Journal of General Internal Medicine

Background: The rapidly evolving United States (U.S.) health and science policy landscape in 2025 may have heterogeneous effects on academic medicine, biomedical research, physician workforce development and patient care. Research Question: How do academic pulmonary and critical care medicine (PCCM) physicians perceive U.S. health and science policy changes and which changes do they consider most influential on research, trainee education and clinical care? Study Design and Methods: We conducted a prospective survey from March 27, 2026 through April 29, 2026 among selected faculty at U.S. academic PCCM programs as part of the Alliance of Scholars and Professionals for Innovation, Research, and Education in Pulmonary and Critical Care Medicine (ASPIRE-PCCM). Results: Ninety-four of 99 ASPIRE-PCCM panel members completed the survey (response rate 95%), representing 18 of 19 ASPIRE-PCCM wave 1 institutions. All respondents reported the rate of changes in U.S. federal health and science policy in the first half of 2025 as 6 or higher on a scale of 1 ("typical pace of change") to 10 ("most change in my lifetime"), with 89 (96%) evaluating the changes as harmful or very harmful. Respondents identified cancellation of research grants, disruptions and changes to NIH scientific review processes, and changes to visa and immigration policies as key factors affecting early career recruitment. Reported negative effects on quality of care included increased vaccine hesitancy, changing reimbursement structures, and diminished research capacity. State-level and non-governmental efforts, including professional society advocacy, institutional bridge funding and personal advocacy efforts were identified as partially mitigating harms. Despite these concerns, 72% of respondents reported that would still pursue careers in PCCM. Interpretation: Academic pulmonary and critical care physicians reported challenges following recent U.S. health and science policy changes that may be mitigated, but not neutralized, by institutional, professional-society, and individual actions.

Abstract Importance Patients with behavioral health presentations leave the emergency department (ED) before evaluation more often than other patients, but outcomes after leaving without being seen (LWBS) have not been described in this population. Objective To compare return visits, admission, and mortality after LWBS vs completed care among behavioral health ED episodes. Design, Setting, and Participants This retrospective episode-level cohort study used a multisystem deidentified electronic health record database of US health systems (data snapshot June 4, 2026). Participants were patients of all ages with an ED visit and same-day behavioral health diagnosis. Index visits (recorded January 26, 2001 to April 13, 2025) each opened a 30-day episode window; in-window were counted as outcomes, and patients could contribute episodes to either group. Data were analyzed in October 2026. Exposure LWBS (diagnosis code Z53.21 on a date with an ED encounter) vs completed care ending in discharge home. Main Outcomes and Measures The primary outcome was ED return visit within 7 days. Secondary outcomes were return visit within 3 and 30 days; admission on day 0, on days 1-7 (principal measure), and within 30 days; and all-cause death within 7 and 30 days, assessed among episodes from 2017 through 2023 using a verified death-record definition. Results The analysis included 1,305,812 episodes (12,248 LWBS; 1,293,564 completed care) from 525,490 patients; 666,930 episodes (51.1%) involved female patients and 66,733 (5.1%) involved patients younger than 18 years. Return visit within 7 days followed 24.5% of LWBS episodes vs 13.2% of completed-care episodes (risk ratio [RR], 1.86; 95% CI, 1.81-1.92), and admission on days 1-7 followed 17.1% vs 3.9% (RR, 4.41; 95% CI, 4.24-4.59). Among 2017-2023 episodes, 30-day mortality was 0.69% (70 of 10,141) after LWBS vs 0.32% (2,426 of 756,140) after completed care (RR, 2.15; 95% CI, 1.70-2.73). Results were similar under alternative episode definitions. Conclusions and Relevance Among patients with behavioral health ED presentations, LWBS was followed by higher rates of return visits, admission, and short-term mortality than completed care. These unadjusted findings describe outcome burden, not causal effects, and highlight patients who leave as a target for rapid follow-up.

