JAMA Internal Medicine Current Issue

December 2017 Issue Highlights

Fri, 01 Dec 2017 00:00:00 GMT

Evolution of Procedural Competency in Internal Medicine Training

Sacks CA, Alba GA, Miloslavsky EM. — Fri, 01 Dec 2017 00:00:00 GMT

This Viewpoint examines the implications of changing the scope of procedural training for general practitioners in internal medicine.

Clinical Care of Lesbian, Gay, Bisexual, and Transgender Older Adults

Torke AM, Carnahan JL. — Fri, 01 Dec 2017 00:00:00 GMT

This Viewpoint suggests several recommendations for quality care for lesbian, gay, bisexual, and transgender older adults that are informed by research evidence and expert opinion.

The Road to Zero Deaths From Motor Vehicle Crashes

Hersman DP, Rosekind MR. — Fri, 01 Dec 2017 00:00:00 GMT

This Viewpoint highlights the role of the health care community in reducing the number of deaths from motor vehicle crashes.

Compounded Bioidentical Hormone Therapy

Stuenkel CA, Manson JE. — Fri, 01 Dec 2017 00:00:00 GMT

This Viewpoint discusses the potential harms of perimenopausal and postmenopausal women taking compounded bioidentical hormone therapy not approved by the US Food and Drug Administration.

Music and Medicine: Something Important

Fitzgibbons S. — Fri, 01 Dec 2017 00:00:00 GMT

“You got any Gershwin?”

Residency Evaluations—Where Is the Patient Voice?

Tummalapalli S. — Fri, 01 Dec 2017 00:00:00 GMT

This Perspective discusses the importance of patient feedback during residency training and proposes how to include it.

The Epidemic of Guns

Bauchner H, Rivara FP, Bonow RO, et al. — Fri, 01 Dec 2017 00:00:00 GMT

The shooting in Las Vegas, Nevada, that left 59 people dead, 10 times that number wounded, and thousands of people with the psychological distress from being present at the scene during and after the massacre has once again raised the issue of what we as a nation can and should do about guns. The solution lies in not just focusing on Las Vegas and the hundreds of other mass shootings that have occurred in the United States in the last 14 months, but rather to underscore that on average almost 100 people die each day in the United States from gun violence. The 36 252 deaths from firearms in the United States in 2015 exceeded the number of deaths from motor vehicle traffic crashes that year (36 161). That same year, the US Centers for Disease Control and Prevention reported that 5 people died from terrorism. Since 1968, more individuals in the United States have died from gun violence than in battle during all the wars the country has fought since its inception.

Cancer Survivorship Care in Advanced Primary Care Practices

Rubinstein EB, Miller WL, Hudson SV, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This case study of 12 advanced primary care practices investigates why primary care has not begun to integrate comprehensive cancer survivorship services.

Gestational Diabetes and Long-term Cardiovascular Disease Risk

Tobias DK, Stuart JJ, Li S, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This cohort study of US women participating in the Nurses’ Health Study II prospectively evaluates the association of a history of gestational diabetes with incident cardiovascular risk.

Wealth-Associated Disparities in Death and Disability in the United States and England

Makaroun LK, Brown RT, Diaz-Ramirez L, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This cohort study evaluates the association between wealth, mortality, and disability among older adults in both the United States and England.

Cost-effectiveness of Testing and Treatment for Latent Tuberculosis

Tasillo A, Salomon JA, Trikalinos TA, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This cohort simulation model evaluates the use of tests and treatment of latent tuberculosis infection in residents born outside the United States.

Work-Family Conflict and Depression Among Male and Female Interns

Guille C, Frank E, Zhao Z, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This prospective longitudinal study examines the increase in depressive symptoms during physicians’ internship year, its potentially disproportionate effect on women, and work-family conflict as a risk factor.

Warfarin Use and Lower Cancer Incidence Among Older Patients

Haaland GS, Falk RS, Straume O, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This population-based cohort study uses the Norwegian national registries to determine the association between warfarin use and cancer incidence among persons aged 52 to 82 years.

Hospital Resource Use and Outcomes of Hospitalists vs PCPs vs Generalists

Stevens JP, Nyweide DJ, Maresh S, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This cohort study uses Medicare claims data to examine differences in health care resource use and outcomes among hospitalized Medicare beneficiaries cared for by hospitalists, their own primary care physicians, or other generalists.

