primary goal of short-term global health clinical care experiences is to improve the health and well-being of the individuals and communities where they occur. In addition, potential benefits for participants in global health include increased awareness of global health issues, new medical knowledge, enhanced physical diagnosis skills when practicing in low-technology settings, improved language skills, enhanced cultural sensitivity, a greater capacity for clinical problem solving, and an improved sense of self-satisfaction or professional satisfaction. However, these activities involve several ethical challenges. Addressing these challenges is critical to protecting patient welfare in all geographic locales, promoting fair and equitable care globally, and maintaining trust in the profession. This paper describes 5 core positions that focus on ethics and the clinical care context and provides case scenarios to illustrate them.

An Innovative Program to Support Gender Equity and Success in Academic Medicine: Early Experiences From the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists

Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of Physicians

Much of what is formally taught in medicine is about the knowledge, skills, and behaviors required of a physician, including how to express compassion and respect for patients at the bedside. What is learned, however, includes not only admirable qualities but also behaviors and qualities that are inconsistent with ethics and professionalism. Positive role models may reinforce the character and values the profession seeks to cultivate; negative ones directly contradict classroom lessons and expectations of patients, society, and medical educators. These positive and negative lessons, which are embedded in organizational structure and culture, are the hidden curricula conveyed in medical schools, residency programs, hospitals, and clinics. This position paper from the American College of Physicians focuses on ethics, professionalism, and the hidden curriculum. It provides strategies for revealing what is hidden to foster the development of reflective and resilient lifelong learners who embody professionalism and clinicians who are, and are perceived as, positive role models. Making the hidden visible and the implicit explicit helps to create a culture reflecting medicine's core values.

American Health Is Global Health

Associations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set (HEDIS) Process Measures

Background: The value of the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program has been questioned as a marker of physician quality. Objective: To assess whether physician MOC status is associated with performance on selected Healthcare Effectiveness Data and Information Set (HEDIS) process measures. Design: Annual comparisons of HEDIS process measures among physicians who did or did not maintain certification 20 years after initial certification. Setting: Fee-for-service Medicare. Participants: 1260 general internists who were initially certified in 1991 and provided care for 85 931 Medicare patients between 2009 and 2012. Measurements: Annual percentage of a physician's Medicare patients meeting each of 5 HEDIS annual or biennial standards and a composite indicating meeting all 3 HEDIS diabetes standards. Results: Among the 1260 physicians, 786 maintained their certification from 1991 to 2012 and 474 did not. The mean annual percentage of HEDIS-eligible diabetic patients who completed semiannual hemoglobin A1c testing was 58.4% among physicians who maintained certification and 54.4% among those who did not (regression-adjusted difference, 4.2 percentage points [95% CI, 2.0 to 6.5 percentage points]; P < 0.001). Diabetic patients of physicians who maintained certification more frequently met the annual standard for low-density lipoprotein (LDL) cholesterol measurement (83.1% vs. 80.5%; regression-adjusted difference, 2.3 percentage points [CI, 0.6 to 4.1 percentage points]; P = 0.008) and all 3 diabetic standards (46.0% vs. 41.6%; regression-adjusted difference, 3.1 percentage points [CI, 0.5 to 5.7 percentage points]; P = 0.019). The regression-adjusted difference in biennial eye examinations was statistically insignificant (P = 0.112). Measures for LDL cholesterol testing in patients with coronary heart disease and biennial mammography were also met more frequently among physicians who maintained certification (79.4% vs. 77.4% and 72.0% vs. 67.8%, respectively), with regression-adjusted differences of 1.7 percentage points (CI, 0.2 to 3.3 percentage points; P = 0.032) and 4.6 percentage points (CI, 2.9 to 6.3 percentage points; P < 0.001), respectively. Limitation: Potential confounding by unobserved patient, physician, and practice characteristics; inability to determine clinical significance of observed differences. Conclusion: Maintaining certification was positively associated with physician performance scores on a set of HEDIS process measures. Primary Funding Source: American Board of Internal Medicine.

“I Haven't Time to Write”: Martha May Eliot and American Medical Education Reform

“We are up to our eyes in work. I have about 32 children tonight all with some contagious disease, if not two, and several very sick!” wrote Dr. Martha May Eliot to her parents in 1920, adding, “The hospital is full almost to overflowing and still they come.” Eliot, who would go on to become an influential American pediatrician and public health authority, as well as the head of the Federal Children's Bureau, wrote her parents frequently during the course of her education at Radcliffe College (Cambridge, Massachusetts), Bryn Mawr College (Bryn Mawr, Pennsylvania), Johns Hopkins Medical School (Baltimore, Maryland), Peter Bent Brigham Hospital (Boston, Massachusetts), St. Louis Children's Hospital (St. Louis, Missouri), and Yale University Medical School (New Haven, Connecticut). Through these letters, she detailed her experience as a woman professional at elite institutions during a key transformative period in U.S. medicine. This article uses Eliot's collection of correspondence to shed light on physicians' experience of the increasingly rigorous training, testing, and licensing processes introduced in top medical schools and to offer insights into the history of women's medical education and experience in building careers as academic professionals during that time. Eliot's letters also illustrate how the newer, higher standards for medical graduates and postgraduates may have hastened—rather than hindered—the progress of some elite women in the medical profession. Today's physicians and medical educators, as well as those completing graduate training, will find much to draw on from the experience revealed by this rich epistolary archive.

Hearing Health Care: Review of a Report From the National Academies of Sciences, Engineering, and Medicine

Diagnosis of Acute Gout: A Clinical Practice Guideline From the American College of Physicians

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the diagnosis of gout. Methods: This guideline is based on a systematic review of published studies on gout diagnosis, identified using several databases, from database inception to February 2016. Evaluated outcomes included the accuracy of the test results; intermediate outcomes (results of laboratory and radiographic tests, such as serum urate and synovial fluid crystal analysis and radiographic or ultrasonography changes); clinical decision making (additional testing and pharmacologic or dietary management); short-term clinical (patient-centered) outcomes, such as pain and joint swelling and tenderness; and adverse effects of the tests. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Target Audience and Patient Population: The target audience for this guideline includes all clinicians, and the target patient population includes adults with joint inflammation suspected to be gout. Recommendation: ACP recommends that clinicians use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. (Grade: weak recommendation, low-quality evidence)

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