ACP Physician Peer Coaching - Career & Professional Development Support

Achieve your full potential with ACP’s coaching services. Coaching has a positive impact on physician professional development and fulfillment, well-being, practice performance, and patient outcomes.

Professional Development for Women in Medicine

ACP’s Women in Medicine (WIM) initiative is a member-exclusive, longitudinal program designed to support your career and professional development needs through every stage of your career.

Career and Professional Development for Internal Medicine Physicians

Career and professional development resources and opportunities to support your personal and professional growth and career journey.

Video Visits | ACP

During the COVID pandemic, many patients utilize telemedicine and will continue seeking this option. Learn about incorporating physician video visits into your practice.

Telephone Visits with Patients | ACP

For patients who do not want to utilize video visits, there is an option to telephone with patients. Find the applicable regulations and waivers you need.

Video Visits: Beyond Simple Cases

Learn best practices for conducting virtual physical exams in these recorded presentations. View Additional Telemedicine 201 Education Programs

Teaching Telemedicine in Undergraduate and Graduate Medical Education

In this session, experienced educators will explain why specific training is needed to prepare medical students and residents to practice telemedicine, and will offer practical tools and strategies for teaching and sup

Leveraging Telehealth for Chronic Disease Management in Ambulatory Care

Practicing internists share their experiences using video visits, RPM, and other telehealth modalities to manage patients with chronic diseases. The speakers cover:

Bringing the Team to the Video Visit: Best Practices and Practical Solutions

Make telemedicine more satisfying and effective for patients and physicians by mobilizing your practice team.

Telemedicine 201 Education Program: Moving Beyond Adoption to Optimal Integration Into Practice

Expand your skills and learn from experienced telemedicine educators in this series of free, one-hour webinars. Webinars will be recorded and reproduced as enduring material on this site after each event. Video Visits Beyond Simple Cases Watch the webinar (in short segments), and access video demonstrations of remote physical exam techniques from Johns Hopkins. Watch Videos

Use of Telehealth Among Medical Visits in the United States: Results From the 2021 Medical Expenditure Panel Survey

Census Tract Rurality, Predominant Race and Ethnicity, and Distance to Lung Cancer Screening Facilities: An Ecological Study: Annals of Internal Medicine: Vol 178, No 2

Background: The U.S. Preventive Services Task Force recommends annual lung cancer screening (LCS) for adults who meet specific age and smoking history criteria. Objective: To evaluate race-, ethnicity-, and rurality-based differences in distance to the nearest LCS facility. Design: Cross-sectional ecological study. Setting: U.S. census tracts. Participants: 71 691 census tracts. Measurements: The outcome variable was road network distance in miles between a census tract and the nearest LCS facility. Distance was log-transformed, and geometric means are reported. Census tracts were classified as majority (>50%) American Indian/Alaska Native (AI/AN), Asian, Black, non-Hispanic White (NHW), no single race, or Hispanic. Rurality was defined using the rural-urban commuting area codes. Ordinary least-squares regression examined the associations between distance and census tract race, ethnicity, and rurality. Results: Geometric mean distance to the nearest LCS facility was 6.5 miles. Compared with NHW-majority census tracts, distance to the nearest LCS facility was 5.26 times (426%) longer in AI/AN-majority census tracts and 7% to 39% shorter in Asian-, Black-, and Hispanic-majority census tracts. Adjustment for rurality reduced the mean distance in AI/AN-majority census tracts, but the mean distance was still 3.16 times the distance in NHW-majority census tracts. Adjustment for rurality reduced the observed advantage in Asian- and Black-majority census tracts and changed the direction of associations in Hispanic-majority census tracts. Limitation: Analyses did not account for travel time or cost. Conclusion: Differences exist in distance to LCS facilities by race and ethnicity that can only be partially explained by rurality. Primary Funding Source: Lung Ambition Alliance and the Center for Lung Research in Honor of Wayne Gittinger.

