Journal of General Internal Medicine最新文献

{"title":"No Margin, No Mission? Financialization, Moral Distress, and the Turn Toward Collective Bargaining in Hospital Medicine.","authors":"Aksharananda Rambachan, Anand R Habib, Elizabeth Dzeng","doi":"10.1007/s11606-026-10890-w","DOIUrl":"https://doi.org/10.1007/s11606-026-10890-w","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110662","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Fostering Locally Led Palliative Care Innovation: A Qualitative Evaluation of the SPHERE-Stanford Collaborative Quality Improvement Program.","authors":"Domenica Disalvo, Karleen Giannitrapani, Karl Lorenz, Kim Offner, Sara-Jane Roberts, Sravanthi Puranam, Jake Mickelsen, Michelle DeNatale, Meera Agar","doi":"10.1007/s11606-026-10824-6","DOIUrl":"https://doi.org/10.1007/s11606-026-10824-6","url":null,"abstract":"<p><strong>Background: </strong>Australia is recognized internationally for high-quality palliative care, yet inequities in access, variable service models, and workforce pressures limit safe, effective, and person-centered care. Quality Improvement (QI) approaches offer a practical method for addressing these gaps. To build local QI capability, the Sydney Partnership for Health, Education, Research and Enterprise partnered with Stanford Medicine to implement an evidence-based QI program in seven Australian palliative care services.</p><p><strong>Objective: </strong>To evaluate clinicians' experiences implementing QI projects through the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)-Stanford Medicine Collaborative QI Program and identify barriers and facilitators influencing successful implementation.</p><p><strong>Participants: </strong>Twenty-five participants were interviewed, including team leaders, team members, mentors, and a service director from seven participating teams.</p><p><strong>Approach: </strong>Teams completed a 6-month structured QI curriculum combining virtual workshops, a 2-day in-person intensive, and ongoing mentor support. Semi-structured interviews explored experiences with QI capacity building and implementation. Guided by the Consolidated Framework for Implementation Research, qualitative content analysis identified determinants of implementation success.</p><p><strong>Key results: </strong>The program developed clinicians' QI knowledge and confidence, enabling teams to identify root causes of service challenges, design targeted interventions, and achieve meaningful improvements, including increased palliative care referrals, enhanced care integration, and more consistent documentation practices. Multidisciplinary collaboration, strong team cohesion, and dedicated mentorship were central facilitators. Executive sponsorship and proactive communication promoted stakeholder buy-in and supported adoption of new practices. Key barriers included varying service models, limited resources, workforce turnover, and insufficient awareness of palliative care across partnering services. Despite these challenges, participants viewed the program as a catalyst for ongoing QI work and identified opportunities for scaling and sharing outcomes.</p><p><strong>Conclusions: </strong>The program strengthened QI capability within Australian palliative care services, generating transferable solutions to improve equity, access, and service quality. Further work is needed to support sustainability, disseminate learning, and expand QI capacity across the broader palliative care sector.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110543","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Culling.","authors":"Michael D Stillman","doi":"10.1007/s11606-026-10871-z","DOIUrl":"https://doi.org/10.1007/s11606-026-10871-z","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110755","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Social Needs Screening and Subsequent Acute Care Utilization in a Large Safety-Net Health System: A Retrospective Cohort Study.","authors":"Miaoqing Jia, Hanbo Dong, Kevin Fiori, Elizabeth Adamson, Manyao Zhang, Darren Tanner, William B Weeks, Peter Speyer, Ann Aerts, Yongkang Zhang","doi":"10.1007/s11606-026-10908-3","DOIUrl":"https://doi.org/10.1007/s11606-026-10908-3","url":null,"abstract":"<p><strong>Background: </strong>Health systems increasingly screen for patients' social needs, but evidence is limited on which specific needs are most associated with subsequent acute care use.</p><p><strong>Objective: </strong>To examine associations between patient-reported social needs and subsequent acute care utilization in a large safety-net population.</p><p><strong>Design: </strong>Retrospective cohort study linking 2023 social needs screening data from a large safety-net health system to longitudinal electronic health records from a multi-health system clinical research network.</p><p><strong>Participants: </strong>20,337 adults with a primary care visit who completed social needs screening in 2023.</p><p><strong>Main measures: </strong>Exposures were positive screening for nine social needs domains (e.g., transportation-related delayed care). Outcomes were any hospitalization, any ED visit, preventable hospitalization, and preventable ED visit. Multivariable logistic regression adjusted for demographics, comorbidities, and neighborhood social conditions.