Background: Patient-facing AI intake chatbots can enter clinical use without regulatory review, so their errors may first surface with actual patients. Objective: To develop and pilot a remote, voice-based standardized patient (SP) method for evaluating an intake chatbot's history-taking, documentation, and patient-centeredness. Methods: Four primary care cases had Easy and Difficult variants. In Phase 1, five SPs completed 40 encounters with internal medicine residents rating portrayal fidelity. In Phase 2, SPs completed 80 encounters with a ChatGPT 4o chatbot, recorded whether critical elements were asked about and addressed satisfactorily, and rated summaries; four debriefing interviews were analyzed. In Phase 3, two blinded clinicians rated transcripts and summaries from 101 encounters (32 resident-led, 69 chatbot-led). Results: Portrayal fidelity averaged 4.52 of 5. The chatbot asked about 59.3% of critical elements in Easy versus 50.2% in Difficult variants (adjusted OR 1.49; 95% CI, 1.15 to 1.93) and addressed 73.3% versus 64.6% (OR 1.47; 1.12 to 1.93); near-ceiling summary quality did not differ. SPs reported missed information and rushed pacing. Reviewer agreement was moderate to substantial for element judgments (AC1 0.49 to 0.70) but poor for totals (ICC 0.10 and 0.21). In exploratory comparisons, residents asked about more elements (adjusted difference 12.5 percentage points; 95% CI, 7.0 to 18.1) and satisfactorily addressed more (9.2 points; 3.8 to 14.6); totals did not differ. Conclusions: SP portrayal was consistent enough for pre-clinical chatbot evaluation, and the method detected lower coverage in harder cases. Documentation ratings alone may miss conversational gaps, which require direct measurement.

Abstract: Background: Opioid Use Disorder (OUD) imposes a rising mortality and health system burden, with opioid related deaths increasing from 8,400 in 2000 to 110,037 in 2023. Medications for opioid use disorder (MOUD) reduce mortality and morbidity, yet only 25.1% of people with OUD are treated with these medications, and inpatient MOUD initiation is inconsistent. Inpatient and Emergency Department (ED) treatment initiation and connection to outpatient care is suboptimal, missing critical opportunities to engage at-risk populations during acute care visits. Our goals were to determine the proportion of patients with OUD treated with MOUD during a hospital/ED stay, and the proportion successfully connected to outpatient care. Methods: This retrospective cohort study included patients 18 years or older with an OUD diagnosis at Duke University Hospital and Duke Regional Hospital (7/1/2023 to 12/31/2025) who had an inpatient or ED encounter with an associated OUD diagnosis code. Primary outcomes were buprenorphine at discharge, 30-day acute care return, and 30 day outpatient follow up. Adjusted modified Poisson regression models with cluster robust standard errors evaluated associations with age, sex, race/ethnicity, insurance, area deprivation index, encounter type, and comorbidity score. Results: Of 5,390 patients with OUD, 42.1% (2,267) had an acute care encounter, generating 3,893 encounters. Neither buprenorphine nor methadone was prescribed at discharge for 46.0% of encounters. Acute care return occurred in 33.6% and outpatient follow up in 32.2% of encounters within 30 days; only 7.4% of follow-ups included a buprenorphine prescription. ED encounters had lower discharge prescribing than inpatient encounters (RR 0.72, 95% CI 0.61,0.86). Black patients had higher 30 day acute care return than White patients (RR 1.16, 95% CI 1.02,1.30) Conclusions: Acute care encounters represent repeated, missed opportunities for MOUD initiation. Disparities were concentrated in post-discharge return and follow up rather than at initial prescribing, and attrition occurred at each transition along the screening-treatment-referral pathway.

PurposeRural Alaska relies on air ambulances ("medevacs") to connect remote villages off the road system to higher-level care. Yet medevac decision-making is complicated by limited guidelines, high costs, and delayed transport. We aimed to quantify variability in physician medevac decisions and identify contributing factors. MethodsWe conducted a cross-sectional survey of physicians (n=20) within the Alaska Tribal Health System using 20 clinical vignettes representing varying levels of transport complexity. Participants selected transport modality (medevac, commercial, or remain in village) and rated confidence. Interrater agreement was assessed using Gwets AC1. A generalized linear mixed model evaluated predictors of medevac use. FindingsAgreement was "almost perfect" for clearly critical cases ("always medevac," AC1=0.97) but declined substantially for intermediate scenarios ("possible medevac" AC1=0.39; "never medevac" AC1=0.26; "special considerations" AC1=0.12). Confidence strongly correlated with agreement (r=0.83, p<0.001), forming distinct clusters of high-, medium-, and low-certainty decisions. Vignette type was the dominant driver of medevac use (OR 455.5 for "always medevac"), but decisions did not change with experience (OR=0.99, 0.94-1.04). Between-physician variability persisted after adjustment (ICC 3.8%; MOR 1.67), consistent with differences in risk tolerance. ConclusionsMedevac decision-making is highly consistent in certain clinical cases but interrater agreement is limited for intermediate cases. Without a shared gold standard of "correct" medevac decisions, future clinical decision support cannot rely on automated medevac decision making. Efforts to improve care should focus on deconstructing decisions, enhancing outcome feedback, and developing targeted decision support rather than prescriptive decision models.

