PDs deemed the fourth year to have a critical role in the curriculum. There was consensus about expected fourth-year competencies and the common clinical experiences that best prepare students for residency training. These findings support using the fourth year to transition students to graduate medical training and highlight areas for curricular innovation.

The Patient's StoryMr A is 85 years old and has multiple skin abnormalities with intractable pruritus of the trunk, groin, perianal area, face, and scalp. He cannot sleep for more than 4 to 5 hours per night because of his pruritus. Mr A was diagnosed as having seborrheic dermatitis, lichen simplex chronicus, seborrheic keratoses, tinea pedis, intertrigo, and xerosis (dry skin) in 2000. Treatments included numerous topical steroids and antifungals. None were effective, leaving Mr A significantly stressed.Mr A lives with his wife in an assisted-living facility. He requires help with dressing, transferring, using the telephone, shopping, and managing medications. His medical history includes type 2 diabetes mellitus, obesity, chronic kidney disease, and significant cardiovascular, cerebrovascular, and peripheral vascular disease. He has had 2 coronary artery bypass graft operations, 2 left carotid endarterectomies, and a left femoral-popliteal bypass operation. He also underwent multilevel lumbar laminectomy for spinal stenosis.His list of 28 oral and inhaled medications includes rosuvastatin and amlodipine. At one visit to Dr I, his geriatrician, Mr A produced 14 different tubes of topical medications, including multiple steroids and antifungals. He and his wife did not understand when and where to apply these medications. Mr A's skin was dry, with erythematous patches, seborrheic keratoses, and areas of excoriation on his trunk. He had bilateral inguinal fold and perianal erythema with a few white perianal plaques and several fissures. On monofilament testing, cutaneous sensation in his feet was absent. Screening for depression was unrevealing. His laboratory test results were notable for mild anemia, elevated creatinine, and normal liver function and routine chemistries.Mr A had several UV-B light treatments, which were minimally helpful. Mr A used over-the-counter diphenhydramine to help him sleep even though Dr I had advised against it because of potential anticholinergic adverse effects. Ultimately, Dr I, in collaboration with IMPORTANCE Pruritus is a common problem among elderly people and, when severe, causes as much discomfort as chronic pain. Little evidence supports pruritus treatment, limiting therapeutic possibilities and resulting in challenging management problems.OBJECTIVES To present the evidence on the etiology, diagnosis, and treatment of pruritus in the elderly and, using the best available evidence, provide an approach for generalist physicians caring for older patients with pruritus.EVIDENCE REVIEW PubMed and EMBASE databases were searched (1946( -August 2013.The Cochrane Database of Systematic Reviews and the Agency for Healthcare Research and Quality Systematic Review Data Repository were also searched from their inception to August 2013. References from retrieved articles were evaluated.FINDINGS More than 50% of elderly patients have xerosis (dry skin). Xerosis treatment should be included in the initial therapy for pruritus in all elderly patients. Calcium channel blockers and hydrochlorot...

This paper examines how physicians determine the quality and quantity of time to devote to each patient, and how these decisions are taught to physicians-in-training as part of the 'hidden curriculum' in medical education. The notion of moral economy is used to analyze how judgments of patient worth come to guide and influence interactions among physicians and physicians-in-training and patients, and how these interactions impact medical care. However, this paper also questions the notion of the hidden curriculum as a static or reified concept. Instead, the paper uses participant narratives to show how physicians-in-training are not simply passive recipients of the hidden curriculum but also actively resist judging patients based on perceptions of worth, even as they learn to operate within a moral economy of care.

Entrustable professional activities (EPAs) describe the core work that constitutes a discipline's specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end‐of‐training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatrician's fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.

BackgroundSales visits by pharmaceutical representatives (“drug detailing”) are common, but little is known about the content of these visits or about the impact of visit characteristics on prescribing behavior. In this study, we evaluated the content and impact of detail visits for gabapentin by analyzing market research forms completed by physicians after receiving a detail visit for this drug.Methods and FindingsMarket research forms that describe detail visits for gabapentin became available through litigation that alleged that gabapentin was promoted for “off-label” uses. Forms were available for 97 physicians reporting on 116 detail visits between 1995 and 1999. Three-quarters of recorded visits (91/116) occurred in 1996. Two-thirds of visits (72/107) were 5 minutes or less in duration, 65% (73/113) were rated of high informational value, and 39% (42/107) were accompanied by the delivery or promise of samples. During the period of this study, gabapentin was approved by the US Food and Drug Administration only for the adjunctive treatment of partial seizures, but in 38% of visits (44/115) the “main message” of the visit involved at least one off-label use. After receiving the detail visit, 46% (50/108) of physicians reported the intention to increase their prescribing or recommending of gabapentin in the future. In multivariable analysis, intent to increase future use or recommendation of gabapentin was associated with receiving the detail in a small group (versus one-on-one) setting and with low or absent baseline use of the drug, but not with other factors such as visit duration, discussion of “on-label” versus “off-label” content, and the perceived informational value of the presentation.ConclusionsDetail visits for gabapentin were of high perceived informational value and often involved messages about unapproved uses. Despite their short duration, detail visits were frequently followed by physician intentions to increase their future recommending or prescribing of the drug.

Hospitals need to ensure that the educational potential of medical students' clinical experiences is maximized when implementing CPOE.

This article describes the curricular milestones for geriatric fellows and the process used to develop them. The curricular milestones were developed to determine what every graduating geriatric fellow should be able to demonstrate to ensure that they will be able to practice effectively and safely in all care settings and with different older adult populations. Three major domains were identified: Caring for the Elderly Patient, Systems‐Based Care for Elder Patients, and Geriatric Syndromes. Six hundred thirty‐five geriatricians each reviewed and commented on one domain. These geriatricians represented important stakeholder groups: geriatric fellowship program directors; Association of Directors of Geriatric Academic Programs (ADGAP) members, who are primarily geriatric program and fellowship directors; the American Geriatrics Society (AGS) and ADGAP Education Committee; the AGS Teacher's Section; Geriatric Academic Career Award awardees; and through the American Board of Internal Medicine and the American Board of Family Medicine, board‐certified geriatricians who spend more than 50% of their time in clinical practice. The AGS and ADGAP boards approved the final set of 76 Geriatric Curricular Milestones, which were posted on the Portal of Geriatric Online Education in December 2012. These curricular milestones are intended to assist geriatric fellowship directors as they develop curricula and assessments to inform program director reporting to the Accreditation Council for Graduate Medical Education in the Next Accreditation System, which begins in July 2014.

Students spend significant amounts of time reading online sources during their medicine clerkship, especially UpToDate. Medical educators should become familiar with these sources and contribute to maximizing their effectiveness for students. Additional research focused on understanding how students build skills in information literacy and how educational programs can facilitate the development of those skills is needed.