BackgroundInterest in nephrology careers among internal medicine residents in the United States is declining. Our objective was to assess the impact of the presence of a nephrology fellowship training program on perceptions and career interest in nephrology among internal medicine residents. A secondary objective was to identify commonly endorsed negative perceptions of nephrology among internal medicine residents.MethodsThis was a repeated cross-sectional survey of internal medicine residents before (Group 1) and 3 years after (Group 2) the establishment of nephrology fellowship programs at two institutions. The primary outcome was the percentage of residents indicating nephrology as a career interest in Group 1 vs. Group 2. Secondary outcomes included the frequency that residents agreed with negative statements about nephrology.Results131 (80.9%) of 162 residents completed the survey. 19 (14.8%) residents indicated interest in a nephrology career, with 8 (6.3%) indicating nephrology as their first choice. There was no difference in career interest in nephrology between residents who were exposed to nephrology fellows during residency training (Group 2) and residents who were not (Group 1). The most commonly endorsed negative perceptions of nephrology were: nephrology fellows have long hours/burdensome call (36 [28.1%] of residents agreed or strongly agreed), practicing nephrologists must take frequent/difficult call (35 [27.6%] agreed or strongly agreed), and nephrology has few opportunities for procedures (35 [27.3%] agreed or strongly agreed). More residents in Group 2 agreed that nephrology is poorly paid (8.9% in Group 1 vs. 20.8% in Group 2, P = 0.04), whereas more residents in Group 1 agreed that nephrologists must take frequent/difficult call (40.0% in Group 1 vs. 18.1% in Group 2, P = 0.02).ConclusionsThe initiation of a nephrology fellowship program was not associated with an increase in internal medicine residents’ interest in nephrology careers. Residents endorsed several negative perceptions of nephrology, which may affect career choice.
Objective Patients receiving dialysis are at increased risk for lower extremity amputations and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and healthcare use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis-dependency and other preoperative factors associated with readmission and/or death after lower extremity amputation. Methods Retrospective cohort study of dialysis-dependent and non-dialysis patients undergoing major lower extremity amputation in the 2012–2013 American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Primary outcomes included: death and/or hospital readmission within 30 days of amputation. Results Of 6,468 patients, 1,166 (18%) were dialysis-dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below knee amputations (62% vs 55%), and inhospital deaths (8% vs 3%; all P<.001). The 30-day postoperative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P<.001) was higher in dialysis patients. Among the live-discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelets associated with death (P<.05; c-statistic 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P=.04; c-statistic 0.58). Conclusions Readmission and/or death following amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, while predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow for targeted interventions to improve outcomes.
Hospitalized patients receiving anticoagulants such as warfarin are at increased risk for adverse events because of difficulties maintaining a therapeutic international normalized ratio (INR). We sought to determine whether a detailed warfarin dosing protocol administered by pharmacists with minimal physician oversight significantly reduced the proportion of hospitalized patients with a supratherapeutic INR. We conducted a prospective, nonrandomized trial with patients on cardiology, internal medicine, and family medicine inpatient services who received at least 1 dose of warfarin while hospitalized. The baseline group included 293 patients, and the intervention group comprised 217 patients. Baseline characteristics were similar in each group, except that more patients received antibiotics in the intervention group. The defect rate (INR > 5 after receiving warfarin) in the baseline group was significantly higher than in the intervention group (7.85 vs. 1.85%). Conversely, the percentage of patients with an INR less than 1.7 after 4 warfarin doses was lower in the intervention patients, indicating overall improvement in therapeutic levels. Dosing discussions were required between the pharmacist and a physician for only 6% of intervention patients. The protocol effectively reduced overanticoagulation without increasing under anticoagulation during hospitalization and reduced the need for close physician oversight.
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