Cessation Advice Plus Active Referral for Smokers

Wang M, Suen Y, Li W, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This pragmatic cluster randomized clinical trial evaluates the effectiveness of advice plus referral to smoking cessation services in individuals with varying levels and lengths of smoking.

Patient Navigation and Financial Incentives on Smoking Cessation

Lasser KE, Quintiliani LM, Truong V, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This randomized clinical trial evaluates a multicomponent intervention to promote smoking cessation among smokers with low socioeconomic status and smokers who are minorities.

Long-term Sustainability of Diabetes Prevention

Haw J, Galaviz KI, Straus AN, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This meta-analysis examines the use of medications and lifestyle modifications to reduce the progression to diabetes in persons with diabetes risks.

Integration of Cancer Survivorship Care and Primary Care Practice

Tonorezos ES, Conigliaro J. — Fri, 01 Dec 2017 00:00:00 GMT

More than 10 years ago, the Institute of Medicine (IOM) released a seminal report, From Cancer Patient to Cancer Survivor: Lost in Transition. In this publication, the IOM highlighted the now more than 15 million US adults with a history of cancer and outlined necessary components of high-quality survivorship care. Not unexpectedly, implementation of the IOM recommendations relied on the availability of well-informed and responsive primary care survivorship clinicians. Yet, in the time since that report, the primary care and oncology workforce has shrunk (and will continue to do so), while clinician uncertainty and survivorship knowledge gaps persist. Therefore, although oncologists, patients, and other stakeholders are looking toward a primary care context for high-quality and life-sustaining survivorship care, uneven survivorship care delivery has continued. Unfortunately, failure to meet the health care needs of cancer survivors seems to result in adverse outcomes.

Pregnancy and Glucose Intolerance in Women of Childbearing Age

Gunderson EP, Jaffe MG. — Fri, 01 Dec 2017 00:00:00 GMT

The increased physiologic and metabolic demands of pregnancy act as a “stress test” that may reveal underlying subclinical disease or provide insight into future chronic disease. Pregnancy complications, such as gestational diabetes (GD) and hypertensive disorders, are “early warning” signs for chronic disease in women decades before the menopausal transition. More than 50 years ago, O’Sullivan and Mahan developed criteria for the diagnosis of GD, glucose intolerance first recognized during pregnancy, based solely on observed higher rates of progression to diabetes in women many years postdelivery. A history of GD confers a 7-fold higher risk of type 2 diabetes mellitus and 3-fold higher cardiometabolic risk for women. In 2011, the American Heart Association added GD history to its CVD risk assessment for women based on the strong link to overt diabetes. Until recently, evidence was insufficient to determine whether a history of GD elevated CVD risk independent of its association with overt diabetes and metabolic disease.

Health and Wealth in the United States and England

McKee M, Stuckler D. — Fri, 01 Dec 2017 00:00:00 GMT

Although superficially they have much in common, health and social policy in the United States and England differ greatly. England provides universal health coverage; notwithstanding the achievements of the Affordable Care Act, the United States does not. England has retained strong social safety nets. Welfare in the United States is much less generous and, although those reaching 65 years can look forward to a range of benefits, support for the young is much less generous. But what do these differences mean for the health of those living in each country? Makaroun and colleagues ask this question in the accompanying article.

Mainstreaming Latent Tuberculosis Infection Testing and Treatment in the US

Flood J, Barry PM. — Fri, 01 Dec 2017 00:00:00 GMT

Every hour in the United States a clinician makes a new diagnosis of tuberculosis (TB) disease, and 5% to 10% of those newly diagnosed will die. The internist has a critical role in changing the fate of patients who are at risk for TB. More than 80% of TB disease in the United States develops years after infection so there is time to intervene. In the United States, there are 13 million to 14 million persons estimated to be living with latent TB infection (LTBI) and it is these persons–often unaware of their infection and untreated–who represent the majority of our TB cases today and in the future. The good news is that TB disease can be prevented through testing and treatment of LTBI. To make TB prevention even simpler, we now have a safer, shorter, effective treatment regimen.

