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1.  Heartsink Hotel, or “Oh No, Look Who’s on My Schedule this Afternoon!” 
Journal of General Internal Medicine  2013;28(11):1385-1386.
doi:10.1007/s11606-013-2447-8
PMCID: PMC3797346  PMID: 23661037
3.  Impressions of the Indiana Global Health Research Conference: An Editor’s Account 
Journal of General Internal Medicine  2013;28(Suppl 3):621-624.
doi:10.1007/s11606-013-2454-9
PMCID: PMC3744282  PMID: 23797911
4.  MANAGEMENT OF CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME: AN EVIDENCE-BASED APPROACH 
Urology  2006;67(5):881-888.
doi:10.1016/j.urology.2005.12.015
PMCID: PMC1463048  PMID: 16698346
chronic prostatitis; chronic pelvic pain syndrome; prostate; CI – confidence interval; CP/CPPS – chronic prostatitis/chronic pelvic pain syndrome; CGI – clinical global improvement; NIH/NIDDK – National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases; NIH-CPSI – National Institutes of Health Chronic Prostatitis Symptom Index; NNT – number needed to treat; PPS – pentosan polysulfate; RR – risk ratio; RCT – randomized controlled trial
7.  Capsule Commentaries 
doi:10.1007/s11606-013-2375-7
PMCID: PMC3599024  PMID: 23423457
8.  Why Residents Consider Working Beyond the Duty Hour Limits: Implications of the ACGME 2011 Duty Hour Standards 
Background
The Accreditation Council for Graduate Medical Education 2011 duty hour standards became effective on 7 1, 2011. One of the new standards allows residents to exceed the limit on continuous duty hours in unusual circumstances relating to patient or family need or rare educational opportunities. There are no data about how often or in what circumstances residents would consider exceeding their duty hour limits using this new provision in the standards. We surveyed internal medicine residents to explore these questions.
Methods
We conducted an anonymous cross-sectional survey of internal medicine residents at a midwestern tertiary-care hospital to determine how often they had considered exceeding duty hour limits in the preceding 2 weeks. We analyzed responses using descriptive statistics and χ2 tests for comparisons.
Results
We obtained responses from 51 of 86 residents (59%). Of those residents, 69% (35/51) indicated that they had wanted to exceed duty hour limits at least once in the prior 2 weeks. The most common reason cited was to provide continuity of care for a patient. The 24 + 6–hour rule was the standard most likely to be broken (cited by 66%; 23/35).
Conclusions
Program leadership should anticipate that residents will commonly identify situations in which they will consider exceeding duty hour limits. It will be important to provide guidance to residents early in the year about the situations that would be appropriate for the application of this new standard.
doi:10.4300/JGME-D-11-00069.1
PMCID: PMC3244329  PMID: 23205212
9.  Therapeutic Intervention for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS): A Systematic Review and Meta-Analysis 
PLoS ONE  2012;7(8):e41941.
Background
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has been treated with several different interventions with limited success. This meta-analysis aims to review all trials reporting on therapeutic intervention for CP/CPPS using the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI).
Methods
We searched Medline, PubMed, the Cochrane Pain, Palliative & Supportive Care Trials, the Cochrane Register of Controlled Trials, CINAHL, ClinicalTrials.gov, and the NIDDK website between 1947 and December 31, 2011 without language or study type restrictions. All RCTs for CP/CPPS lasting at least 6 weeks, with a minimum of 10 participants per arm, and using the NIH-CPSI score, the criterion standard for CP/CPPS, as an outcome measure were included. Data was extracted from each study by two independent reviewers. Gillbraith and I-squared plots were used for heterogeneity testing and Eggers and Peters methods for publication bias. Quality was assessed using a component approach and meta-regression was used to analyze sources of heterogeneity.
Results
Mepartricin, percutaneous tibial nerve stimulation (PTNS), and triple therapy comprised of doxazosin + ibuprofen + thiocolchicoside (DIT) resulted in clinically and statistically significant reduction in NIH-CPSI total score. The same agents and aerobic exercise resulted in clinically and statistically significant NIH-CPSI pain domain score reduction. Acupuncture, DIT, and PTNS were found to produce statistically and clinically significant reductions in the NIH-CPSI voiding domain. A statistically significant placebo effect was found for all outcomes and time analysis showed that efficacy of all treatments increased over time. Alpha-blockers, antibiotics, and combinations of the two failed to show statistically or clinically significant NIH-CPSI reductions.