PurposeLong COVID literature often describes new-onset symptoms or conditions following SARS-CoV-2 infection; however, Long COVID also encompasses the exacerbation of pre-existing conditions. We describe health conditions reportedly worsened by COVID-19 illness and associated concerns in U.S. adults. MethodsWe collected longitudinal data from adults 18 years and older participating in the Track Post COVID-19 Conditions, an active Long COVID cohort surveillance project. Respondents completed surveys 3-, 6-, and 12- months after COVID-19 illness, beginning in July 2023. In each survey, respondents were asked whether they had any health conditions or concerns that were made worse by COVID-19. Those with an affirmative response were asked to specify the worsening condition(s) via free text. Some respondents used this free text to describe challenges or experiences related to their worsening conditions. This report categorizes and quantifies reported conditions and concerns by body system categories and qualitatively describes associated challenges and experiences using direct quotes from respondents free text responses. ResultsAmong 2,227 adults, 263 (11.8%) respondents reported at least one worsening condition or concern following COVID-19 illness. Of these, nearly 32% reported a worsening respiratory condition or concern. Adults with worsening pre-existing conditions reported challenges accessing adequate care, completing daily activities, and managing their symptoms following COVID-19. DiscussionWhile Long COVID literature often focuses on the development of new-onset long-term symptoms, more than 1 in 10 adults reported worsening of a pre-existing condition following COVID-19. Reported challenges with accessing care and daily activities highlight potential need for accommodations or support for adults with Long COVID.

Background Pediatric neurocritical care (PNCC) has emerged as a distinct field, and many hospitals have moved to establishing dedicated PNCC programs. How practice change is implemented within these programs is not well understood. This study had two objectives. First, we sought to understand the barriers and facilitators of practice change in PNCC from the perspectives of the multiprofessional clinicians who deliver it. Second, we sought to characterize how well the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation determinant framework captures them. Methods We conducted semi-structured interviews with a purposive sample of clinicians involved in PNCC at three U.S. academic medical centers. The interview guide was developed using i-PARIHS to organize barriers and facilitators of practice change across the innovation, recipients, context, and facilitation constructs. We applied framework analysis, combining deductive i-PARIHS, study-specific, and inductively derived categories. Two coders independently indexed the transcripts and reconciled them to consensus, with first-author adjudication. Preliminary site-level findings were validated with participants. Results We interviewed 33 clinicians: 24 physicians, 7 nurses, and 2 advanced practice providers. Most determinants of practice change mapped to existing i-PARIHS constructs, but three were not adequately captured by the framework as currently specified. The most consequential was an interprofessional authority gradient that determined whose preferences prevailed when intensive care, neurology, and neurosurgery disagreed. The other two were clinician autonomy, which served as the lens through which the acceptability of a change was judged, and the affective state clinicians bring to practice change. Receptivity depended more on recipients' values, prior experience, and capacity to absorb change into a demanding workflow. Facilitation was variable, frequently under-resourced, and dependent on credibility across professional groups. We translated these findings into three propositions linked to implementation strategies and outcomes. Conclusions Participants attributed practice change in PNCC more to the recipients of change, the multiprofessional context, and the availability of facilitation than to the strength of evidence for a given practice. i-PARIHS captured most barriers and facilitators well but may be adapted in this setting. Credible, resourced, authority-sensitive facilitation may improve the prospects for sustained practice change as institutions develop PNCC programs.