Association Between False-Positive Results and Return to Screening Mammography in the Breast Cancer Surveillance Consortium Cohort

Background: False-positive results on screening mammography may affect women’s willingness to return for future screening. Objective: To evaluate the association between screening mammography results and the probability of subsequent screening. Design: Cohort study. Setting: 177 facilities participating in the Breast Cancer Surveillance Consortium (BCSC). Patients: 3 529 825 screening mammograms (3 184 482 true negatives and 345 343 false positives) performed from 2005 to 2017 among 1 053 672 women aged 40 to 73 years without a breast cancer diagnosis. Measurements: Mammography results (true-negative result or false-positive recall with a recommendation for immediate additional imaging only, short-interval follow-up, or biopsy) from 1 or 2 screening mammograms. Absolute differences in the probability of returning for screening within 9 to 30 months of false-positive versus true-negative screening results were estimated, adjusting for race, ethnicity, age, time since last mammogram, BCSC registry, and clustering within women and facilities. Results: Women were more likely to return after a true-negative result (76.9% [95% CI, 75.1% to 78.6%]) than after a false-positive recall for additional imaging only (adjusted absolute difference, −1.9 percentage points [CI, −3.1 to −0.7 percentage points]), short-interval follow-up (−15.9 percentage points [CI, −19.7 to −12.0 percentage points]), or biopsy (−10.0 percentage points [CI, −14.2 to −5.9 percentage points]). Asian and Hispanic/Latinx women had the largest decreases in the probability of returning after a false positive with a recommendation for short-interval follow-up (−20 to −25 percentage points) or biopsy (−13 to −14 percentage points) versus a true negative. Among women with 2 screening mammograms within 5 years, a false-positive result on the second was associated with a decreased probability of returning for a third regardless of the first screening result. Limitation: Women could receive care at non-BCSC facilities. Conclusion: Women were less likely to return to screening after false-positive mammography results, especially with recommendations for short-interval follow-up or biopsy, raising concerns about continued participation in routine screening among these women at increased breast cancer risk. Primary Funding Source: National Cancer Institute.

Annals Video Summary - Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers for Advanced Chronic Kidney Disease

Glomerular Filtration Estimating Equations and Clinical Outcomes: What Are We Measuring?

Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 177, No 10

Background: The standard salvage technique used for difficult bile duct cannulation is precut sphincterotomy, whereas endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively newer method. Prospective comparative data between these 2 techniques as salvage for biliary access in patients with benign biliary disease and difficult bile duct cannulation is lacking. Objective: To compare EUS-RV and precut sphincterotomy as salvage technique for difficult bile duct cannulation in benign biliary obstruction. Design: Participant-masked, parallel-group, superiority, randomized controlled trial. (Clinical Trials Registry of India: CTRI/2020/07/026613) Setting: Tertiary care academic institute from July 2020 to May 2021. Participants: All patients with benign biliary disease and difficult bile duct cannulation requiring salvage strategy. Intervention: Patients were randomly assigned by computer-generated randomized blocks sequence in 1:1 fashion to either EUS-RV or precut sphincterotomy. Patients with failure in EUS-RV were crossed over to precut sphincterotomy and vice versa. Measurements: The primary outcome measure was technical success. The other outcome measures included procedure time, radiation dose, and adverse events. Results: In total, 100 patients were randomly assigned to EUS-RV (n = 50) and precut sphincterotomy (n = 50). The technical success rate (92% vs. 90%; P = 1.00; relative risk, 1.02 [95% CI, 0.90 to 1.16]), median procedure time (10.1 vs. 9.75 minutes), and overall complication rate (12% vs. 10%; relative risk, 1.20 [CI, 0.39 to 3.68]) were similar between the 2 groups. Five patients (10%) in the EUS-RV group and 5 patients (10%) in the precut sphincterotomy group had developed post–endoscopic retrograde cholangiopancreatography pancreatitis. All failed cases in either salvage group could be successfully cannulated when crossed over to the other group. Limitation: Single center study done by experts. Conclusion: Endoscopic ultrasound-guided rendezvous technique and precut sphincterotomy have similar success rates as salvage techniques in the technically challenging cohort of difficult bile duct cannulation for benign biliary disease, with acceptable complications rates. Primary Funding Source: None.

