Beginning Of Residency Research Articles

Body composition change during the intern year of emergency medicine residency

Study objectives: Interest in the often extreme workloads of residents has led to changes in the American Council on Graduate Medical Education guidelines. Although this will certainly have a positive effect on resident health, the fitness and nutritional needs of residents have still not been addressed. Long work hours and related stress, combined with limited access to exercise and good nutrition, can quickly lead to unhealthy body composition changes. The objective of this study is to determine whether a measurable detriment to body composition can be detected during a 6-month period at the beginning of residency. Methods: This was a prospective cohort study of first-year emergency medicine residents at 2 Midwestern, urban, tertiary trauma centers. This study was conducted from August 2002 through February 2004. Two classes of residents were included in this study. Each class was eligible for inclusion in August of their intern year. Entry and 6-month measurements were taken. Physical measurements included age, sex, height, weight, and bioimpedance. Bioimpedance was measured using the Bioanalogics ELG II ElectroLipoGraph. The Bioanalogics QuickComp Portable Body Composition program was used to calculate percentage of body fat and percentage of lean body mass. Body mass index was calculated using the National Institutes of Health multiplier. Statistical significance was analyzed using SPSS software (version 10.00). Repeated-measures analysis of variance and Student's t test for paired means were calculated. Results: Thirty-one residents participated in this study; 8 were lost to follow-up. The subject group had a mean entry age of 28 years, with 65.2% male subjects. Comparison of means showed a mean weight increase of 2.4% ( P =.004). Weight gain was seen in 14 subjects, with an average gain of 7.9 lbs (3.6 kg). Weight gain was only significant, defined as 8 to 20 lbs (3.6 to 9.1 kg), in 7 subjects. During the study period, there was a 13% increase in those identified as overweight according to the National Institutes of Health recommendations on body mass index. Percentage of lean body mass decreased 3.3% ( P =.033), whereas percentage of body fat increased 13.3% ( P =.033). Actual mass of body fat in pounds increased 18.6% ( P =.011). Conclusion: Even with more limits on work hours, residents have limited time for exercise and nutrition. Often their access is limited to what the hospital provides. Additional attention needs to be paid to this issue to maximize resident performance. It is shown that even in as short as a 6-month period, interns experience detrimental changes in body composition. Although weight change is not clinically significant, it can mask underlying changes in body composition. Significant increases in body fat percentage, accompanied by decreases in percentage of lean body mass, were seen. The study was limited because subjects were nonblinded and had access to the results of their measurements, which might account for somewhat of a study effect, and it is suggested that a blinded study might show a greater increase in weight. Future studies might also concentrate on standardizing the residency affect by correcting for exercise and dietary outliers.

A Communication Assessment and Skill-building Exercise (CASE) for First-year Residents

Good communication skills are essential for residents entering postgraduate education programs. However, these skills vary widely among medical school graduates. This pilot program was designed to create opportunities for (1) teaching essential interviewing and communication skills to trainees at the beginning of residency, (2) assessing resident skills and confidence with specific types of interview situations, (3) developing faculty teaching and assessment skills, (4) encouraging collegial interaction between faculty and new trainees, and (5) guiding residency curricular development. During residency orientation, all first-year internal medicine residents (n = 26) at the University of Minnesota participated in the communication assessment and skill-building exercise (CASE). CASE consisted of four ten-minute stations in which residents demonstrated their communication skills in encounters with standardized patients (SPs) while faculty members observed for specific skills. Faculty and SPs were oriented to the educational purposes and goals of their stations, and received instructions on methods of providing feedback to residents. With each station, residents were provided one and a half minutes of direct feedback by the faculty observer and the SP. The residents were asked to deal with an angry family member, to counsel for smoking cessation, to set a patient-encounter agenda, and to deliver bad news. A resident's performance was analyzed for each station, and individual profiles were created. All residents and faculty completed evaluations of the exercise, assessing the benefits and areas for improvement. Evaluations and feedback from residents and faculty showed that most of our objectives were accomplished. Residents reported learning important skills, receiving valuable feedback, and increasing their confidence in dealing with certain types of stressful communication situations in residency. The activity was also perceived as an excellent way to meet and interact with faculty. Evaluators found the experience rewarding, an effective method for assessing and teaching clinical skills, a faculty development experience for themselves in learning about structured practical skills exercises, and a good way to meet new interns. The residency program director found individual resident performance profiles valuable for identifying learning issues and for guiding curricular development. Time constraints were the most frequently cited area for improvement. The exercise became feasible by collaborating with the medical school Office of Education-Educational Development and Research, whose mission is to collaborate with faculty across the continuum of medical education to improve the quality of instruction and evaluation. The residency program saved considerable time, effort, and expense by using portions of the medical school's existing student skills-assessment programs and by using chief residents and faculty as evaluators. We plan to use CASE next year with a wider variety of physician-patient scenarios for interns, and to expand the program to include beginning second- and third-year residents. Also, since this type of exercise creates powerful feedback and assessment opportunities for instructors and course directors, and because feedback was so favorable from evaluators, we will encourage participation in CASE as part of our faculty educational development program.

What influences career choices among graduates of a primary care training program?

To identify factors that influence primary care residents to become generalists or specialists. Structured survey and interview. A large university-based, internal medicine residency program in primary care. Of 92 residency graduates who completed training between 1979 and 1993, 88 (96%) participated. Although 82% of the participating graduates reported themselves very committed to primary care at the beginning of residency, only 68% pursued generalist careers. Factors influencing career choice that were more important to generalists than specialists included breadth of knowledge used in primary care practice (p = .04), breadth of clinical problems in practice (p = .001), and opportunity for continuity of care (p = .01). Although salary was rated "not important," 50% of generalists and specialists advocated increased salaries for generalists as a way to increase interest in primary care. Other promoting factors included mentors, increased prestige for generalists, community-based training, lifestyle changes, and decreased paperwork. Seventy-three percent of participants felt it was easier to be a specialist than a generalist. A substantial minority of primary care residents pursue specialty careers. To produce more generalists, graduates recommend addressing income inequities, providing generalist role models, increasing community-based teaching, and increasing prestige for generalists.