Background: Clinical decision support (CDS) systems may improve chronic pain management by providing guideline-based recommendations within clinical workflows. However, low clinician use can limit their effectiveness. Understanding the association between CDS use and guideline-recommended care may help distinguish implementation challenges from limitations in CDS functionality. Objective: To estimate the association of OneSheet, a CDS system for chronic pain management, and guideline-recommended care when the system was used during patient encounters. Methods: We conducted a per-protocol secondary data analysis of data from a pragmatic randomized clinical trial conducted from October 2020 to May 2022 across 25 primary care clinics at 2 academic health systems in Indiana and North Carolina. The parent trial enrolled 137 primary care clinicians. This analysis included 145511 eligible chronic pain encounters and 15480 long term opioid therapy (LTOT) encounters that occurred after OneSheet implementation. OneSheet use at a patient encounter was the exposure of interest. Propensity score matching was used to create comparable groups of encounters with and without OneSheet use. Outcomes included documentation of pain-related goals, documentation of pain and function using the Pain, Enjoyment of Life and General Activity (PEG) scale, prescription drug monitoring (PDMP) review, urine drug screening (UDS) orders, and naloxone orders. Results: OneSheet was used in 959 of 145511 chronic pain encounters (0.7%) and 582 of 15480 LTOT encounters (4.0%). In matched analyses, OneSheet use was associated with increased documentation of pain-related goals (relative risk (RR)=11.70 (95% CI 4.25-32.50) and PEG score documentation (RR=9.70 (95% CI 4.14-22.31). Among LTOT encounters, OneSheet use was associated with increased UDS ordering (RR=1.52 (95% CI 1.40-1.65) and PDMP review (RR=1.06 (95% CI 1.03-1.09), but decreased naloxone ordering (RR=0.13 (95% CI, 0.02-0.90). Conclusions: OneSheet use was associated with several guideline-recommended chronic pain management actions, suggesting that they system may support care quality when clinicians use it. However, use was rare, indicating that increasing routine use through better workflow integration may be necessary to achieve population-level improvements in chronic pain care.

Health systems increasingly record ICD-10 Z59 social-needs codes for housing, food, transportation, and related hardship to trigger referrals, report quality, and adjust risk. However code documentation occurs at varying rates and no study has separated what the code says about a patient's hardship from what it says about being documented at all. Using a linked electronic health record and claims corpus covering 4.95 million patients in 21 identifiable health systems, we matched 26,153 adults with a first outpatient Z59 code to similar uncoded patients and, as a negative control, repeated the entire design around an administrative code. Coding ranged from 1 percent to 24 percent of patients across systems and remained highly variable after adjustment for patient mix. A hardship code was associated with 67% (95% CI=1.61, 1.74) more emergency department (ED) visits and 43% ( 95% CI=1.38, 1.49) more hospital admissions in the next year (62 versus 49 of every 100 patients with any acute event). The administrative-code reproduced 46 percent of the Z59 association for ED visits and 70 percent for admissions. In the five systems with the most complete stay dates, no hardship-specific admission excess was detectable. Homelessness codes forecast two and a half times the ED visit rate. At national planning prices, excess emergency and preventable hospital care totaled roughly $2,000 to $2,500 per coded patient-year ($2,516 base scenario; about $1,100 under an exploratory assumed-discount scenario (not an estimate of hardship-attributable spending)), with the largest emergency burden among Medicaid patients. The Z code added no increment to clinical and utilization-based risk prediction models in any system.

Background: Multiple performance measures are used to assess the management of common cardiovascular conditions, such as coronary artery disease (CAD), heart failure with reduced ejection fraction (HFrEF), and atrial fibrillation (AF). These measures are sometimes used to assess individual clinicians, despite lack of evidence of reliability and accuracy. We used national Veteran Affairs (VA) data to test medication-based performance measures for assessment of clinician performance in outpatient cardiology care. Methods: This retrospective study examined VA cardiology clinician/Veteran dyads from 2017-2023 to evaluate 10 medication-based performance measures for CAD, HFrEF, or AF with elevated stroke risk. Achievement of each performance measure was defined as an active prescription of an indicated medication for each eligible patient encounter, summarized at the clinician level. Reliability was calculated using the beta-binomial method. A Bayesian causal model was used to assess the impact of case complexity on performance measure achievement. Finally, we performed peer review of a subset of cases (n=952) to assess the accuracy of three representative performance measures. Results: Of 456,071 unique cardiology encounters, 312,331 included CAD, 224,599 included HFrEF, and 178,678 included AF. These patients were treated by 1,043 cardiology clinicians. Median performance measure achievement ranged from 0.23 (SGLT2i for HFrEF) to 0.99 (beta blocker for HFrEF). Measure reliability varied from 0.63 to 0.90. Case complexity did not significantly affect performance measure achievement. Using peer review as the gold standard, accuracy was poor to moderate (balanced accuracy 0.51-0.73), and measures underestimated performance relative to peer review. Conclusions: Ten medication-based performance measures for CAD, HFrEF, and AF can be efficiently measured using electronic health record data, and most have sufficient reliability to support clinician benchmarking and the identification of potential care gaps. However, suboptimal accuracy compared with a peer review indicates that these measures may be insufficient as a standalone assessment of clinician quality.

