Academic Internal Medicine Residency Program Research Articles

Association of Interview and Holistic Review Metrics With Resident Performance-Related Difficulties in an Internal Medicine Residency Program.

Background The utility of traditional academic factors to predict residency candidates' performance is unclear. Many programs utilize holistic review processes assessing applicants on an expanded range of application and interview characteristics. Determining which characteristics might predict performance-related difficulty in residency is needed. Objective We aim to elucidate factors associated with residency performance-related difficulty in a large academic internal medicine residency program. Methods In 2022, we conducted a retrospective cohort study of Electronic Residency Application Service and interview data for residents matriculating between 2018 and 2020. The primary outcome was a composite of performance-related difficulty during residency (referral to the Clinical Competency Committee; any rotation evaluation score of 2 out of 5 or lower; and/or a confidential "comment of concern" to the program director). Logistic regression models were fit to assess associations between resident characteristics and the composite outcome. Results Thirty-eight of 117 residents met the composite outcome. Gold Humanism Honor Society (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.16-0.87) or Alpha Omega Alpha (OR 0.36, 95% CI 0.14-0.99) members were less likely to have performance-related difficulty, as were residents with higher United States Medical Licensing Examination Step 2 Clinical Knowledge scores (OR 0.97, 95% CI 0.47-1.00). One-point increases in general faculty overall interview score, leadership competency score, and leadership overall score were associated with 41% to 63% lower odds of meeting the composite outcome. Interview or file review "flags" had an OR of 2.82 (95% CI 1.37-5.80) for the composite outcome. Conclusions Seven metrics were associated with the composite outcome of resident performance-related difficulty.

Abstract P359: Resident Management Of Hypertensive Urgency

Objective: Hypertensive urgency is generally defined as a severely elevated blood pressure without evidence of end-organ damage. Consensus statements do not recommend the acute lowering of blood pressure nor referral to the emergency room. Rapid lowering of blood pressure in patients who are chronically hypertensive carries the risk of hypoperfusion and therefore ischemia to vital organs. The objective of this study was to assess residents’ perception of the management of hypertensive urgency. Methods: An anonymous survey was sent via email to all active resident physicians of an academic internal medicine residency program. It comprised of 8 questions regarding the outpatient and inpatient treatment of hypertensive urgency. Results: A total of 47 residents responded to the survey. Most respondents (44 of 47) knew that evaluating for reversible causes of elevated blood pressure is the first step of management. Fewer residents (37 of 47) said the next course of action would be to up-titrate the oral blood pressure regimen. When asked about real life practice, 35 of 47 attested to conservative management with 12 of 47 respondents regularly using IV antihypertensives to treat hypertensive urgency. The most common contributing reason (25 of 47) to pushing IV antihypertensives was pressure from colleagues and staff, with only 2 residents denying ever administering IV antihypertensives. Residents were also aggressive in the management of hypertensive urgency in the outpatient setting with 15 of 47 respondents reporting most commonly referring patients to the ER for blood pressure lowering (31.91%) and 5 of 47 reporting administering clonidine in the office for quick blood pressure lowering. Conclusion: Resident physicians in our program should be less aggressive in treating hypertensive urgency, especially in the outpatient setting. We suspect that the notion that hypertensive urgency warrants immediate blood pressure lowering is prevalent as pressure from staff/colleagues was the largest cited reason to giving IV antihypertensives in urgency. Further efforts should be pursued to educate residents about the current guidelines regarding hypertensive urgency.

"Teaching old dogs new tricks" - POCUS Education for Senior Faculty.

Point of Care Ultrasound (POCUS) is a growing diagnostic modality across a variety of specialties and is increasingly being taught in undergraduate medical education. Uptake within internal medicine has been slow but is becoming more commonplace. Training of extant hospital medicine faculty, including senior members, in POCUS is an unmet need in graduate medical education with significant pedagogical and patient safety implications. With this in mind, we created a training program for the core teaching faculty at our academic internal medicine residency program. The experiential, hands-on curriculum explored the reasoning behind concepts and emphasized psychological safety for senior faculty learners and was successful and well-received. In our piece, we aim to explore the existing literature around training this unique population in POCUS and report on our single-center experience. We also provide a framework for how our program succeeded, collate tips derived from the expert ultrasound teachers and list pearls learned while teaching these experienced educators. Although this worthwhile effort requires planning and support, it was appreciated even by senior faculty.

Health Justice Standards in Graduate Medical Education: Moving from Performative to Concrete Change.

