Background It is widely acknowledged that there is need for redesign of internal medicine training. Duty hour restrictions, an increasing focus on patient safety, the possibility of inadequate training in ambulatory care, and a growing shortage of primary care physicians are some factors that fuel this redesign movement. Intervention We implemented a 4∶1 scheduling template that alternates traditional 4-week rotations with week-long ambulatory blocks. Annually, this provides 10 blocks of traditional rotations without continuity clinic sessions and 10 weeks of ambulatory experience without inpatient responsibilities. To ensure continuous resident presence in all areas, residents are divided into 5 groups, each staggered by 1 week. Evaluation We surveyed residents and faculty before and after the intervention, with questions focused on attitudes toward ambulatory medicine and training. We also conducted focus groups with independent groups of residents and faculty, designed to assess the benefits and drawbacks of the new scheduling template and to identify areas for future improvement. Results Overall, the scheduling template minimized the conflicts between inpatient and outpatient training, promoted a stronger emphasis on ambulatory education, allowed for focused practice during traditional rotations, and enhanced perceptions of team development. By creating an immersion experience in ambulatory training, the template allowed up to 180 continuity clinic sessions during 3 years of training and provided improved educational continuity and continuity of patient care. Conclusion Separating inpatient and ambulatory education allows for enhanced modeling of the evolving practice of internists and removes some of the conflict inherent in the present system.

We evaluated the significance of magnetic resonance imaging findings in patients with patellar tendinitis. Midline sagittal magnetic resonance images were taken of 12 knees from 10 patients and of 17 knees from 15 age- and activity-matched subjects who underwent imaging for reasons other than patellar tendinitis. Of the 12 magnetic resonance imaging scans of knees with clinical patellar tendinitis, 3 (25%) exhibited no defect and only 7 (58%) had unequivocal intratendinous lesions. Among the 17 scans of subjects without clinical patellar tendinitis, 5 (34%) showed no defect and 4 (24%) had unequivocal intratendinous lesions. Proximal tendon width was significantly larger for the tendinitis patient group (5.0 +/- 1.7 mm versus 3.9 +/- 1.0 mm), although considerable overlap was present. All subjects with unequivocal intratendinous signal changes had a significantly longer nonarticular inferior patellar pole and were significantly older (38.1 years versus 26.8 years). Only Blazina stage III lesions were associated with abnormal findings on magnetic resonance imaging. As a whole, the sensitivity and specificity of magnetic resonance imaging was 75% and 29%, respectively. In younger patients with relatively mild symptoms, magnetic resonance imaging did not show significant changes; in older, active patients changes may be present in asymptomatic knees.

Heterotopic pancreatic tissue, also known as a pancreatic rest, is an uncommon congenital anomaly defined as extrapancreatic tissue located far from the pancreas and without connection via vascular or anatomical means to it. Such tissue may occur throughout the GI tract but has a propensity to affect the stomach and the proximal small intestine. The majority of patients with pancreatic heterotopia are asymptomatic, but when symptoms occur, they can present in a variety of ways. We report a case of a patient whose pancreatic rest presented primarily as dysphagia for solid food and in whom endoscopic ultrasound was used to further define the lesion. There have been only two cases reported of a pancreatic rest causing symptoms of dysphagia. A review of the literature on pancreatic heterotopia as well as the use of endoscopic ultrasound as an aid in evaluation is included.

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