Background: Patient satisfaction is a key measure of healthcare quality among people experiencing homelessness. Student-run free clinics (SRFCs) provide care to underserved populations, but the role of student involvement in patient satisfaction remains unclear. Methods: We conducted a cross-sectional study of patients receiving care at an SRFC. From February 2024 to February 2025, patients completed post-visit surveys assessing satisfaction that were evaluated using regression analyses. Results: Eighty-eight patients completed surveys, reporting high overall satisfaction (mean 9.26/10). In separate linear regression models adjusted for age, gender, and race, greater perceived benefit of student involvement was associated with higher satisfaction ({beta} = .298, p = .037), whereas perceiving the visit as too long was associated with lower satisfaction ({beta} = -.285, p = .019). Conclusion: Greater perceived benefit of student involvement was associated with higher patient satisfaction, whereas longer perceived visit duration was associated with lower satisfaction. These findings highlight the importance of balancing educational opportunities with efficient workflows in SRFCs.

Background Best practice alerts (BPAs) used in emergency departments (EDs) to identify patients with possible sepsis lack specificity and some ED patients with sepsis BPAs are discharged. We evaluated factors associated with ED discharge following a sepsis BPA and with subsequent 7-day return admissions with sepsis or infection. Methods We conducted a retrospective cohort study using an electronic health record data query from five hospitals (2022-2024). Using logistic regression, we evaluated the association of participant demographics and clinical characteristics with ED discharge and factors at the initial ED visit associated with return admission. Results Among 62,068 ED visits with a sepsis BPA, one third resulted in ED discharge. Discharged participants were younger and more often female, Black, multiracial, and/or Hispanic; they more often had an initially normal pulse, respiratory rate, blood pressure, and lactic acid than admitted participants. Discharged participants more often had a fever on arrival (adjusted odds ratio (aOR) 6.03; p<0.001) and a white blood cell (WBC) count 11,000-14,999 (aOR 4.57; p<0.001) or 15,000-19,999/uL (aOR 2.01; p<0.001). One percent of discharged participants experienced a 7-day return admission with a diagnosis of sepsis or infection, which was associated with older age, White or Asian race, diastolic hypotension, WBC count [&le;]15,000/uL or <4,000/uL, and an index visit BPA response indicating sepsis or non-response. Conclusions Return admissions among discharged ED patients with a sepsis BPA are rare. Several factors are associated both with hospital admission at the index visit and return admission, indicating a need for additional risk-stratification tools.

Background: CPR is the primary intervention for cardiac arrest, and the mortality trends before and after the pandemic remain are not fully understood. Methods: This cross-sectional study used the National Inpatient Sample (NIS) database from 2016-2022 and International Classification of Diseases, Tenth Revision (ICD-10) codes to evaluate the mortality trend for adult patients undergoing CPR after in-hospital cardiac arrest (IHCA). Primary exposures were calendar year, demographics, socioeconomic factors, and hospital characteristics. Multivariable weighted logistic regression was performed to identify predictors of mortality after CPR for IHCA. Results: Among 612,930 weighted adult hospitalizations undergoing CPR for IHCA between 2016 and 2022, overall in-hospital mortality was 67.8%. Risk-adjusted mortality declined through 2019 before increasing sharply during the COVID-19 pandemic, peaking in 2021 and remaining above pre-pandemic levels in 2022. Compared with 2016, admission in 2020 (aOR 1.18, 95% CI 1.12-1.25; p<0.001) and 2021 (aOR 1.26, 95% CI 1.19-1.33; p<0.001) was independently associated with higher mortality, whereas admission in 2019 was associated with lower mortality (aOR 0.89, 95% CI 0.84-0.95; p<0.001). Higher mortality was also associated with increasing age (aOR 1.01 per year; p<0.001), female sex (aOR 1.05, 95% CI 1.02-1.08; p<0.001), Black (aOR 1.14, 95% CI 1.10-1.18; p<0.001) and Hispanic race/ethnicity (aOR 1.20, 95% CI 1.15-1.26; p<0.001), and self-pay insurance (aOR 1.62, 95% CI 1.51-1.74; p<0.001). Protective factors included private insurance (aOR 0.91, 95% CI 0.87-0.94; p<0.001), residence in the highest income quartile (aOR 0.91, 95% CI 0.87-0.94; p<0.001), and treatment at private, non-profit hospitals (aOR 0.89, 95% CI 0.85-0.94; p<0.001). Conclusion: This large nationwide patient database analysis demonstrates that mortality following CPR for IHCA declined before the COVID-19 pandemic but increased during 2020, remaining above pre-pandemic levels through 2022. Independent predictors of mortality reveal socioeconomic disparities in mortality outcomes.