Evidence-Based Interventions for Trainee and Physician Wellness

Shea JA, Bellini LM. — Fri, 01 Dec 2017 00:00:00 GMT

In this issue of JAMA Internal Medicine, Guille and colleagues present a prospective longitudinal cohort study of medical internship in the United States during the 2015 to 2016 academic year. Their results showed that both men and women end medical school with about the same levels of depression but experience a marked increase in depressive symptoms during their internship year, with the increase being significantly greater for women. Additionally, when work-family conflict was accounted for, the sex disparity in the increase in depressive symptoms was reduced by about one-third. In the end, the authors suggest that systemic modifications to alleviate conflict between work and family life may improve physician mental health and, in turn, improve patient care and reduce physician career attrition.

Costs and Benefits of Hospital Care by Primary Physicians

Willett LL, Landefeld C. — Fri, 01 Dec 2017 00:00:00 GMT

In 1948, LIFE magazine published the “Country Doctor” (http://time.com/3456085/w-eugene-smiths-landmark-photo-essay-country-doctor/), the photographic essay by W. Eugene Smith that established the iconic American physician as one who provides comprehensive care for his or her patients wherever they were, whenever they were needed. In Kremmling, Colorado, Dr Ernest Ceriani cared for people at home, in the office, and in the hospital, sometimes carrying them bodily from one place to another. Since 1948, times have changed, and comprehensive care with continuity in the relationship of a patient with “my doctor” has decreased, especially during inpatient hospital care. In 1996, Wachter and Goldman heralded the emerging role of hospitalists, and the proportion of general medicine inpatient services attributed to hospitalists has increased rapidly, from 9% in 1995 to 37% in 2006 and 58% in 2013.

The Business Case for Investing in Physician Well-being

Shanafelt T, Goh J, Sinsky C. — Fri, 01 Dec 2017 00:00:00 GMT

This Special Communication applies financial principles to determine the cost of physician burnout and the financial return on organizational investments to reduce it.

Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing

Eaton KP, Levy K, Soong C, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This Special Communication describes the effect of interventions used to reduce ordering of laboratory tests for inpatients to lower hospital costs and adverse event rates.

Point-of-Care Ultrasonography

Liu RB, Donroe JH, McNamara RL, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This review examines basic concepts and applications of point-of-care ultrasonography, as well as issues surrounding training and implementation.

Unnecessary Use of Inferior Vena Cava Filters

Goswamy RV, Maiti A, Escobar MA. — Fri, 01 Dec 2017 00:00:00 GMT

This Teachable Moment examines the case of a woman in her 20s with ulcerative colitis, unprovoked deep vein thromboses, and pulmonary embolism who had been taking coumadin and presented with acute-onset left-sided pleuritic chest pain for 3 days.

Treating the “Wake-up Call” of Alcohol Use

Roy P, Worsham C. — Fri, 01 Dec 2017 00:00:00 GMT

This Teachable Moment explores the case of a patient who gained new insight into his own patterns of unhealthy drinking after having a seizure.

Unnecessary Thyroid Ultrasonography and Laboratory Thyroid Abnormalities

Gupta A, Arora N, Gruntmanis U. — Fri, 01 Dec 2017 00:00:00 GMT

This Teachable Moment looks at the case of a woman with hypothyroidism and the risks of unnecessary thyroid ultrasonography in the workup of this disorder.

Appropriate Use of Imaging for Acute Abdominal Pain

Schifeling CH, Williams DA. — Fri, 01 Dec 2017 00:00:00 GMT

The case described in this Teachable Moment demonstrates that clinicians should consider the costs and downsides of additional imaging when acute abdominal pain is deemed nonurgent by clinical assessment.

Pitfalls of Single-Electrocardiogram Lead Monitoring

Nishtala A, Goldschlager N. — Fri, 01 Dec 2017 00:00:00 GMT

A man in his 30s with no significant medical history was admitted for community-acquired pneumonia. He was prescribed trimethoprim/sulfamethaxazole for treatment of his infection. During his hospital course, he was afebrile, had a regular heart rate of 65 bpm, and a blood pressure of 113/67 mm Hg. His room air oxygen saturation was 98%, and he was breathing comfortably at a rate of 16 breaths per minute. Pulmonary examination revealed bronchial breath sounds, tactile fremitus, and egophony at the right lung base. Cardiac examination was notable for normal central venous pressure and waveforms, a regular cardiac rhythm, nondisplacement of the point of maximal impulse, no precordial lifts, normal first and second heart sounds, and no murmurs, rubs, or gallops. Laboratory test results were all normal.

