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.

Background: In primary care, rising demand and shrinking capacity produce chaotic variability during clinic days, yet this daily "schedule volatility" and its drivers are rarely measured. Objective: To measure primary care physicians' (PCPs') assessments of daily schedule volatility and its contributing factors, and to identify potential electronic health record (EHR)-derived measures to proxy these constructs. Design: Observational pilot study pairing contemporaneous end-of-day text-message (SMS) surveys with matched EHR data. Setting: Five primary care clinics in the University of Maryland Medical System, August to December 2025. Participants: Eight PCPs with at least 50% clinical effort. Measurements: Daily schedule volatility (5-point Likert rating) and contributing factors, collected by SMS after clinic close; four EHR-derived outcome measures (same-day visit closure, cumulated time to chart closure, and the presence and volume of EHR work after 7pm) and 16 contributing-factor measures spanning tardiness, no-shows and cancellations, asynchronous ("InBasket") volume, and schedule structure. PCP-rated volatility was dichotomized (top two "difficult-to-manage" categories vs. others) and compared using bivariate tests. Results: Of 150 surveys, 105 were completed (70% response rate; median response 27 minutes). Difficult-to-manage days were uncommon (14% of days), although patient tardiness, no-shows, long-running visits, and InBasket burden were each reported on >40% of days. Difficult days involved more evening EHR work (55% vs. 19%; p=0.033), higher asynchronous volume (median 13 vs. 4 patient-message encounters; p=0.022), and higher visit volume (median 17 vs. 7; p=0.001). No-shows and same-day cancellations were not associated with volatility. Limitations: Single-system pilot; bivariate, cross-sectional, and hypothesis-generating. Conclusion: PCPs' experience of chaotic clinic days is measurable and appears driven more by asynchronous burden and visit volume than by patient no-shows or tardiness; evening EHR work is a promising scalable proxy. Primary Funding Source: American Medical Association.

Background: People with disabilities (PWD) represent over one-quarter of the US population and disproportionately experience chronic pain, yet limited research explores disparities they face in opioid use disorder (OUD) treatment. Objective: To examine disparities across disability status regarding opioid use disorder (OUD)-related outcomes and understand how chronic pain interacts with these associations. Methods: We completed a cross-sectional, secondary analysis of data from the All of Us Research Program, including 370,722 adults with electronic health record data available between January 2021-September 2023. We identified prevalence of disability, chronic pain, OUD, receipt of medications for OUD (MOUD), and OUD remission using diagnostic codes. We performed interaction analyses between chronic pain, disability subtype, and MOUD receipt in affecting OUD outcomes. Results: OUD was more common among individuals with physical (aOR: 2.74, 95% CI: 2.54-2.95), cognitive (2.19, 1.94-2.45), and multiple disabilities (2.43, 2.19-2.68), compared to those without disabilities. Among patients with OUD, those with physical disabilities were less likely to receive MOUD (0.81, 0.69-0.94). Compared to those without disabilities, chronic pain was associated with higher probabilities of OUD diagnosis and lower probabilities of MOUD and OUD remission across all subjects. These relationships were stronger for OUD diagnosis in cognitive disabilities, MOUD in multiple disabilities, and OUD remission in physical disabilities. Conclusions: Disability and chronic pain jointly shape disparities in OUD treatment and underscore the urgent need for care models that integrate OUD treatment with pain management and address the unique access challenges faced by people with disabilities.

Supervised psilocybin services are expanding across the United States, yet how individuals accessing these programs compare with those using psilocybin in the general population is unknown. We conducted a cross-sectional descriptive comparison of Oregon Psilocybin Services (OPS) data from licensed service centers in 2025 (5,935 encounters) and the 2024 National Survey on Drug Use and Health (NSDUH) public-use file (1,822 of 47,299 adults reporting past-year psilocybin use), examining demographics, reasons for use, self-reported disability, and past-year psychiatric conditions and treatment. OPS clients were predominantly female (58.2%) and aged 35 or older (82.1%), whereas adults reporting psilocybin use nationally were predominantly male (64.0%) and younger than 35 (56.7%). Racial and ethnic minority representation was narrower in Oregon (0.9% Black, 2.5% Hispanic vs. 5.4% and 14.3% nationally). OPS clients reported higher incomes (58.5% earning >$95,000) and primarily cited wellness; self-reported disability was uncommon. Adults using psilocybin nationally had high past-year rates of major depressive episode (22.7%), serious psychological distress (36.8%), substance use disorder (61.7%), and mental health treatment receipt (42.9%). Oregon's open-access model selects higher-income, clinically stable, wellness-oriented adults, while millions with psychiatric and substance-use burden use psilocybin outside supervised channels; its safety and utilization data should not be generalized.