Modern clinical medicine depends on reducing complex human realities into forms that support knowledge, judgment, and action. Such reduction is indispensable to scientific medicine, but necessarily selective. A medical framing may therefore remain well warranted within medicine while becoming insufficient in relation to the reality of a particular patient. What happens clinically when the adequacy of such a framing itself becomes uncertain remains insufficiently understood. We conducted an abductive, theory-generating qualitative study of 44 patients who attended a supplementary Dialogue-Based Outpatient Clinic within a breast oncology service in Japan between 2021 and 2023, comprising 111 consultations. The clinic had no predefined clinical agenda, allowing patients to raise concerns that mattered to them. Through iterative comparison within and across cases, we examined how patients' concerns were understood and responded to clinically. Across cases, a recurrent clinical process became apparent when patient reality called the adequacy of existing medical framing into question. Exploration of patients' concerns could expose a consequential mismatch between their reality and the framing through which medicine understands and represents clinical reality. Such mismatches prompted inquiry into medical framing to identify what required reopening. Reopening occurred when the identified framing, previously treated as provisionally settled, became reconsiderable in relation to the patient's reality. Reconsideration involved examining what had been reopened and exploring clinical responses through dialogue between clinician and patient, followed by a clinical response and provisional closure. We describe this recurrent process as Clinical Epistemic Reopening (CER). CER identifies a clinical process through which the framing produced by medicine's necessary selectivity in making complex reality clinically knowable and actionable can itself become reconsiderable when patient reality reveals its limits. CER can thereby reverse the usual direction of clinical scrutiny: aspects of medicine that ordinarily function as means of understanding and acting upon the patient can themselves become objects of clinical inquiry. CER thus allows medicine to remain open to patient reality beyond the limits of its existing framings.

Background: Workplace discrimination and violence against health workers including sexual harassment is a societal problem worldwide. We aimed to assess the frequency, predictive factors, and effects of sexual harassment using a nationwide survey of physicians working in Switzerland. Materials and Methods: We conducted a self-administered questionnaire survey of physicians working in Swiss healthcare institutions. The questionnaire assessed experiences of sexual harassment at work, including frequency, types, and sources of harassment. It also asked about the impact of sexual harassment, whether incidents were reported, and what actions were taken following a report. Results: Among the 1837 physicians that participated in the survey, 575 (31.3%) had experienced sexual harassment at least once during their career. Among those reporting sexual harassment, 39.1% of women and 13.2% of men had experienced harassment at least once in their job. Women reported more verbal harassment, while men reported more physical harassment. Women were also more likely to face both forms combined. The main sources of harassment were colleagues of the same profession (46.7%), patients (42.3%), and superiors (41.0%). The most frequently reported impacts included stress (60.1%), emotional exhaustion (34.7%), reduced motivation at work (30%), and considering leaving the job (7.5%). Gender-men was associated with a lower likelihood of experiencing harassment 0.24 (0.18 to 0.31), whereas working in the German-speaking region was associated with a slightly higher likelihood of having experienced sexual harassment at least once (OR 1.35, 95% CI:1.02-1.81). Conclusions: Sexual harassment is common among physicians in Swiss healthcare institutions. It adversely affects the mental health and career trajectories of both men and women yet remains widely underreported due to fears of reprisals and inaction. Institutions should effectively intervene to ensure that reported incidents result in appropriate actions, and that those who report them receive adequate protection from reprisals.