A Blueprint for U.S. Health Insurance Reform

The current U.S. health insurance “system” was not deliberately planned and constructed but has emerged piecemeal over the past half-century through a series of incremental and haphazard reforms. That policy history also reveals a clear but unfulfilled societal commitment to providing access to essential health care regardless of resources. To fulfill this obligation, the solution proposed in this article has 2 key elements: 1) universal coverage that is automatic, free, and basic, and 2) the option to buy supplemental coverage in a well-designed market. Such a system could, if desired, be created without raising taxes and without disrupting or changing the delivery of medical care.

Artificial Intelligence for Real-Time Prediction of the Histology of Colorectal Polyps by General Endoscopists

Background: Real-time prediction of histologic features of small colorectal polyps may prevent resection and/or pathologic evaluation and therefore decrease colonoscopy costs. Previous studies showed that computer-aided diagnosis (CADx) was highly accurate, though it did not outperform expert endoscopists. Objective: To assess the diagnostic performance of histologic predictions by general endoscopists before and after assistance from CADx in a real-life setting. Design: Prospective, multicenter, single-group study. (ClinicalTrials.gov: NCT04437615) Setting: 6 centers across the United States. Participants: 1252 consecutive patients undergoing colonoscopy and 49 general endoscopists with variable experience in real-time prediction of polyp histologic features. Intervention: Real-time use of CADx during routine colonoscopy. Measurements: The primary end points were the sensitivity and specificity of CADx-unassisted and CADx-assisted histologic predictions for adenomas measuring 5 mm or less. For clinical purposes, additional estimates according to location and confidence level were provided. Results: The CADx device made a diagnosis for 2695 polyps measuring 5 mm or less (96%) in 1252 patients. There was no difference in sensitivity between the unassisted and assisted groups (90.7% vs. 90.8%; P = 0.52). Specificity was higher in the CADx-assisted group (59.5% vs. 64.7%; P < 0.001). Among all 2695 polyps measuring 5 mm or less, 88.2% and 86.1% (P < 0.001) in the CADx-assisted and unassisted groups, respectively, could be resected and discarded without pathologic evaluation. Among 743 rectosigmoid polyps measuring 5 mm or less, 49.5% and 47.9% (P < 0.001) in the CADx-assisted and unassisted groups, respectively, could be left in situ without resection. Limitation: Decision making based on CADx might differ outside a clinical trial. Conclusion: CADx assistance did not result in increased sensitivity of optical diagnosis. Despite a slight increase, the specificity of CADx-assisted diagnosis remained suboptimal. Primary Funding Source: Olympus America Corporation served as the clinical study sponsor.

Comparative Performance of Common Fecal Immunochemical Tests: A Cross-Sectional Study: Annals of Internal Medicine: Vol 177, No 10

Background: Despite widespread use of fecal immunochemical tests (FITs) for colorectal cancer (CRC) screening, data to guide test selection are limited. Objective: To compare the performance characteristics of 5 commonly used FITs, using colonoscopy as the reference standard. Design: Cross-sectional study. (ClinicalTrials.gov: NCT03264898) Setting: Three U.S. academic medical centers and affiliated endoscopy units. Participants: Patients aged 50 to 85 years undergoing screening or surveillance colonoscopy. Intervention: Participants completed 5 different FITs before their colonoscopy, including 4 qualitative tests (Hemoccult ICT, Hemosure iFOB, OC-Light S FIT, QuickVue iFOB) and 1 quantitative test (OC-Auto FIT, which was run at the manufacturer's threshold for positivity of >100 ng/mL). Measurements: The primary outcome was test performance (sensitivity and specificity) for each of the 5 FITs for advanced colorectal neoplasia (ACN), defined as advanced polyps or CRC. Positivity rates, positive and negative predictive values, and rates of unevaluable tests were compared. Multivariable models were used to identify factors affecting sensitivity. Results: A total of 3761 participants were enrolled, with a mean age of 62.1 years (SD, 7.8); 63.2% of participants were female, 5.7% were Black, 86.4% were White, and 28.7% were Hispanic. There were 320 participants with ACN (8.5%), including 9 with CRC (0.2%). The test positivity rate varied 4-fold (3.9% to 16.4%) across FITs. Rates of unevaluable FITs ranged from 0.2% to 2.5%. The sensitivity for ACN varied from 10.1% to 36.7%, and specificity varied from 85.5% to 96.6%. Differences in sensitivity between FITs were all statistically significantly different except between Hemosure iFOB and QuickVue iFOB, and specificity differences were all statistically significantly different from one another. In addition to FIT brand, distal location of ACN was also associated with higher FIT sensitivity. Limitation: The study did not assess the programmatic sensitivity of annual FIT. Conclusion: Although considered a single class, FITs have varying test performance for detecting ACN and should not be considered interchangeable. Primary Funding Source: National Institutes of Health.

