General Internal Medicine Update 2016

Bernadette M. Miller, MD

Program Director

Internal Medicine Residency

OU School of Community Medicine

Presenter Disclosures

• No affiliations to disclose

Objectives

• Discuss Current US Internal Medicine Issues: • Internal Medicine education structure in America

• Opioid Epidemic of 2016 in American Medicine and New CDC guidelines

• Examine Practice Updates: • Understand recommendations for Influenza Vaccines for 2016

• Review the 2015 USPSTF recommendations for Diabetes Screening

2016 Academic Internal Medicine: Training the Physicians of 2025

The Next Generation of IM Physicians

2025 Projected US Physician Demand

2025 Projected US Primary Care Demand

Internal Medicine Residency Statistics

IM Residency Training in the US

• 2 major bodies of accreditation (ACGME & AOA)

• 2 main residency matches

• Single GME Accreditation System 1 residency match • July 2015: Implementation

• July 2020: Final phase complete

• COMLEX = USMLE

IM Residency Training in the US

• 36 months of training

• <80 hrs wk

• 10 hrs between shifts

• Average 1 day off in 7

• Limitations on number of patient encounters

• 1/3-1/2 time spent in outpatient setting

IM Residency Training for 2025

How are we doing it?

The American Opioid Epidemic of 2016

Pain Killers and People Killers?

“9.4 million Americans take opioids for long-term pain and 2.1 million are estimated by the NIH to be hooked.” 6/15/16

CDC Guidelines for Opioid Prescribing

CDC Guidelines for Opioid Prescribing for Chronic Pain

(Pain outside of active cancer, palliative, and end-of-life care)

• Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain.

• Consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

• If used, opiates should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.

CDC Guidelines for Opioid Prescribing for Chronic Pain

(Pain outside of active cancer, palliative, and end-of-life care)

• Before starting opioid therapy for chronic pain, clinicians should: • Establish treatment goals with all patients, including realistic goals for pain

and function

• Consider how therapy will be discontinued if benefits do not outweigh risks.

• Discuss with patients:

• known risks and realistic benefits of opioid therapy

• patient and clinician responsibilities for managing therapy.

CDC Guidelines for Opioid Prescribing for Chronic Pain

(Pain outside of active cancer, palliative, and end-of-life care)

• Clinicians should continue opioid therapy: • only if there is clinically meaningful improvement in pain and function that

outweighs risks to patient safety.

• Periodically during opioid therapy, clinicians should discuss with patients: • Known risks and realistic benefits of opioid therapy.

• Patient and clinician responsibilities for managing therapy.

Just Last Month…

Just This Month…

Influenza Vaccine Update 2016

White House (Pete Souza) 2009 - The Official White House Photostream

Influenza Vaccine Types

• Inactivated quadrivalent (2A, 2B)

• Inactivated trivalent (2A, 1B; standard or high dose)

• Adjuvanted (aluminum or monophosphoryl lipid A) Inactivated trivalent

• Recombinant trivalent (antigen produced by recombinant DNA)

• Live attenuated, quadrivalent (FluMist)

Influenza Vaccines

Advisory Committee for Immunization Practices Recommendations for 2016-17 Influenza Season

• Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications.

• Live Attenuated Influenza Vaccine should not be used.

• No preferential recommendation is made for one influenza vaccine product over another for persons for whom more than one licensed, recommended product is otherwise appropriate.

Advisory Committee for Immunization Practices Recommendations for 2016-17 Influenza Season

• Persons with egg allergy: • Removal of the recommendation that egg-allergic recipients should be

observed for 30 minutes post-vaccination for signs and symptoms of an allergic reaction. (15min obs for all vaccines to watch for syncope)

• A recommendation that persons with a history of severe allergic reaction to egg (i.e., any symptom other than hives) should be vaccinated in an inpatient or outpatient medical setting

(including but not necessarily limited to hospitals, clinics, health departments, and physician offices), under the supervision of a health care provider who is able to recognize and manage severe allergic conditions.

Type 2 Diabetes Mellitus Screening in Asymptomatic Adults Update

2015 USPSTF Recommendations for Type 2 Diabetes Mellitus Screening in

Asymptomatic Adults

2015 USPSTF Recommendations for Type 2 Diabetes Mellitus Screening in

Asymptomatic Adults

Type 2 Diabetes Mellitus Screening in Asymptomatic Adults 2015 Update

Due to increased risk for diabetes at a younger age or at a lower body mass index, clinicians should consider screening earlier than age 40 in asymptomatic persons with 1 or more of these characteristics:

• Family history of diabetes

• History of gestational diabetes or polycystic ovarian syndrome

• Are members of certain racial/ethnic groups (African Americans, American Indians or Alaskan Natives, Asian Americans, Hispanics or Latinos, or Native Hawaiians or Pacific Islanders)

Type 2 Diabetes Mellitus Screening Details

(Photo: NASA)

Thank You

References 1. https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf accessed Sept 2016

2. http://www.nrmp.org/wp-content/uploads/2015/05/Main-Match-Results-and-Data-2015_final.pdf accessed Sept 2016

3. http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf accessed Sept 2016

4. http://www.osteopathic.org/inside-aoa/single-gme-accreditation-system/Pages/default.aspx accessed Sept 2016

5. http://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf accessed Sept 2016 accessed Sept 2016.

6. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm accessed Sept 2016 accessed Sept 2016.

7. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates accessed Sept 2016.

8. http://www.cdc.gov/flu/protect/vaccine/vaccines.htm accessed Sept 2016.

9. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49.

10. Florence, Curtis S. PhD; Zhou, Chao PhD; Luo, Feijun PhD; Xu, Likang MD. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care: October 2016 - Volume 54 - Issue 10 - p 901–906.

11. Dall TM, Gallo PD, Chakrabarti R, West T, Semilla AP, Storm MV. An aging population and growing disease burden will require a large and specialized health care workforce by 2025. Health Aff (Millwood). 2013;32:2013-2020.

12. Ann Intern Med. 2015 Dec 1;163(11):861-8. doi: 10.7326/M15-2345. Epub 2015 Oct 27. Siu AL; Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement. U S Preventive Services Task Force.