Background: Capillary refill time (CRT) is an increasingly endorsed bedside perfusion marker in septic shock.Publicly available intensive care unit (ICU) databases such as MIMIC-IV and eICU-CRD enable large-scale multi-database research, but the cross-database comparability of CRT operationalization has not been systematically examined. Methods: We conducted a retrospective, descriptive, cross-database methodological analysis of adult ICU stays in MIMIC-IV v3.1 (2008-2022) and eICU-CRD v2.0 (2014-2015). CRT availability, definitional thresholds, recording patterns and time windows, bilateral measurement consistency, and selection bias in the CRT-documented population were characterized descriptively. Results: Among 94,458 MIMIC-IV and 200,234 eICU-CRD adult ICU stays, CRT availability differed markedly:79.85% of MIMIC-IV stays had at least one CRT record within the first 24 hours, versus 6.35% of eICU-CRD stays across the entire ICU stay, a 73.5-percentage-point gap. The abnormality threshold was 3 seconds in MIMIC-IV and 2 seconds in eICU-CRD. Among CRT-available MIMIC-IV stays, the mean number of CRT records in the first 24 hours was 7.0 (median 6, interquartile range (IQR) 4-10); 99.6% had bilateral records, with 99.4% left-right agreement (Cohen's kappa 0.914). The temporal distribution of CRT records was strikingly similar between databases: only 28.7% of MIMIC-IV and 29.1% of eICU-CRD records occurred within 24 hours of ICU admission (including pre-admission records), with roughly 71% in both databases recorded later in the stay. In eICU-CRD, the CRT-documented population had higher illness severity than the undocumented population (Acute Physiology and Chronic Health Evaluation (APACHE) IV 60.0 versus 54.4; standardized mean difference 0.21), consistent with selection by indication. Structured peripheral perfusion index fields were unavailable in both databases. Conclusions: CRT operationalization differs fundamentally across MIMIC-IV and eICU-CRD in availability, definitional thresholds, recording patterns, bilateral structure, and patient selection. Cross-database CRT research should explicitly declare definitional heterogeneity, avoid pooling across thresholds, and treat sparsely documented subsets as selected populations. Selection bias was evident in both databases, in opposite directions. Severity-score-based comparison was possible only in eICU-CRD. Standardized common data elements for bedside perfusion assessment are needed to make cross-database CRT research valid by design.

Objective: To test the hypothesis that selected SIRS and SOFA criteria measured at ICU admission have divergent associations with (1) the development of new culture-confirmed infections and (2) early empiric broad-spectrum antibiotic receipt in critically ill patients with cirrhosis. Design: Retrospective, observational study using electronic health record (EHR) data. Setting: Both community and academic ICUs within a five-hospital health system between July 2017 and December 2025. Subjects: Adult patients >18 years of age diagnosed with cirrhosis admitted to the ICU within 96 hours of hospital admission. Patients transferred from outside facilities and those with positive cultures collected >24 hours before ICU admission were excluded. Interventions: None. Measurements: Multivariable logistic regression tested the association of the most aberrant values in nine SIRS/SOFA vital sign and laboratory parameters measured during the 24 hours prior to ICU admission with (1) the development a newly positive culture collected during the 24 hours before through the 96 hours after ICU admission and (2) receipt of broad-spectrum antibiotics during the 24 hours before through the 24 hours after ICU admission. Main Results: The presence of hyperthermia, hypothermia, hypoxia, or hypotension at ICU admission was associated with both culture positivity and antibiotic receipt. The presence of leukocytosis was associated with antibiotic receipt but not culture positivity. Among patients in the 21.6% of encounters with newly positive cultures, normothermia and normal WBC were common (respectively present in 97.2% and 77.5% of encounters) and associated with antibiotic omission at ICU admission despite the subsequent development culture positivity. Conclusions: Traditional physiologic markers of infection are often absent in critically ill patients with cirrhosis who develop new culture-confirmed infections at ICU admission, possibly contributing to delayed antibiotics. There may be opportunities to improve antibiotic delivery and stewardship at ICU admission in this high-risk population.

Background AI use is growing by HPE scholars, and disclosure of that use is required by scientific ethics and journal policy. In spite of growing unease about the meaning, and meaningfulness, of AI-use disclosures in published manuscripts, little is known about how authors represent their AI use in published disclosure statements. Without such understanding, we are ill-equipped to redirect disclosure practices for increased sufficiency and sincerity, undermining efforts towards transparency in the era of AI-supported scholarship Methods In this descriptive qualitative study, 18 HPE researchers with experience disclosing generative AI use in publications from 2025-2026 were interviewed using Zoom. Data collection and thematic analysis proceeded iteratively, exploring participant experiences with AI use, their disclosure decisions, and evolving disclosure practices. Results Participants reported a wide range of experience writing AI-use disclosures (from 1-16 disclosures/participant); in total 31 published disclosures were shared by participants and discussed during the interviews. Our analysis identified four themes: A spectrum of AI uses; Multi-factorial disclosure decisions; Discrepancies between actual and disclosed use; and Emotions around disclosure. Discussion AI-disclosure takes place at the intersection of shared ethical principles and situated pragmatic concerns. Disclosure is both an intellectual and an emotional practice, changing over time as AI use evolves and journal expectations develop. More generative uses may provoke divisive responses and are related to uncertainty about how to disclose, concern about disclosure penalties, and periodic use-disclosure discrepancies. Understanding how researchers are navigating these complexities may help the HPE community articulate clearer guidance for transparent and meaningful disclosure of AI-use in scholarly work. Reflective methodologies can help bring these issues to the surface of ongoing conversations about AI use.