The Concertina Case of Ventricular Preexcitation

Muniyappa A, Nishtala A, Goldschlager N. — Fri, 01 Dec 2017 00:00:00 GMT

A healthy man in his early 40s presented to the emergency department after a second syncopal episode in 2 weeks. Both episodes occurred without prodromal symptoms, tonic-clonic movements, tongue biting, or incontinence, and the patient felt normal afterward.

A Case of Chest Pain and Transient Cardiac Arrest

Chiu MH. — Fri, 01 Dec 2017 00:00:00 GMT

A woman in her 50s with a medical history of hypertension, hypothyroidism, and dyslipidemia presented to the emergency department with 15-minute episode of severe rest angina on a background of a 3-month history of self-limited exertional dyspnea and typical chest discomfort associated with diaphoresis and nausea. She had no chest pain on assessment, and her initial vital signs revealed a heart rate of 56 bpm, blood pressure of 145/96 mm Hg (similar in both arms), and normal respiratory rate. Her precordial examination findings were noncontributory, with no extra heart sounds or murmurs. Complete blood cell count, serum chemical analysis, and serial troponin levels were normal, and her initial electrocardiogram (ECG) in the emergency department was unremarkable. She was admitted to the cardiology service and treated for unstable angina. Twenty-four hours into her admission, she had a recurrence of her chest discomfort with acute loss of consciousness and no palpable pulse. Her ECG on the telemetry is shown in the Figure.

Assessing Health Insurance Coverage Characteristics

Park ER, Kirchhoff AC, Nipp RD, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This study assessed a randomly selected, age-stratified sample of 698 childhood cancer survivors and 210 siblings and insurance coverage characteristics to determine the impact of underinsurance.

Association of Racial Differences With End-of-Life Care Quality

Sharma RK, Freedman VA, Mor V, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This cross-sectional analysis of survey data collected from 2011 to 2015 for the National Health and Aging Trends Study assesses whether racial differences in the quality of end-of-life care persist in the United States.

US Trends in Inferior Vena Cava Filter Placement, 2005-2014

Saeed MJ, Turner TE, Brown DL. — Fri, 01 Dec 2017 00:00:00 GMT

This population-based study examines the change in the rates of inferior cava filter placement in US inpatients from 2005 to 2014.

Spatial and Temporal Mapping to Identify Nosocomial Disease Transmission of C difficile

Murray SG, Yim JL, Croci R, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This study evaluates the use of spatial and temporal mapping to identify nosocomial disease transmission of Clostridium difficile.

Use of Firearms in Terrorist Attacks

Tessler RA, Mooney SJ, Witt CE, et al. — Fri, 01 Dec 2017 00:00:00 GMT

This analysis of the Global Terrorism Database evaluates differences in the use of firearms in terrorist attacks between the United States, Canada, Europe, Australia, and New Zealand.

Drug Trials Snapshots and Sexless Drug Labels

Cook G, Wilhelm EE. — Fri, 01 Dec 2017 00:00:00 GMT

We would like to thank the US Food and Drug Administration (FDA) for their continued efforts to make drug safety and efficacy data for subpopulations more transparent to the public. The FDA’s Drug Trials Snapshots (DTS) are a welcome addition to other drug information tools; DTS help to address a void in publicly available and readily understandable information about medical products.

Drug Trials Snapshots and Sexless Drug Labels—Reply

Whyte J, Woodcock J, Wang J. — Fri, 01 Dec 2017 00:00:00 GMT

In Reply We posited that the difference between the number of sex-specific statements made in the Drug Trials Snapshots vs the drug label may be owing to the legal requirements imposed on the prescribing information, for which sex demographic labeling is not a required subsection. Our premise was that the prescription drug label and Drug Trials Snapshots fulfill different purposes, which may lead to differences in the number of sex-specific statements.