Conclusion
Results from this meta-analysis reflect our current inability to effectively manage CP/CPPS. Clinicians and researchers must consider placebo effect and treatment efficacy over time and design studies creatively so we can more fully elucidate the etiology and role of therapeutic intervention in CP/CPPS.
doi:10.1371/journal.pone.0041941
PMCID: PMC3411608  PMID: 22870266
10.  A Cohort Study Assessing Difficult Patient Encounters in a Walk-In Primary Care Clinic, Predictors and Outcomes 
Background
Previous studies have found that up to 15% of clinical encounters are experienced as difficult by clinicians.
Objectives
Explore patient and physician characteristics associated with being considered “difficult” and assess the impact on patient outcomes.
Design
Prospective cohort study.
Participants
Seven hundred fifty adults presenting to a primary care walk-in clinic with a physical symptom.
Main Measures
Pre-visit surveys assessed symptom characteristics, expectations, functional status (Medical Outcome Study SF-6) and the presence of mental disorders [Primary Care Evaluation of Mental Disorders, (PRIME-MD)]. Post-visit surveys assessed satisfaction (Rand-9), unmet expectations and trust. Two-week assessment included symptom outcome (gone, better, same, worse), functional status and satisfaction. After each visit, clinicians rated encounter difficulty using the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ). Clinicians also completed the Physician’s Belief Scale, a measure of psychosocial orientation.
Key Results
Among the 750 subjects, 133 (17.8%) were perceived as difficult. “Difficult” patients were less likely to fully trust (RR = 0.88, 95% CI: 0.77–0.99) or be fully satisfied (RR = 0.78, 95% CI: 0.62–0.98) with their clinician, and were more likely to have worsening of symptoms at 2 weeks (RR = 0.75, 95% CI: 0.57–0.97). Patients involved in “difficult encounters” had more than five symptoms (RR = 1.8, 95% CI: 1.3–2.3), endorsed recent stress (RR = 1.9, 95% CI: 1.4–3.2) and had a depressive or anxiety disorder (RR = 2.3, 95% CI: 1.3–4.2). Physicians involved in difficult encounters were less experienced (12 years vs. 9 years, p = 0.0002) and had worse psychosocial orientation scores (77 vs. 67, p < 0.005).
Conclusion
Both patient and physician characteristics are associated with “difficult” encounters, and patients involved in such encounters have worse short-term outcomes.
doi:10.1007/s11606-010-1620-6
PMCID: PMC3101981  PMID: 21264521
11.  The Validity of Peer Review in a General Medicine Journal 
PLoS ONE  2011;6(7):e22475.
All the opinions in this article are those of the authors and should not be construed to reflect, in any way, those of the Department of Veterans Affairs.
Background
Our study purpose was to assess the predictive validity of reviewer quality ratings and editorial decisions in a general medicine journal.
Methods
Submissions to the Journal of General Internal Medicine (JGIM) between July 2004 and June 2005 were included. We abstracted JGIM peer review quality ratings, verified the publication status of all articles and calculated an impact factor for published articles (Rw) by dividing the 3-year citation rate by the average for this group of papers; an Rw>1 indicates a greater than average impact.
Results
Of 507 submissions, 128 (25%) were published in JGIM, 331 rejected (128 with review) and 48 were either not resubmitted after revision was requested or were withdrawn by the author. Of 331 rejections, 243 were published elsewhere. Articles published in JGIM had a higher citation rate than those published elsewhere (Rw: 1.6 vs. 1.1, p = 0.002). Reviewer quality ratings of article quality had good internal consistency and reviewer recommendations markedly influenced publication decisions. There was no quality rating cutpoint that accurately distinguished high from low impact articles. There was a stepwise increase in Rw for articles rejected without review, rejected after review or accepted by JGIM (Rw 0.60 vs. 0.87 vs. 1.56, p<0.0005). However, there was low agreement between reviewers for quality ratings and publication recommendations. The editorial publication decision accurately discriminated high and low impact articles in 68% of submissions. We found evidence of better accuracy with a greater number of reviewers.
Conclusions
The peer review process largely succeeds in selecting high impact articles and dispatching lower impact ones, but the process is far from perfect. While the inter-rater reliability between individual reviewers is low, the accuracy of sorting is improved with a greater number of reviewers.
doi:10.1371/journal.pone.0022475
PMCID: PMC3143147  PMID: 21799867
13.  Different Finite Durations of Anticoagulation and Outcomes following Idiopathic Venous Thromboembolism: A Meta-Analysis 
Thrombosis  2010;2010:540386.