Inadequate support for underrepresented-in-medicine physicians, lack of physician knowledge about structural drivers of health, and biased patient care and research widen US health disparities. Despite stating the importance of health equity and diversity, national physician education organizations have not yet prioritized these goals. To develop a comprehensive set of Health Justice Standards within our residency program to address structural drivers of inequity. The J. Willis Hurst Internal Medicine Residency Program of Emory University is an academic internal medicine residency program located in Atlanta, Georgia. This initiative was led by the resident-founded Churchwell Diversity and Inclusion Collective, modified by Emory IM leadership, and presented to Emory IM residents. We used an iterative process to develop and implement these Standards and shared our progress with our coresidents to evaluate impact. In the year since their development, we have made demonstrable progress in each domain. Presentation of our work significantly correlated with increased resident interest in advocacy (p<0.001). A visionary, actionable health justice framework can be used to generate changes in residency programs' policies and should be developed on a national level.

Impact of a Resident-Driven Research Club on Scholarly Activity in an Academic Internal Medicine Residency Program During the COVID-19 Pandemic.

Traditional journal clubs have been shown to be insufficient in improving residents' scholarly productivity, often due to the inability to sustain residents' interest and participation. Additionally, the 2019 novel coronavirus (COVID-19) pandemic restrictions caused a decline in academic scholarly productivity across residency programs. We evaluated the impact of a resident-led research club called 'journal café' on residents' scholarly productivity by comparing scholarly output between the journal café members and non-members during the COVID-19 pandemic. The journal café was established in the 2012/2013 academic year by internal medicine residents of a university residency program in Atlanta, Georgia, to foster self-directed collaboration among residents based on shared interests in academic research. The journal café runs independently of the residency program's journal club. We categorized IM residents at our institution into journal café members and non-members and collected data on their research productivity during residency training and the COVID-19 pandemic. The survey was conducted between April and June 2021 and analyzed data presented using frequencies, tables, and appropriate charts. Sixty-eight residents (29 journal café members and 39 non-members) completed the survey (response rate of 85%). A significantly higher number of journal café members reported having five or more research publications (55.1% vs 7.1%, P < .001) and scientific presentations (48.3% vs 2.6%, P < .001) compared with non-members. Additionally, more journal café members published COVID-19-related research in peer-reviewed journals compared with non-members (68% vs 32%, n = 19). Finally, most of the residents cited the opportunity of a platform to share and brainstorm on research ideas as the reason for joining the journal café. We found an association between journal café participation and increased scholarly activity, particularly during the COVID-19 pandemic. Independent resident-led research clubs supported by the residency program may complement the traditional journal clubs and enhance residents' participation in research.

Implementation of a Night-Float Curriculum: Impact on Intern Confidence over Time.

Formal nighttime education is becoming increasingly necessary as more internal medicine (IM) residency programs adopt night-float rotations (NFRs); however, the efficacy of an NFR curriculum throughout an academic year and which topics in an NFR curriculum increase trainee confidence are unknown. We implemented a 12-module, self-paced NFR curriculum for 76 postgraduate year-1 residents at an academic IM residency program. We evaluated the impact of this curriculum on postgraduate year-1 residents' clinical confidence, as well as longitudinal efficacy of the curriculum. Night-float interns' (NFIs) clinical confidence regarding specific curricular topics was evaluated overall and during specific timeframes within the academic year. Pre- and post-NFR surveys using Likert scales for each topic were administered to NFIs from June 24, 2020 to March 2, 2021, representing 32 week-long NFR cycles. NFIs' pre- and postrotation confidence in managing clinical scenarios significantly improved for all 12 topics in the NFR curriculum. The NFR curriculum resulted most significantly in improved confidence during the first 4 months of the academic year, with 11 of 12 curricular topics reaching the threshold for statistical significance. Modules on altered mental status, hypotension, narrow-complex tachyarrhythmias, new fever, and sepsis and antibiotic escalation maintained their efficacy for the longest periods of time. It may be especially important to emphasize an NFR curriculum at the beginning of the academic year. IM residency programs also may wish to carefully consider that certain topics may maintain their efficacy throughout the year, whereas other topics should potentially be replaced with more complex modules as the academic year progresses.

Differences in rates of low-dose computed tomography screening for lung cancer amongst various outpatient care centers.