Search Images and Extrapolation Risk

Rothschild BM. — Fri, 01 Dec 2017 00:00:00 GMT

To the Editor An Original Investigation by Halpern and colleagues and Invited Commentary by Subak and Grady, both published in a recent issue of JAMA Internal Medicine, suggest that evaluation of asymptomatic microscopic hematuria may not be cost-effective. Their focus was on subsequent recognition of genitourinary cancer and would have major implications for use of the test, if that were the only implication of identification of red blood cells in urine. A recent article relating the lack of reliability of the dipstick method for recognizing significant hematuria may provide insight. Microscopic examination revealed significant number of red blood cells in 1 of 8 consecutively evaluated individuals (undergoing safety monitoring for medication-related toxic effects) whose dipstick testing did not reveal hematuria. That expands the pool of individuals with microscopic individuals beyond that evaluated by Halpern et al. That would seem to reinforce their views, except for an important detail. Workup of those individuals revealed clinically significant pathology in 20%.

Search Images and Extrapolation Risk

Brown RS. — Fri, 01 Dec 2017 00:00:00 GMT

To the Editor In their cost-effectiveness evaluation of diagnostic approaches to asymptomatic microscopic hematuria in a recent issue of JAMA Internal Medicine, Halpern et al point out the superiority of using ultrasonography over the alternative of computed tomography together with cystoscopy for detection of urinary tract cancer. However, I believe that their advice needed to be more nuanced to properly inform the reader. While occult cancer may be of greatest concern, glomerular disease with its attendant risks for chronic kidney disease and premature death is a serious condition in those with microscopic hematuria, particularly when affected patients present in the primary care setting and are not referred to specialty clinics or urologists. First, a careful urinary sediment examination looking for either erythrocyte casts or greater than 5% acanthocytes, which has almost 100% specificity for glomerular disease, is a noninvasive way to spare patients from unnecessary imaging or cystoscopy.

Search Images and Extrapolation Risk—Reply

Grady D, Subak L. — Fri, 01 Dec 2017 00:00:00 GMT

In Reply Dr Rothschild points out that urine dipstick testing is not accurate for detection of microscopic hematuria. We fully agree with this point, and we noted in our Invited Commentary that asymptomatic microscopic hematuria (AMH) should be defined as 3 or more red blood cells per high-powered microscopic field on urine microscopy and should not be based on dipstick results.

Search Images and Extrapolation Risk—Reply

Halpern JA, Chughtai B, Ghomrawi H. — Fri, 01 Dec 2017 00:00:00 GMT

In Reply We read with great interest the contrasting views from Dr Rothschild and Dr Brown suggesting that evaluation of asymptomatic microscopic hematuria is either insufficiently sensitive or too aggressive for the detection of genitourinary pathology. The crux of this debate pertains to the yield and potential value of early detection of genitourinary conditions in the setting of asymptomatic microscopic hematuria. Our Original Investigation focused on detection of malignancy, which we believe is paramount, since patients with urothelial cancer may have progression of disease by the time they develop symptoms.

Specialty Societies and Breast Cancer Screening Recommendations

Lee CI, Scheel JR, Lee JM. — Fri, 01 Dec 2017 00:00:00 GMT

To the Editor In their research letter published in a recent issue of JAMA Internal Medicine, Radhakrishnan and colleagues describe the results from a survey of primary care physicians and gynecologists (the Breast Cancer Social Networks Study). Among 871 respondents, they report that 81% recommend screening to women ages 40 to 44 years, and 88% recommend screening to women ages 45 to 49 years. Moreover, only 23% of physicians trusted US Preventive Services Task Force (USPSTF) guidelines the most and recommended biennial screening beginning at age 50 years, while 26% trusted the American Congress of Obstetricians and Gynecologists (ACOG) the most and recommended annual screening starting at age 40 years.

Specialty Societies and Breast Cancer Screening Recommendations—Reply

Radhakrishnan A, Parker AM, Pollack CE. — Fri, 01 Dec 2017 00:00:00 GMT

In Reply Lee and colleagues reinforce differences in recommending breast cancer screening by physician specialty and underscore the importance of adherence to different guidelines across physician specialties.