Introduction. Controversy remains over the optimal length of anticoagulation following idiopathic venous thromboembolism. We sought to determine if a longer, finite course of anticoagulation offered additional benefit over a short course in the initial treatment of the first episode of idiopathic venous thromboembolism. Data Extraction. Rates of deep venous thrombosis, pulmonary embolism, combined venous thromboembolism, major bleeding, and mortality were extracted from prospective trials enrolling patients with first time, idiopathic venous thromboembolism. Data was pooled using random effects meta-regression. Results. Ten trials, with a total of 3225 patients, met inclusion criteria. For each additional month of initial anticoagulation, once therapy was stopped, recurrent venous thromboembolism (0.03 (95% CI: −0.28 to 0.35); P = .24), mortality (−0.10 (95% CI: −0.24 to 0.04); P = .15), and major bleeding (−0.01 (95% CI: −0.05 to 0.02); P = .44) rates measured in percent per patient years, did not significantly change. Conclusions: Patients with an initial idiopathic venous thromboembolism should be treated with 3 to 6 months of secondary prophylaxis with vitamin K antagonists. At that time, a decision between continuing with indefinite therapy can be made, but there is no benefit to a longer (but finite) course of therapy.
doi:10.1155/2010/540386
PMCID: PMC3211079  PMID: 22084660
14.  Tricyclic antidepressants and headaches: systematic review and meta-analysis 
Objective To evaluate the efficacy and relative adverse effects of tricyclic antidepressants in the treatment of migraine, tension-type, and mixed headaches.
Design Meta-analysis.
Data sources Medline, Embase, the Cochrane Trials Registry, and PsycLIT.
Studies reviewed Randomised trials of adults receiving tricyclics as only treatment for a minimum of four weeks.
Data extraction Frequency of headaches (number of headache attacks for migraine and number of days with headache for tension-type headaches), intensity of headache, and headache index.
Results 37 studies met the inclusion criteria. Tricyclics significantly reduced the number of days with tension-type headache and number of headache attacks from migraine than placebo (average standardised mean difference −1.29, 95% confidence interval −2.18 to −0.39 and −0.70, −0.93 to −0.48) but not compared with selective serotonin reuptake inhibitors (−0.80, −2.63 to 0.02 and −0.20, −0.60 to 0.19). The effect of tricyclics increased with longer duration of treatment (β=−0.11, 95% confidence interval −0.63 to −0.15; P<0.0005). Tricyclics were also more likely to reduce the intensity of headaches by at least 50% than either placebo (tension-type: relative risk 1.41, 95% confidence interval 1.02 to 1.89; migraine: 1.80, 1.24 to 2.62) or selective serotonin reuptake inhibitors (1.73, 1.34 to 2.22 and 1.72, 1.15 to 2.55). Tricyclics were more likely to cause adverse effects than placebo (1.53, 95% confidence interval 1.11 to 2.12) and selective serotonin reuptake inhibitors (2.22, 1.52 to 3.32), including dry mouth (P<0.0005 for both), drowsiness (P<0.0005 for both), and weight gain (P<0.001 for both), but did not increase dropout rates (placebo: 1.22, 0.83 to 1.80, selective serotonin reuptake inhibitors: 1.16, 0.81 to 2.97).
Conclusions Tricyclic antidepressants are effective in preventing migraine and tension-type headaches and are more effective than selective serotonin reuptake inhibitors, although with greater adverse effects. The effectiveness of tricyclics seems to increase over time.
doi:10.1136/bmj.c5222
PMCID: PMC2958257  PMID: 20961988
15.  Measuring Continuing Medical Education Outcomes: A Pilot Study of Effect Size of Three CME Interventions at an SGIM Annual Meeting 
BACKGROUND
The ACCME is phasing in new criteria for accreditation from 2008 to 2012. These criteria require CME providers to assess the impact of their interventions.
OBJECTIVES
To assess the feasibility of measuring outcomes at a national meeting, the SGIM evaluation committee conducted a pilot assessment of two workshops and one precourse.
DESIGN AND PARTICIPANTS
Session coordinators prepared a five-item questionnaire to assess the knowledge and confidence of participants. The questionnaire was administered pre, immediately post, and 9 months after the educational sessions.
MEASUREMENTS
Changes in performance were calculated as a standardized difference, or effect size.
RESULTS
All three sessions demonstrated initial knowledge acquisition with effect sizes ranging from 0.39 (small) to 0.99 (large) immediately after the sessions. One session demonstrated sustainment of knowledge over the subsequent 9 months while the other two demonstrated decay. Confidence levels decreased following one of the sessions with an effect size of −0.72 (modest effect).