245 Background: Despite low-dose computed tomography (LDCT) screening for lung cancer recommended by the United States Preventive Services Task Force (USPSTF) demonstrating a relative reduction in mortality, there remains low rates of testing nationwide. Yet studies are limited regarding specific differences in screening rates amongst various outpatient care settings. Methods: We performed retrospective chart reviews of patients followed by resident providers within an academic internal medicine residency program who met USPSTF guidelines for lung cancer screening between 2015-2020. This was conducted at three separate outpatient clinic sites including a state-funded academic institution, inner city community health center, and veteran affairs medical center. Data collection included patient demographic and smoking histories as well as rates of ordered and completed LDCT screening. Results: A total of 832 patients were identified as current or former smokers between the ages of 55 and 80 years: 320 from Hartford Hospital Community Health Center (HHCHC), 262 from University of Connecticut Health Center (UCHC), and 250 from the Veteran Affairs (VA) Medical Center. 85 (27%) of these patients from HHCHC, 84 (32%) from UCHC, and 56 (22%) from the VA met USPSTF eligibility criteria for LDCT screening. Overall compliance rates of screening were found to be 44% at HHCHC, 59.5% at UCHC, and 51.8% at the VA. Results are outlined in Table. Conclusions: Screening rates for lung cancer with LDCT remain low but have been steadily improving throughout the United States following new recommendations and increased awareness provided by multiple medical organizations. We sought to compare differences in compliance rates amongst various outpatient clinics within the same internal medicine residency program at University of Connecticut. Our findings demonstrate significant differences in LDCT screening for lung cancer between the program’s community health center versus its state and federally funded outpatient clinics. Automatic reminders to providers can potentially improve rates of lung cancer screening. Patients should also be educated about the importance of screening to improve adherence with imaging. [Table: see text]

Timing and Predictors of Subspecialty Career Choice Among Internal Medicine Residents: A Retrospective Cohort Study.

Internal medicine residents face numerous career options after residency training. Little is known about when residents make their final career choice. We assessed the timing and predictive factors of final career choices among internal medicine residents at graduation, including demographics, pre-residency career preferences, and rotation scheduling. We conducted a retrospective study of graduates of an academic internal medicine residency program from 2014 to 2017. Main measures included demographics, rotation schedules, and self-reported career choices for residents at 5 time points: recruitment day, immediately after Match Day, end of postgraduate year 1 (PGY-1), end of PGY-2, and at graduation. Of the 138 residents eligible for the study, 5 were excluded based on participation in a fast-track program for an Accreditation Council for Graduate Medical Education subspecialty fellowship. Among the remaining 133 residents, 48 (36%) pursued general internal medicine fields and 78 (59%) pursued fellowship training. Career choices from recruitment day, Match Day, and PGY-1 were only weakly predictive of the career choice. Many choices demonstrated low concordance throughout training, and general medicine fields (primary care, hospital medicine) were frequently not decided until after PGY-2. Early clinical exposure to subspecialty rotations did not predict final career choice. Early career choices before and during residency training may have low predictability toward final career choices upon graduation in internal medicine. These choices may continue to have low predictability beyond PGY-2 for many specialties. Early clinical exposure may not predict final career choice for subspecialties.

Beyond duty hours: leveraging large-scale paging data to monitor resident workload

Monitoring and managing resident workload is a cornerstone of policy in graduate medical education, and the duty hours metric is the backbone of current regulations. While the duty hours metric measures hours worked, it does not capture differences in intensity of work completed during those hours, which may independently contribute to fatigue and burnout. Few such metrics exist. Digital data streams generated during the usual course of hospital operations can serve as a novel source of insight into workload intensity by providing high-resolution, minute-by-minute data at the individual level; however, study and use of these data streams for workload monitoring has been limited to date. Paging data is one such data stream. In this work, we analyze over 500,000 pages—two full years of pages in an academic internal medicine residency program—to characterize paging patterns among housestaff. We demonstrate technical feasibility, validity, and utility of paging burden as a metric to provide insight into resident workload beyond duty hours alone, and illustrate a general framework for evaluation and incorporation of novel digital data streams into resident workload monitoring.