Considerations Concerning Disease Redefinition

Yang Z, Fan H, Tang J. — Fri, 01 Dec 2017 00:00:00 GMT

To the Editor In a Special Communication published in a recent issue of JAMA Internal Medicine, Doust et al raised timely concerns about modifying disease definitions, which, in essence, addresses what constitutes a disease and is a fundamental question for modern medicine where diseases are often diagnosed without symptoms and signs. However, the checklist proposed mixed the criteria for modifying a disease definition (items 6 through 8 in Table 2) with the reasons (item 3) and consequences (items 1, 2, and 4) of making the change. For defining a disease, the risk of the condition and the benefits and harms of interventions should be set as primary determinants.

Considerations Concerning Disease Redefinition—Reply

Doust J, Qaseem A, Glasziou P. — Fri, 01 Dec 2017 00:00:00 GMT

In Reply We thank Dr Yang and colleagues for raising important points regarding our Special Communication on modifying disease definitions, many of which we alluded to in our article but that we agree need further discussion.

Concerns About Conclusions of Self-monitoring of Blood Glucose

Pimazoni-Netto A, Rodbard D. — Fri, 01 Dec 2017 00:00:00 GMT

To the Editor In a recent issue of JAMA Internal Medicine, an Original Investigation by Young et al reports the results of a randomized clinical study wherein use of daily self-monitoring of blood glucose failed to improve glycated hemoglobin (HbA_1c) levels compared with the study’s control participants. Young et al conclude that glucose monitoring in patients with non–insulin-treated type 2 diabetes should not be routine, and Figure 1 shows a reduction of HbA_1c by 0.35% in patients using self-monitoring of blood glucose after 6 months. Glycated hemoglobin levels gradually returned to baseline levels by 1 year, but 33% of study participants had stopped monitoring after 6 months while 40% to 60% stopped monitoring after 1 year. If half the participants did not adhere to the intervention, a sustained response should not have been expected, especially with the well-known progression of glucose intolerance in type 2 diabetes.

Concerns About Conclusions of Self-monitoring of Blood Glucose—Reply

Young L, Buse J, Donahue K. — Fri, 01 Dec 2017 00:00:00 GMT

In Reply We thank Pimazoni-Netto et al for their letter and include our response to their concerns. In considering our published results, it is of tantamount importance that readers understand the tenets of comparative effectiveness research (CER). Comparative effectiveness research studies are pragmatic in nature, and they are designed to: (1) inform health care decisions and/or policy; (2) evaluate 2 or more interventions that have the potential to represent best practice; and (3) be executed in real-world, clinical settings. The MONITOR trial was designed as a comparative effectiveness trial. For those steeped in the traditions of efficacy trials, fully embracing the tenets of CER can be challenging.

Selection Does Not Equate Consumption

Cohen JW, Richardson S, Rimm EB. — Fri, 01 Dec 2017 00:00:00 GMT

To the Editor We applaud Turnwald et al for their experimental design to test inexpensive interventions to increase healthy food consumption within the Stanford University dining hall. In a Research Letter published in a recent issue of JAMA Internal Medicine, Turnwald et al reported that indulgent descriptors of healthy vegetables dramatically increased “consumption” compared with alternatively labeling the same food. The assumption that measuring the quantity of a vegetable selected equates to consumption is flawed and may misrepresent the results and overstate the conclusions. The authors cited a review by Wansink and Johnson that found that on average 92% of foods selected are consumed.

Selection Does Not Equate Consumption—Reply

Turnwald BP, Boles DZ, Crum AJ. — Fri, 01 Dec 2017 00:00:00 GMT

In Reply We agree with Dr Cohen and colleagues about the importance of measuring taste and consumption. We also agree that work should be done to upgrade the preparation of healthy foods. The ultimate taste and experience of any food is a synergy of quality ingredients, their preparation, and one’s mindset about those foods. Thus, improving consumption is best achieved by changing both our negative mindsets about healthy foods and the preparation of the foods themselves.

Incorrect Author Affiliation

Fri, 01 Dec 2017 00:00:00 GMT

In the article titled “Distribution of Medical Education Debt by Specialty, 2010-2016,” the affiliation for Ari B. Friedman, MD, PhD, was incorrect. Dr Friedman’s correct affiliation is the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts. This article was corrected online.

JAMA Internal Medicine

Fri, 01 Dec 2017 00:00:00 GMT

Mission Statement: To promote the art and science of medicine and the betterment of human health by publishing manuscripts of interest and relevance to internists practicing as generalists or as medical subspecialists.