Objectives Outpatient buprenorphine-naltrexone (bup-nx) treatment reduces overdose risk, yet many patients still return to use or disengage from treatment. We sought to understand how patients and prescribers experience and manage relapse risk, monitoring, and treatment agency in routine bup-nx treatment to identify gaps in current practice. Methods We conducted a qualitative needs assessment using semi structured, critical incident interviews with patients receiving outpatient bup-nx and prescribers who manage bup-nx treatment. Interviews examined situations involving relapse risk and empowerment in treatment decisions. We structured data collection and analysis using the Theoretical Domains Framework and COM B model to characterize determinants. Transcripts were coded deductively and inductively until code level saturation was reached. Results Participants (9 patients, 8 prescribers) described nine treatment needs mapped to the Capability, Opportunity, and Motivation components of the COM B model. These themes highlighted how patient agency in bup-nx treatment was constrained by physiologic and emotional states, with withdrawal, craving, pain, and distress often overriding longer term goals. Relapse vulnerability was experienced as dynamic and intensifying between visits, while clinical detection remained anchored to visit bound assessments, urine drug testing, refill patterns, and crisis driven contact, creating blind spots. Structural friction (pharmacy rules, insurance disruptions, transportation and housing instability), stigma from family and recovery communities, and motivational processes tied to fluctuating readiness and trust in monitoring further shaped engagement, disclosure, and dosing decisions; the same monitoring tools could either support honest disclosure or provoke concealment when perceived as punitive. Conclusions Relapse risk and agency in bup-nx treatment are negotiated as dynamic processes within structurally constrained and trust sensitive systems. Addressing the identified capability, opportunity, and motivation gaps will require patient centered, trust preserving approaches to monitoring and shared decision making.

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: Healthcare has witnessed administrative staffing roles balloon to twice the number of employed clinicians, resulting in $950 billion per year in administrative costs to deliver healthcare. Administrative workflows, like fax routing, are ripe for automation given the high human labor cost necessary to complete these tasks. Facsimile transmissions remain a key mode of communication in modern healthcare, requiring substantial manpower, and incurring significant, though not well-characterized, costs to health systems. Opportunities may exist for agentic artificial intelligence (AI) to automate this administrative task. Methods: This quality improvement study was performed in 2 phases at Duke University's Division of Cardiology, a single tertiary-care cardiac referral center. The first retrospective phase employed an observational time study design surveying manual fax routing processes at 3 representative cardiology clinics from April 1, 2024, to July 12, 2024. The second phase quantified all inbound faxes received through the division's communication hub from July 1, 2025, to December 31, 2025, and applied direct labor costs observed in the time study to quantify the economic burden of manual fax routing across the hub. Results: The observational time study (Phase 1) demonstrated fax routing processing times ranging from 4.4 to 9.4 minutes depending on fax type, with a mean processing time of 6.0 minutes per fax. On average, the ambulatory clinics received 1,694 faxes per month and spent 169.1 person-hours routing faxes. The divisional communication hub (Phase 2) received 24,420 faxes over the study period, averaging 4,070 inbound faxes and 13,341 pages of information per month. Extrapolating direct labor efforts from the time study, 407 person-hours per month were spent processing inbound faxes. For our institution, this translated to $10,663.40 in total monthly costs, roughly 2.5 full-time equivalents. Conclusion: Manual fax routing represents a substantial, measurable, and previously under-characterized operational and administrative burden. Given the significant opportunity to reduce labor time and costs, our study establishes fax routing as a high-value target for automation. Future work is needed to determine the impact of AI-automated fax routing on the time, labor, accuracy, and economics within clinical settings.

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.