An Internal Medicine Residency Hospitalist Pathway: A 2-year Follow Up

This article was migrated. The article was not marked as recommended. Purpose: The Stanford Hospitalist Advanced Practice and Education (SHAPE) Program was established in 2015 as a hospital medicine training track within an academic internal medicine residency program. It is unique because it was created and is currently run by residents with a goal of better preparing residents for careers in hospital medicine. The SHAPE curriculum is based on three principles: (1) clinical excellence in hospitalist-relevant clinical areas, (2) academic development through research and quality improvement, and (3) career mentorship. We provide a two-year follow-up since the establishment of SHAPE and resident attitudes toward the program's effectiveness. Methods: We assessed resident attitudes toward the SHAPE Program and subjective readiness to begin practice via electronic survey from 2015 to 2017. Results: 154 out of 324 (47.5%) total internal medicine residents responded to the surveys. Of those, 17 out of 21 (81.0%) were members of SHAPE. Compared to non-hospitalist-bound residents, SHAPE residents reported improved readiness for independent practice (OR 3.39 [95% CI: 1.1-10.9]) and providing care within the specific domain of palliative care. Conclusions: Here we describe the challenges of maintaining a hospitalist curriculum and the successes that have come from the first resident-run hospitalist training program in the country.

A pilot study to standardize and peer-review shift handoffs in an academic internal medicine residency program: The DOCFISH method.

With increased oversight of residency work hours, there has been an increase in shift handoffs, which are prone to medical errors. To date, there are no evidence-based recommendations on essential elements of shift handoffs. We implemented a standardized shift-handoff rubric at an academic medicine residency program. Compliance, resident/faculty perceptions, and surrogate markers of patient safety were measured.Shift-handoff documents were collected January-February 2016 (control) April-June 2016 (intervention). Signouts were scored based on inclusion of seven elements: Daily events, Overnight events, Code status, Follow up tasks, If/then statements, ‘sick or stable’ and History present illness. The mnemonic ‘DOCFISH’ was taught in a grand-rounds forum then embedded into a shift-handoff tool within our electronic health record (EHR). Senior residents were assigned to supervise/provide feedback on shift handoffs from April-June 2016. Faculty and resident perceptions regarding quality of shift handoffs was measured by the annual ACGME (Accreditation Council Graduate Medical Education) program survey.Patient safety was measured by number of rapid-response teams (RRT) initiated for unstable vital signs. Handoffs were 74% complete in intervention group and 60% in control group (p < .0001). Median DOCFISH features present in patients that required RRT was 3 of 7 whereas, total post-intervention group had 5 of 7 (p < .001). ‘Daily events’ and ‘follow -up tasks’ were less frequent in patients that required RRT (20%, 67% respectively, p < .001).Academic medical centers can implement standardized shift handoffs by embedding high-yield information in an EHR with peer-review. Information during shift changes that may have significant improvement on patient safety includes: ‘daily events’ and ‘follow -up tasks.’

Those Who Teach, Can Do: Characterizing the Relationship Between Teaching and Clinical Skills in a Residency Program.

Teaching practice is presumed to have significant overlap with clinical skills, yet few studies to date have assessed how residents' teaching skills influence their clinical performance. We examined the relationship between the professional roles of residents as teachers and as practicing clinicians as well as how learning about teaching contributes to enhanced skills in the clinical realm. Using the framework method, the authors performed a 2-phased (exploratory and confirmatory) qualitative analysis on the data sets to characterize the relationship between resident teaching and clinical skills. To investigate the relationship between teaching and clinical work, we extracted qualitative data from 300 evaluations of clinical performance for residents in a large, urban, academic internal medicine residency program submitted over a 3-year period. Informed by the preliminary framework that evolved from this analysis, we conducted a focus group of 6 residents in a dedicated clinician-educator track to examine how teaching was related to clinical work. We identified attributes and skills of good resident teachers that enhance clinical skills, categorized as 18 subdomains within 4 domains: relationships, communication, relation to self, and relationship with knowledge. Themes that link clinical and teaching skills are similar for both patient-physician and learner-teacher relationships. Improving residents' teaching skills may not only benefit the education of learners but also improve the care of patients.

Point-of-Care Ultrasound Needs Assessment, Curriculum Design, and Curriculum Assessment in a Large Academic Internal Medicine Residency Program.