A Tale of Three Hospitals

Industry-funded study identifies risk factors for UTI treatment failure

Statin therapy alone does not appear to increase diabetes risk in patients with HIV

Put words in our mouth

Early Bird registration is open for Internal Medicine Meeting 2025

ACP announces 2024-2025 recipients of Mastership and national awards

Abnormal urine protein dipstick results rarely followed up, study finds

MKSAP Quiz: Consultation after cervical cancer diagnosis

Periop cardiovascular guideline updated, calls for avoiding overscreening

Population-based suicide care program yielded 25% reduction in suicide attempts

Put words in our mouth

Take a quiz about the April 23 issue! | ACP Hospitalist

New FDA commissioner sworn in | ACP Hospitalist

Intervention reduced restraint use in older inpatients with cognitive impairment | ACP Hospitalist

Initiation of naltrexone at discharge reduced heavy alcohol use at three months | ACP Hospitalist

Hospital-onset resistant infection rate rose during pandemic, stayed elevated | ACP Hospitalist

Falls common after ICU stays, especially in first three months after discharge | ACP Hospitalist

When AI plays doctor | ACP Hospitalist

Therapeutic anticoagulation improves outcomes in sickle cell ACS vs. prophylactic dose | ACP Hospitalist

The spark of contrast in the kidney | ACP Hospitalist

Take a quiz about the April 16 issue! | ACP Hospitalist

An Unusual Case of an Incidentally Detected Angioplasty Wire in the Aorta | Annals of Internal Medicine: Clinical Cases

A retained angioplasty wire is rarely described, and there are no guidelines as to how it should be managed. Thus the management of this complication remains highly individualized. In the present instance, a 74-year-old woman was found on routine transthoracic echocardiography to have a linear echogenic structure that was initially concerning for a dissection flap. A computed tomography angiogram of the aorta revealed a linear density that followed the curvature of the aortic arch, which was concerning for a retained angioplasty wire from a percutaneous coronary intervention done 11 years earlier. Because the patient had not reported any symptoms, a multidisciplinary decision was made to defer any surgical intervention.

Upper Thoracic Back Pain Due to Acute Calcific Tendinitis of the Longus Colli | Annals of Internal Medicine: Clinical Cases

A 56-year-old woman presented with acute left upper back pain and odynophagia. By thoracic computed tomography, she was diagnosed with acute calcific tendinitis of the longus colli and treated with nonsteroidal anti-inflammatory drugs.

A Case Report of Spontaneous Coronary Artery Dissection | Annals of Internal Medicine: Clinical Cases

Atherothrombosis is the leading cause of acute coronary syndrome (ACS). Spontaneous coronary artery dissection (SCAD) refers to a nonatherosclerotic lesion involving the tearing and splitting of the coronary wall. The creation of a false lumen and blockage of the true lumen generates an oxygenation mismatch in the myocardial tissue. A middle-aged woman with unremarkable medical history developed chest pain. Uptrending cardiac enzymes and electrocardiogram changes prompted further testing. Coronary angiography showed a type 3 SCAD lesion in the left circumflex artery. SCAD lacks the average risk factors of ACS and its recognition can be delayed. On the other hand, it preserves the typical presentation of ACS.