CONCLUSIONS
Effect size measurement of sessions provides quantitative information about their impact on learning and is one way to achieve ACCME compliance. The method, however, poses methodological and logistical challenges that raise questions about the feasibility of tracking learning and retention following a national meeting.
doi:10.1007/s11606-009-0902-3
PMCID: PMC2669855  PMID: 19263177
CME; accreditation; practice performance; continuum of medical education; quality and improvements in health care
16.  Medically Unexplained Physical Symptoms 
doi:10.1007/s11606-009-0932-x
PMCID: PMC2659163  PMID: 19255810
17.  Aggression and Violence Among Elderly Patients, a Growing Health Problem 
Journal of General Internal Medicine  2009;24(10):1167-1168.
doi:10.1007/s11606-009-1099-1
PMCID: PMC2745572  PMID: 19730956
18.  Association Between Alcohol Consumption and Both Osteoporotic Fracture and Bone Density 
The American journal of medicine  2008;121(5):406-418.
OBJECTIVE
Alcoholism is a risk factor for osteoporotic fractures and low bone density, but the effects of moderate alcohol consumption on bone are unknown. We performed a systematic review and meta-analysis to assess the associations between alcohol consumption and osteoporotic fractures, bone density and bone density loss over time, bone response to estrogen replacement, and bone remodeling.
METHODS
MEDLINE, Current Contents, PsychINFO, and Cochrane Libraries were searched for studies published before May 14, 2007. We assessed quality using the internal validity criteria of the US Preventive Services Task Force.
RESULTS
We pooled effect sizes for 2 specific outcomes (hip fracture and bone density) and synthesized data qualitatively for 4 outcomes (non-hip fracture, bone density loss over time, bone response to estrogen replacement, and bone remodeling). Compared with abstainers, persons consuming from more than 0.5 to 1.0 drinks per day had lower hip fracture risk (relative risk = 0.80 risk [95% confidence interval, 0.71-0.91]), and persons consuming more than 2 drinks per day had higher risk (relative risk = 1.39 [95% risk confidence interval, 1.08-1.79]). A linear relationship existed between femoral neck bone density and alcohol consumption. Because studies often combined moderate and heavier drinkers in a single category, we could not assess relative associations between alcohol consumption and bone density in moderate compared with heavy drinkers.
CONCLUSION
Compared with abstainers and heavier drinkers, persons who consume 0.5 to 1.0 drink per day have a lower risk of hip fracture. Although available evidence suggests a favorable effect of alcohol consumption on bone density, a precise range of beneficial alcohol consumption cannot be determined.
doi:10.1016/j.amjmed.2007.12.012
PMCID: PMC2692368  PMID: 18456037
Alcohol; Bone mineral density; Hip fracture; Meta-analysis; Osteoporosis
19.  Identifying Medical Students Likely to Exhibit Poor Professionalism and Knowledge During Internship 
Journal of General Internal Medicine  2007;22(12):1711-1717.
CONTEXT
Identifying medical students who will perform poorly during residency is difficult.
OBJECTIVE
Determine whether commonly available data predicts low performance ratings during internship by residency program directors.
DESIGN
Prospective cohort involving medical school data from graduates of the Uniformed Services University (USU), surveys about experiences at USU, and ratings of their performance during internship by their program directors.
SETTING
Uniformed Services University.
PARTICIPANTS
One thousand sixty-nine graduates between 1993 and 2002.
MAIN OUTCOME MEASURE(S)
Residency program directors completed an 18-item survey assessing intern performance. Factor analysis of these items collapsed to 2 domains: knowledge and professionalism. These domains were scored and performance dichotomized at the 10th percentile.
RESULTS
Many variables showed a univariate relationship with ratings in the bottom 10% of both domains. Multivariable logistic regression modeling revealed that grades earned during the third year predicted low ratings in both knowledge (odds ratio [OR] = 4.9; 95%CI = 2.7–9.2) and professionalism (OR = 7.3; 95%CI = 4.1–13.0). USMLE step 1 scores (OR = 1.03; 95%CI = 1.01–1.05) predicted knowledge but not professionalism. The remaining variables were not independently predictive of performance ratings. The predictive ability for the knowledge and professionalism models was modest (respective area under ROC curves = 0.735 and 0.725).
CONCLUSIONS
A strong association exists between the third year GPA and internship ratings by program directors in professionalism and knowledge. In combination with third year grades, either the USMLE step 1 or step 2 scores predict poor knowledge ratings. Despite a wealth of available markers and a large data set, predicting poor performance during internship remains difficult.
doi:10.1007/s11606-007-0405-z
PMCID: PMC2219838  PMID: 17952512
predicting; intern; professionalism; knowledge; medical education
20.  PHARMACOLOGICAL MANAGEMENT OF PAINFUL BLADDER SYNDROME/INTERSTITIAL CYSTITIS: A SYSTEMATIC REVIEW 
Archives of internal medicine  2007;167(18):1922-1929.