Internal medicine (IM) residency point-of-care ultrasound (POCUS) curricula are being developed but often are limited in scope or components. In this article, we discuss the demonstration of a need for POCUS training in our large academic IM residency program; the development of a longitudinal curriculum; and the impact of the curriculum on POCUS knowledge, use, and confidence. In 2014, we designed a cross-sectional POCUS survey and knowledge test for all IM residents at the University of California, San Francisco. The results of this assessment drove the design of a longitudinal POCUS curriculum that included a 2-hour workshop for all IM interns and a 1-month elective offered to all IM residents. Residents were tested on their POCUS knowledge and image interpretation before the elective and were given the same test 6 months after the elective. The posttest included a survey of self-reported POCUS use and confidence. In the needs assessment, residents scored a mean of 27% on the knowledge test, and across all applications the percentage of residents reporting confidence in their POCUS skills was lower than the percentage reporting use of the application in clinical practice. Residents scored a mean of 37% on the elective pretest and 74% on the posttest, an increase of 37% (95% confidence interval 31.6-42.8, P < 0.001), with improvements seen across all applications. After the elective, self-reported use of POCUS and confidence in POCUS skills were increased for the applications, using the needs assessment as an approximate baseline. For core cardiac and pulmonary applications, 76% to 95% of residents, depending on application, reported "high" or "very high" use and 79% to 100% reported "high" or "very high" confidence in their POCUS skills. We used a needs assessment to guide the development of a longitudinal, multidisciplinary POCUS curriculum. Residents who completed all components showed substantial long-term gains in knowledge in all major applications and high use of and confidence in cardiac and pulmonary applications.

Maintaining a Twitter Feed to Advance an Internal Medicine Residency Program's Educational Mission.

BackgroundResidency programs face many challenges in educating learners. The millennial generation’s learning preferences also force us to reconsider how to reach physicians in training. Social media is emerging as a viable tool for advancing curricula in graduate medical education.ObjectiveThe authors sought to understand how social media enhances a residency program’s educational mission.MethodsWhile chief residents in the 2013-2014 academic year, two of the authors (PB, AN) maintained a Twitter feed for their academic internal medicine residency program. Participants included the chief residents and categorical internal medicine house staff.ResultsAt the year’s end, the authors surveyed residents about uses and attitudes toward this initiative. Residents generally found the chief residents’ tweets informative, and most residents (42/61, 69%) agreed that Twitter enhanced their overall education in residency.ConclusionsData from this single-site intervention corroborate that Twitter can strengthen a residency program’s educational mission. The program’s robust following on Twitter outside of the home program also suggests a need for wider adoption of social media in graduate medical education. Improved use of data analytics and dissemination of these practices to other programs would lend additional insight into social media’s role in improving residents’ educational experiences.

Development of a Structured Year-End Sign-Out Program in an Outpatient Continuity Practice

In an effort to prevent medical errors, it has been recommended that all healthcare organizations implement a standardized approach to communicating patient information during transitions of care between providers. Most research on these transitions has been conducted in the inpatient setting, with relatively few studies conducted in the outpatient setting. To develop a structured transfer of care program in an academic outpatient continuity practice and evaluate whether this program improved patient safety as measured by the documented completion of patient care tasks at 3 months post-transition. Graduating residents and the corresponding incoming interns inheriting their continuity patient panels were randomized to the pilot structured transfer group or the standard transfer group. The structured transfer group residents were asked to complete written and verbal sign-outs with their interns; the standard transfer group residents continued the current standard of care. Thirty-two resident-intern pairs in an academic internal medicine residency program in New York City. Three months after the transition, study investigators evaluated whether patient care tasks assigned by the graduating residents had been successfully completed by the interns in both groups. In addition, follow-up appointments, continuity of care and house officer satisfaction with the sign-out process were evaluated. Among patients seen during the first 3 months, the clinical care tasks were more likely to be completed by interns in the structured group (73 %, n = 49) versus the standard group (46 %, n = 28) (adjusted OR 3.21; 95 % CI 1.55-6.62; p = 0.002). This was further enhanced if the intern who saw the patient was also the assigned primary care provider (adjusted OR 4.26; 95 % CI 1.7-10.63; p = 0.002). A structured outpatient sign-out improved the odds of follow-up of important clinical care tasks after the year-end resident clinic transition. Further efforts should be made to improve residents' competency with regard to sign-outs in the ambulatory setting.

Does scale length matter? A comparison of nine- versus five-point rating scales for the mini-CEX