</p><p><strong>Key results: </strong>Overall, 15.9% screened positive for ≥ 1 social need. The most prevalent needs were food insecurity (5.9%) and problems with residence (5.6%), followed by housing stability concerns (4.6%) and transportation barriers (4.1%). After covariate adjustment, transportation-related delayed care was associated with a 6.8-percentage-point increase in the probability of having ≥ 1 hospitalization (95% CI, 4.1 to 9.5; p < 0.001), an 8.4-percentage-point increase in the probability of having ≥ 1 ED visit (95% CI, 4.8 to 12.0; p < 0.001), a 1.2-percentage-point increase in the probability of having ≥ 1 preventable hospitalization (95% CI, 0.1 to 2.3; p = 0.04), and a 4.2-percentage-point increase in the probability of having ≥ 1 preventable ED visit (95% CI, 1.6 to 6.7; p = 0.002). A positive screening for housing-related problems was associated with increased probability of having ≥ 1 ED visit. Other domains were not significantly associated with outcomes.</p><p><strong>Conclusions: </strong>In a safety-net setting, transportation barriers showed the strongest and most consistent associations with subsequent acute care use. Targeted transportation and care-navigation strategies may be critical components of social care interventions.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110761","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Impact of Outpatient Documentation Standardization on Internal Medicine Resident Efficiency and Well-Being.","authors":"Eric Kutscher, Douglas Halket, Abigail Feinberg, Cary Blum, Alison Koransky, Ronald Tamler, Alex Federman, Mary Fishman","doi":"10.1007/s11606-026-10858-w","DOIUrl":"https://doi.org/10.1007/s11606-026-10858-w","url":null,"abstract":"<p><strong>Background: </strong>Documentation in the electronic health record (EHR) is frequently cited as a primary reason for burnout among physicians.</p><p><strong>Objective: </strong>To determine if standardization of documentation in the outpatient setting improved resident EHR efficiency and well-being.</p><p><strong>Design: </strong>Pre-post difference-in-differences evaluation of EHR efficiency metrics comparing intervention residents with a historical control group; pre-post survey on well-being for intervention residents.</p><p><strong>Participants: </strong>Fifty-two post-graduate year (PGY) 2 and 55 PGY3 internal medicine residents compared with 55 PGY2 and 49 PGY3 historical controls at an urban academic clinic.</p><p><strong>Intervention: </strong>Standardized documentation templates and medication ordering practices and mandatory training on their use, with incentivized opportunities to practice documentation methods.</p><p><strong>Main measures: </strong>Time spent per appointment in chart review, note writing, and placing orders; length of notes measured in characters; number of characters of text copied from prior notes and pasted into the current note (copy/paste text); Mini-Z well-being survey assessed pre- and post-intervention implementation aggregated for PGY2 and PGY3 residents.</p><p><strong>Key results: </strong>The intervention was associated with an 18.8-min and 12.0-min decrease in per-encounter documentation time for residents during their PGY2 year (p < 0.0001) and PGY3 year, respectively (p < 0.0001). Standardization was associated with a decrease in note length of 3650 characters (43.3%) for PGY2 residents (p < 0.0001) and 1608 characters (17.7%) for PGY3 residents (p < 0.0001), as well as a 66.7% and 74.6% decrease in copy/paste text for PGY2 (p < 0.0001) and PGY3 (p < 0.0001) residents, respectively. Among clinic residents completing pre (N = 42) and post (N = 28) surveys, there were no significant changes in Mini-Z scores, though the single item question on burnout improved from 3.2 pre-intervention to 3.7 post-intervention (p = 0.01).</p><p><strong>Conclusions: </strong>Documentation standardization was associated with significant decreases in documentation time per visit, note length, and percentage of copy-paste text among PGY2 and PGY3 resident physicians. No change was detected on well-being metrics; however, analysis was limited by low response rate to well-being questions.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110911","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Autonomy Trap: When Respect for Choice Becomes Withdrawal of Professional Responsibility.","authors":"Carter Winberg, Marat Slessarev","doi":"10.1007/s11606-026-10866-w","DOIUrl":"https://doi.org/10.1007/s11606-026-10866-w","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110733","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Does Intensive Therapy Targeting Modifiable Risk Factors Prevent Diabetic Neuropathy in Adults with Type 2 Diabetes? A Systematic Review and Meta-analysis of Randomized Clinical Trials.","authors":"Alana L Sheehan, Jordan M O'Malley, Sophia Gunawan, Gregory Laynor, Andrew Nicholson, Nicholas Illenberger, Sundar Natarajan","doi":"10.1007/s11606-026-10801-z","DOIUrl":"https://doi.org/10.1007/s11606-026-10801-z","url":null,"abstract":"<p><strong>Background: </strong>Diabetic peripheral neuropathy (DPN) is a serious complication of type 2 diabetes (T2DM). Guidelines recommend targeting modifiable risk factors for primary prevention, but their effectiveness is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of interventions targeting modifiable risk factors to prevent DPN in adults with T2D.