Background
Over 180 different types of therapy have been used in the treatment and management of painful bladder syndrome/interstitial cystitis (PBS/IC), yet evidence from clinical trials remains inconclusive. This study aimed to evaluate the efficacy of pharmacological approaches to PBS/IC, quantify the effect size from randomized controlled trials, and begin to inform a clinical consensus of treatment efficacy for PBS/IC.
Methods
We identified randomized controlled trials for the pharmacological treatment of PBS/IC patients diagnosed on the basis of NIDDK or operational criteria. Study limitations include considerable patient heterogeneity as well as variability in the definition of symptoms and in outcome assessment.
Results
We included a total of 1470 adult patients from 21 randomized controlled trials. Only trials for pentosan polysulfate had sufficient numbers to allow a pooled analysis of effect. According to a random-effects model, the pooled estimate of the effect of pentosan polysulfate therapy suggested benefit, with a relative risk for patient-reported improvement in symptoms of 1.78 (95% confidence interval, 1.34 – 2.35). This result was not heterogeneous (p= 0.47) and was without evidence of publication bias (p= 0.18). Current evidence also suggests efficacy of DMSO and amitryptiline. Hydroxyzine, intravesical BCG and RTX failed to demonstrate efficacy, but evidence was inconclusive due to methodological limitations.
Conclusions
Pentosan polysulfate may be modestly beneficial for symptoms of PBS/IC. There is insufficient evidence for other pharmacological treatments. A consensus on standardized outcome measures is urgently needed.
doi:10.1001/archinte.167.18.1922
PMCID: PMC2135553  PMID: 17923590
21.  Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training? 
Background
Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Purposes
Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.
Methods
We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990–1999 for IM residency program graduates from a training program.
Results
Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4–3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.
Conclusions
Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM’s action to remove resident procedural competence from the monthly ABIM-MEF ratings.
doi:10.1007/s11606-006-0068-1
PMCID: PMC1824756  PMID: 17356968
procedural skills; Internal Medicine residency training program; ABIM evaluation
22.  Managing Somatization Medically Unexplained Should Not Mean Medically Ignored 
doi:10.1111/j.1525-1497.2006.00514.x
PMCID: PMC1924713  PMID: 16808789
23.  The Impact of the Stanford Faculty Development Program on Ambulatory Teaching Behavior 
CONTEXT
Faculty development has received considerable investment of resources from medical institutions, though the impact of these efforts has been infrequently studied.
OBJECTIVE
To measure the impact of the Stanford Faculty Development Program in Clinical Teaching on ambulatory teaching behavior.
DESIGN
Pre-post.
SETTING AND PARTICIPANTS
Eight internal medicine faculty participating in local faculty development.
INTERVENTION
Participants received 7 2-hour sessions of faculty development. Each session included didactic, role-play, and videotaped performance evaluation.
MAIN OUTCOME MEASURE
Before and after the intervention, faculty were video-taped during a case presentation from a standardized learner, who had been trained to portray 3 levels of learners: a third-year medical student, an intern, and a senior medical resident. Teacher and learner utterances (i.e, phrases) were blindly and randomly coded, using the Teacher Learner Interaction Analysis System, into categories that capture both the nature and intent of the utterances. We measured change in teaching behavior as detected through analysis of the coded utterances.
RESULTS
Among the 48 videotaped encounters, there were a total of 7,119 utterances, with 3,203 (45%) by the teacher. Examining only the teacher, the total number of questions asked declined (714 vs 426, P = .02) with an increase in the proportion of higher-level, analytic questions (44% vs 55%, P<.0001). The quality of feedback also improved, with less “minimal” feedback (87% vs 76%, P<.0005) and more specific feedback (13% vs 22%) provided.
CONCLUSIONS
Teaching behaviors improved after participation in this faculty development program, specifically in the quality of questions asked and feedback provided.
doi:10.1111/j.1525-1497.2006.00422.x
PMCID: PMC1484783  PMID: 16704383
faculty development; medical teaching; medical education
24.  Dying on the Streets 
doi:10.1007/s11606-007-0145-0
PMCID: PMC1829440  PMID: 17372810
25.  Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training? 
Background
Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Purposes
Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.
Methods
We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990–1999 for IM residency program graduates from a training program.
Results
Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4–3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.
Conclusions
Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM’s action to remove resident procedural competence from the monthly ABIM-MEF ratings.
doi:10.1007/s11606-006-0068-1
PMCID: PMC1824756  PMID: 17356968
procedural skills; Internal Medicine residency training program; ABIM evaluation

Results 1-25 (30)