Objective: To assess the efficacy of an executive peer coaching program, Charting Champions Program (CCP), in helping physicians manage their administrative workload, thereby improving time management, workflow and well-being. Findings: In this longitudinal survey study, physicians self-reported significant improvements in completing charting and administrative paperwork during their clinical day. Physicians reported significant improvements in mental, cognitive and emotional states after the program. Meaning: The Charting Champions Program is an effective intervention that supports physicians in problem-solving the administrative burden of their clinical day, improving workflow efficiency, completing administrative requirements during clinical hours, and enhancing work-life balance and personal satisfaction. Background: Physicians are subject to high levels of mental, physical, and emotional stress, partly due to increasing administrative burdens. Online coaching is a proven intervention to help physicians improve workflow efficiency, reduce administrative burden and improve job satisfaction. Design: This voluntary longitudinal survey took place between 2020 and 2023. Physicians were asked to complete a survey at program entry and again 30-90 days after program completion. The survey consisted of 14 Likert scale questions, and a final sample of 280 physicians completed both surveys. Intervention: CCP contains modules that teach workflow improvements for clinical days, including timely charting, administrative task workflow, managing patient consultations and reducing interruptions. Interventions include self-paced modules, live coaching, recordings and an online peer community. Results: Post-CCP physicians reported a significant decrease in hours spent charting (P<0.0001) and completing clinical paperwork outside of clinical hours (P<0.006). Physicians also reported a decrease in work-related dread (P<0.001), feelings of burnout (P<0.001), and thoughts of quitting due to administrative burdens (P<0.001). Physicians felt more focused at work (P<0.001), felt more in control of the clinical day (P<0.001), and rated their mental energy at work higher (P<0.001). The program did not affect the number of patients seen in a full clinical day (P > 0.918). Conclusion and Relevance: The CCP reduces the time physicians spend on tasks outside of clinical hours, increasing free time without decreasing the number of patients seen per day.

Importance: Physician-scientist careers depend on sustained research funding, protected time, and institutional resources. However, data on career-retention attitudes across career stages are limited. Objective: To characterize career intentions and associated research-environment factors among MD-PhD students and early-career physician-scientists. Design: Two independent, national cross-sectional surveys were conducted during nonoverlapping periods in 2025; MD-PhD applicant and matriculant trends were also examined. Setting: Medical schools and academic health centers in the United States. Participants: MD-PhD students and early-career physician-scientists (ECPS). Exposures: MD-PhD exposures included perceived institutional support, training-related mental health impact, and research disruption. ECPS exposures included institutional support, adverse funding-related wellbeing, and direct National Institutes of Health funding-process disruption. Main Outcome and Measures: Primary outcomes were consideration of leaving the physician-scientist pathway among MD-PhD students and consideration of leaving academic medicine or research among ECPS. Secondary outcomes included likelihood of staying in academic medicine, research-intensive career preference, and consideration for leaving the US to continue research. Results: Among MD-PhD programs confirmed to have distributed the survey, 838 student responses were received (estimated response rate of 19.3%); 175 ECPS responses were received, with no calculable individual-level response rate. Among MD-PhD students, 423 of 835 (50.7%) reported considering leaving the physician-scientist pathway; 712 of 837 (85.1%) reported a high likelihood of remaining in academic medicine, and 664 of 836 (79.4%) preferred a research-intensive career. Adequate institutional support was associated with lower odds of considering leaving (adjusted odds ratio [aOR], 0.28; 95% CI, 0.14-0.54) and higher odds of staying in academic medicine (aOR, 5.65; 95% CI, 2.91-10.98). Training-related mental health impact (aOR, 2.34; 95% CI, 1.72-3.19) and research disruption (aOR, 1.83; 95% CI, 1.35-2.48) were associated with greater odds of considering leaving. Among ECPS, 57.7% considered leaving, 52.6% reported a high likelihood of staying, and 42.9% considered leaving the United States to continue research. Adverse funding-related well-being was associated with considering leaving academic medicine (aOR, 3.13; 95% CI, 1.52-6.63) and leaving the United States to continue research (aOR, 5.29; 95% CI, 2.35-13.12). Conclusions and Relevance: Consideration of leaving was common despite continued interest in academic and research-intensive careers. Institutional support, adverse well-being, and research disruptions were associated with career intentions.

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.