Hemorrhagic Adrenal Mass: A Rare Presentation of Primary Adrenal Choriocarcinoma | Annals of Internal Medicine: Clinical Cases

Choriocarcinoma comprises less than 5% of all germ cell tumors in men, and primary extragonadal manifestation in the adrenal glands is a subset of that low percentage. Primary adrenal choriocarcinoma is a rare yet devastating diagnosis, with few cases reported in men. Delays in diagnosis can lead to increased morbidity and mortality given choriocarcinoma's aggressive growth; therefore, clinicians must recognize this clinical entity and consider it part of the differential diagnosis of a mass in the adrenals, lung, gastrointestinal tract, or brain, and expedite treatment if index of suspicion is high.

Postpartum Recurrent Mastitis Despite Resolution of Prior Prolactinoma | Annals of Internal Medicine: Clinical Cases

We present a 35-year-old woman with history of a prolactinoma who presented 11 weeks postpartum with recurrent mastitis. Per the patient, in the past she took cabergoline but stopped about 5 years previously. Despite attempts to wean, postpartum, she continued to express an excessive amount of breast milk. Magnetic resolution imaging revealed a slightly heterogeneous appearance of the pituitary gland, and she was started on dopaminergic agents. This case demonstrates that significant lactotroph hyperplasia can occur after breastfeeding ends despite the resolution of a prior prolactin-secreting microadenoma.

Transient Perivascular Inflammation of the Carotid Artery Syndrome | Annals of Internal Medicine: Clinical Cases

A previously healthy 52-year-old woman presented with left anterior cervical pain that had persisted for 10 days. Cervical magnetic resonance imaging revealed a high-intensity signal in the region exhibiting short-inversion-time inversion recovery; therefore, the patient was diagnosed with transient perivascular inflammation of the carotid artery (TIPIC) syndrome. TIPIC syndrome is a nonspecific inflammatory finding in the soft tissues surrounding the carotid arteries and should be included in the differential diagnoses of patients with acute anterior cervical pain.

Disseminated Cutaneous Mycobacterium marinum Infection | Annals of Internal Medicine: Clinical Cases

Infection with Mycobacterium marinum has been associated with inhibitors of tumor necrosis factor alpha but rarely reported in patients given golimubab. We report an unusual case of disseminated cutaneous M marinum infection in an immunocompromised patient being treated with this agent.

A Giant Posterior Mediastinal Metastatic Mass of GIST Gastric Origin | Annals of Internal Medicine: Clinical Cases

Gastrointestinal stromal tumors (GISTs) are uncommon visceral sarcomas that predominantly arise from the gastrointestinal tract, particularly from interstitial cells of Cajal. Although the liver is a common site for metastasis, rarely GISTs show extraintestinal manifestation in the bone and lungs. We report a case patient with an uncommon location and unusually large GIST metastasis as a mediastinal mass 3 years after undergoing total gastrectomy and chemotherapy with imatinib, a tyrosine kinase inhibitor.

Uncommon Presentation of Autoimmune Pancreatitis With Refractory Ulcerative Colitis | Annals of Internal Medicine: Clinical Cases

Patients diagnosed with autoimmune pancreatitis (AIP) are at significantly higher risk for ulcerative colitis (UC), and the concurrent diagnoses continue to be a challenge to recognize. A previously healthy symptomatic 23-year-old man was diagnosed with type II AIP with UC and, despite aggressive treatment with steroids and infliximab, ultimately had a total colectomy. This patient case illustrates the association between AIP and UC and proposes that a concomitant diagnosis suggests a worse prognosis. Determining the relationship between these 2 pathologies and early diagnosis will allow physicians to escalate therapy more quickly and improve outcomes in patients.

Severe Retiform Purpura Associated With COVID-19 Infection | Annals of Internal Medicine: Clinical Cases

A healthy, unvaccinated 44-year-old woman developed a severe, diffusely spread, and intensely painful purpuric rash following mild COVID-19 infection. A punch skin biopsy revealed small vessel inflammation and intravascular thrombi consistent with thrombotic leukocytoclastic vasculitis. She was successfully managed with therapeutic anticoagulation, high-dose steroids, intravenous immunoglobulin, and aggressive analgesia. This case highlights an atypical and severe presentation of an uncommon cutaneous manifestation of COVID-19 that has been linked with significant morbidity and mortality.