Background: During emergency tracheal intubation, clinicians use waveform capnography or colorimetric carbon dioxide (CO2) detection to confirm exhaled CO2 from the endotracheal tube to determine its location. Both devices reliably yield a negative result when the tube is in the esophagus. However, in most emergency intubations the tube is correctly located in the trachea, and in this circumstance the relative diagnostic accuracy of the two devices is uncertain. If one device more often fails to detect exhaled CO2 despite correct tube placement (a false negative result), this could lead to unnecessary tube removal, repeated intubation attempts, and an increased risk of serious complications. Research Question: Among critically ill adults undergoing emergency tracheal intubation, is waveform capnography or colorimetric CO2 detection more sensitive for identifying an endotracheal tube correctly placed in the trachea? Study Design and Methods: The WAVE study is a pragmatic, prospective, paired diagnostic accuracy study conducted in emergency departments and intensive care units in the United States. The study compares waveform capnography and colorimetric CO2 detection (index tests) against a non-CO2-based reference standard for endotracheal tube location among 2,092 critically ill adults undergoing tracheal intubation. The primary outcome is the sensitivity of each index test for identifying a tube located in the trachea. The secondary outcome is specificity for identifying a tube located outside the trachea. Results: Enrollment began on April 21, 2025 and is ongoing, with completion anticipated in 2026. Interpretation: The WAVE study will provide prospective evidence comparing waveform capnography with colorimetric CO2 detection for determination of endotracheal tube location in critically ill adults. These findings may inform clinical practice and guideline recommendations regarding the optimal test of exhaled CO2 for use in the ED and ICU. Prespecifying the protocol and statistical analysis plan before completion of enrollment enhances the rigor, reproducibility, and transparency of the study.

Importance: The Medicare Physician Fee Schedule values ambulatory services using survey-based estimates of physician time, a costly process vulnerable to inaccuracy. EHR audit logs are passively and universally collected and likely meet the American Medical Association Relative Value Scale Update Committee (AMA RUC) Extant Database Standards for alternative data to inform service valuation estimates. However, audit logs' validity for estimating face-to-face time, a core component of many of the most used procedural codes, is unknown. Objective: To assess whether EHR audit logs can facilitate accurate estimation of physician-patient face-to-face time during ambulatory visits. Design: Single-site validation study pairing EHR audit logs with direct audio/video recordings of ambulatory primary care visits (reference standard). We assessed agreement between audit-log estimates and recorded visit duration with Bland-Altman analysis and mean absolute error. Setting: University of Pennsylvania Observer data repository, a multi-modal database of ambulatory visits to Penn Medicine primary care clinics including video and audio recordings, transcripts, clinical EHR data, and EHR audit-log data. Participants: 75 visits from 12 physicians with data collected between August 2023 and February 2025. Exposures: A rule-based algorithm estimated face-to-face time via clusters of physician EHR activity relative to patient check-in time. Inactivity thresholds were applied to differentiate intraservice time with no EHR activity (e.g., a physical exam) from the end of a visit, with longer thresholds used for longer visits. Main Outcomes and Measures: Duration of recorded face-to-face visit time. Results: Recorded face-to-face time averaged 31.6 minutes (SD, 13.9). The audit-log estimator was unbiased (mean bias: -0.63 minutes; 95% CI: -6.0 to 2.6; mean absolute error: 9.0 minutes) and estimated face-to-face time within approximately 2% (38 seconds) of the recorded visit time with no proportional bias (slope: 0.13; P = .25). The 95% limits of agreement were -25.7 to 24.4 minutes, and 37% of estimates fell within 10% of recorded duration. Conclusions and Relevance: In this validation study, EHR audit logs recovered unbiased estimates of ambulatory face-to-face time. Larger-scale studies are required to verify generalizability, but EHR audit logs offer a scalable means to improve the rigor of retrospective physician work relative value unit estimation. This study represents a first step in a potential paradigm shift for measuring components of the fee schedule across procedures, settings, and provider types.