Educators must often decide how many points to use in a rating scale. No studies have compared interrater reliability for different-length scales, and few have evaluated accuracy. This study sought to evaluate the interrater reliability and accuracy of mini-clinical evaluation exercise (mini-CEX) scores, comparing the traditional mini-CEX nine-point scale to a five-point scale. The authors conducted a validity study in an academic internal medicine residency program. Fifty-two program faculty participated. Participants rated videotaped resident-patient encounters using the mini-CEX with both a nine-point scale and a five-point scale. Some cases were scripted to reflect a specific level of competence (unsatisfactory, satisfactory, superior). Outcome measures included mini-CEX scores, accuracy (scores compared to scripted competence level), interrater reliability, and domain intercorrelation. Interviewing, exam, counseling, and overall ratings varied significantly across levels of competence (P < .0001). Nine-point scale scores accurately classified competence more often (391/720 [54%] for overall ratings) than five-point scores (316/723 [44%], P < .0001). Interrater reliability was similar for scores from the nine- and five-point scales (0.43 and 0.40, respectively, for overall ratings). With the exception of correlation between exam and counseling scores using the five-point scale (r = 0.38, P = .13), score correlations among all domain combinations were high (r = 0.46-0.89) and statistically significant (P < or = .015) for both scales. Mini-CEX scores demonstrated modest interrater reliability and accuracy. Although interrater reliability is similar for nine- and five-point scales, nine-point scales appear to provide more accurate scores. This has implications for many educational assessments.

Replacing an Academic Internal Medicine Residency Program With a Physician Assistant—Hospitalist Model: A Comparative Analysis Study

This study describes a comparative analysis of replacing medical residents with physician assistants and hospitalists on patient outcomes in a community hospital. Prospective data during the physician assistants-hospitalists service for 2 years was compared with 2 years of retrospective data of the medical residents model. Outcome measures included mortality, adverse events, readmissions, and patient satisfaction. For physician assistants- hospitalists versus medical residents models, all-cause and case mix index-adjusted mortality was 107/5508 (1.94%) and 0.019 versus 156/5458 (2.85%) and 0.029, respectively (P < or = .001). The adverse event cases were 9 versus 5 ( P = .29), and the readmission rate within 30 days was 64 versus 69 (P = .34). Patient satisfaction was 95% versus 96% (P = .33). Quality of care provided by the physician assistants-hospitalists model was equivalent. All-cause and case mix index- adjusted mortality was significantly lower during the physician assistants-hospitalists period.Although the application of these findings to other institutions requires further study, the authors found no intrinsic barriers that would impede implementation elsewhere.

Effect of evaluator and resident gender on the American Board of Internal Medicine evaluation scores.

To examine the effects of resident and attending physician gender on the evaluation of residents in an internal medicine training program. Cross-sectional study. Large urban academic internal medicine residency program. During their first 2 years of training, 132 residents (85 men, 47 women) received a total of 974 evaluations from 255 attending physicians (203 men, 52 women) from 1989 to 1995. The primary measurements were the numerical portions of the American Board of Internal Medicine evaluation form. Separate analyses were performed for each of the nine evaluation dimensions graded on a scale of 1 to 9. The primary outcome was the difference in the average scores received by each resident from male versus female attending physicians. Compared with female trainees, male residents received significantly higher scores from male attending physicians than from female attending physicians in six of the nine dimensions: clinical judgment, history, procedures, relationships, medical care, and overall. Similar trends, not reaching conventional levels of statistical significance, were observed in the other three categories: medical knowledge, physical exam, and attitude. These differences ranged from 0.24 to 0.60 points, and were primarily due to higher grading of male residents by male attending physicians than by female attending physicians. In one academic training program, we found a significant interaction in the grading process between the gender of internal medicine residents and the gender of their attending evaluators. This study raises the possibility that subtle aspects of gender bias may exist in medical training programs.

Characteristics of materials distributed by drug companies. An evaluation of appropriateness.

To describe material distributed to physicians by pharmaceutical companies; to describe characteristics of the drugs discussed in the material; to determine whether the material complies with Food and Drug Administration (FDA) regulations and whether it contains promotional and educational characteristics. Cross-sectional study. An academic internal medicine residency program, a private internist's office, and a health maintenance organization (HMO). A consecutive sample of 486 items, excluding gifts and drug samples, distributed by drug companies between August 11, 1993 and March 1, 1994. Of the 486 items collected, 207 were reprints, 196 were advertisements, 51 were general information, and 32 were other. Reprints were delivered to residents significantly more often than to the HMO (p < .001) or to the private internist's office (p < .001). By contrast, the internist's office received a greater proportion of personal correspondence compared with the other locations (p < .001 for both). Of the drugs publicized, 10] were substantial improvements over other therapeutic choices. Forty-two percent of the items failed to comply with at least one of three FDA regulations assessed, including 17 items that discussed unapproved uses for drugs. Advertisements, as well as items that were not obviously promotional, contained promotional characteristics. Thirty-nine percent of the items offered scientific support for their claims. Little of the material distributed by pharmaceutical companies to physicians conveys information about important therapeutic breakthroughs; some of it fails to comply with FDA regulations. The material contains both educational and promotional characteristics.