</p><p><strong>Methods: </strong>We searched PubMed, Embase, and ClinicalTrials.gov databases for RCTs published since 1980 investigating glycemia, lipids, blood pressure (BP), smoking cessation, lifestyle, and multifactorial interventions. Two reviewers independently screened articles; a third reviewer resolved disagreements. Meta-analysis used a random-effects model. Results are reported as odds ratios (ORs) with 95% confidence and prediction intervals.</p><p><strong>Results: </strong>From 1287 identified articles, 863 underwent title/abstract screening, with 41 full-text review, yielding nine studies with extractable data. Eight had low risk of bias (Cochrane RoB 1); one had unclear risk. The glycemic control meta-analysis (n = 5) yielded OR = 0.89 (95% CI 0.66-1.19; prediction interval 0.37-2.15; I² = 77.8%). Sensitivity analysis identified BARI-2D as the dominant heterogeneity source; its removal reduced I² to 23% and narrowed the prediction interval (0.80-1.08). This is clinically explainable: BARI-2D compared insulin-sensitizing versus insulin-providing drug strategies rather than glycemic intensity targets, in patients with coronary artery disease. The four-study analysis showed glycemic control may result in little to no difference in DPN risk (OR 0.93, 95% CI 0.85-1.02). In BARI-2D, an insulin-sensitizing strategy may reduce incident DPN independently of achieved HbA1c (0.84 (95% CI 0.71-0.99)) (low certainty). Single-study evidence suggests that BP-lowering and multifactorial interventions may reduce incident DPN (low certainty).</p><p><strong>Discussion: </strong>Glycemic intensity interventions may result in little to no difference in incident DPN risk. The BARI-2D drug class-specific finding and single-study evidence suggesting benefit from BP-lowering and multifactorial interventions warrant further rigorous research on incident DPN.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110515","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When Patients Have No Ride Home: Addressing Transportation Barriers That Exacerbate Disparities in Access to Timely Diagnostic Colonoscopies.","authors":"Kevin Martz, Catherine S Hwang","doi":"10.1007/s11606-026-10889-3","DOIUrl":"https://doi.org/10.1007/s11606-026-10889-3","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110823","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Chop Wood, Carry Water.","authors":"Samuel Cross","doi":"10.1007/s11606-026-10863-z","DOIUrl":"https://doi.org/10.1007/s11606-026-10863-z","url":null,"abstract":"","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110562","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prioritisation Is Treatment: What Generalists Do When Guidelines Collide.","authors":"Waseem Jerjes, Azeem Majeed","doi":"10.1007/s11606-026-10861-1","DOIUrl":"https://doi.org/10.1007/s11606-026-10861-1","url":null,"abstract":"<p><p>Generalists do not merely implement guidelines; they decide which recommendations matter most, for whom, and in what order. In the era of multimorbidity, polypharmacy, patient complexity, fragmented care, and rising treatment burden, that work is treatment. Disease-specific guidance remains valuable, but it can become unsafe when applied cumulatively without regard to competing risks, uncertainty, treatment burden, functional priorities, and the realities of patients' lives. This Perspective argues that prioritisation should be recognised as a core clinical intervention in generalism rather than a compromise caused by time pressure. We distinguish prioritisation from adjacent concepts such as shared decision-making, deprescribing, treatment burden, and Choosing Wisely: its distinctive work is deciding what should come first now, what can wait, and what should stop. Recent evidence shows that patients and clinicians often prioritise different outcomes, that care aligned with patient priorities can improve meaningful outcomes, and that goal-oriented models offer a more coherent approach for people with multiple long-term conditions. Everyday generalist care should move from checklist completion to explicit prioritisation: identifying what matters most now, selecting the next action with the greatest likely benefit and lowest burden, and actively stopping, simplifying, or deferring care that does not support the agreed goal. Training, quality metrics, and service design should reward this work.</p>","PeriodicalId":15860,"journal":{"name":"Journal of General Internal Medicine","volume":" ","pages":""},"PeriodicalIF":4.1,"publicationDate":"2026-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149110811","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}