IM Residents Research Articles

9397 Shatter Proofing Bones: Revamping Osteoporosis Screening

Abstract Disclosure: R. Subramani: None. T. Gupta: None. M. Anwar: None. J. Pamula: None. Background: Osteoporosis is a common disease characterized by low bone mass, structural deterioration of bone tissue, and increased risk of fractures. The World Health Organization (WHO) has defined osteoporosis based on bone density measurements. According to their definition, osteoporosis is diagnosed when the bone density at the hip or spine is at least 2.5 standard deviations (SDs) below the mean bone density of a reference population of young, healthy women (T score ≤ -2.5). According to NHANES data from 2017-2018, the overall prevalence of osteoporosis among adults over 50 was found to be 12.6%. It was observed that the prevalence of osteoporosis was higher among women (19.6%) compared to men (4.4%). According to US Preventative Services Task Force (USPSTF), the guidelines for screening are as follows: BMD Testing (DEXA) for all women aged 65 and older, postmenopausal women younger than 65 with clinical risk factors for fracture including advancing age, previous fracture, glucocorticoid therapy, parental history of hip fracture, low body weight, current cigarette smoking, excessive alcohol consumption, rheumatoid arthritis, secondary osteoporosis. BMD Testing for Men is not recommended. The most used bone measurement test to screen for osteoporosis is central DXA which measures BMD at the hip and lumbar spine. Goal: To improve the osteoporosis screening using DXA scan in the outpatient internal medicine resident patient panel by 5% Study Design:Subjects were identified by an EPIC report and will include retrospective chart review of records from July 2022 and prospective screening until April 2024 for the outpatient IM clinic list of patients including both resident panel. Methods: Pre-intervention data analysis of current rates; Educating residents about appropriate screening; Utilization of osteoporosis screening as care-gap in EPIC ;Calling patients who are due for screening from IM residents patient panels; Post-interventional data analysis Results: The total number of patients on the residents panel was 196. Before interventions, screening rate for osteoporosis were 71.2% among residents' patients. After intervention, screening rates increased to 75.5%. There was a 4.3 % improvement in screening rate. Conclusion: Resident education, addressing Osteoporosis care gaps in EPIC and patient outreach are effective interventions to improve screening rates. Discussion: Osteoporosis screening remains an area of needed improvement in IM clinic. EPIC system should not only take age for prompting osteoporosis screening but also other factors such as family history, pre-mature fractures, steroid use, etc. Adding osteoporosis screening into the metric system are few steps to be considered for future directions. Presentation: 6/3/2024

Does hematology rotation impact the interest of internal medicine residents in considering hematology as a career?

BackgroundThe ongoing need for hematologists is not met in many parts of the world. The hematology rotation during internal medicine residency is an opportunity to attract more physicians to the hematology field. This study aimed to assess the impact of a hematology rotation on internal medicine residents’ interest in considering a hematology career.MethodsInternal medicine residents were invited to complete an anonymous questionnaire before and after a mandatory hematology rotation. Their interest in pursuing a hematology career was assessed by asking them to rate “Consider hematology as a career” on a 0 to 10 scale (0 = never, 10 = strongly agree). In addition, viewing the hematology workload as manageable, comfort in dealing with cancer and satisfaction with the hematologist lifestyle were assessed before and after the rotation.ResultsSixty out of 62 IM residents completed the pre- and post-hematology rotation questionnaire (response rate 97%). 80% were in the age range of 25–29 years and 73% were males. Two-thirds were in the senior level (3rd and 4th year) of their residency program and 40% had a prior rotation in a hematology unit. Rating considering hematology as a career increased significantly from a median of 7 (IQR: 5–9) pre-rotation to 8.5 (IQR: 7–10) post-rotation (p = 0.0018). Subgroup analysis showed a significant increase in interest among subgroups except residents > 29 years of age, those with prior hematology rotation and junior residents (1st and 2nd year residency). The change in viewing hematology workload as manageable, comfort in dealing with cancer patients and perceiving the hematologist lifestyle as satisfactory were strongly positively correlated with the change in considering hematology as a career (p = 0.0014, < 0.0001 and < 0.0001; respectively).ConclusionsA hematology rotation is associated with an increase in the interest of internal medicine residents in considering hematology as a career. Further research is needed to Identify factors that may make hematology rotations an effective tool in attracting residents to the hematology field.

A Comparison of Remote vs In-Person Proctored In-Training Examination Administration for Internal Medicine.

In response to COVID-19, the American College of Physicians provided residents the option to complete the 2020 Internal Medicine In-Training Examination (IM-ITE) via in-person and remote proctoring. This study evaluated the extent to which scores obtained from both testing modalities were comparable. Data were analyzed from residents from all U.S.-based Accreditation Council for Graduate Medical Education-accredited IM residency programs and participating Canadian and international programs who completed the IM-ITE in 2020. The final sample contained 27,115 IM residents: 9,205 postgraduate year (PGY) 1, 9,332 PGY-2, and 8,578 PGY-3. Testing modality, gender, PGY, time spent on assessment, and native language were used to predict percent-correct scores in a multilevel regression model. This model included all main effects and all 2-way interactions between testing modality and each resident-level demographic variable, allowing those effects to be controlled for. Of 27,115 residents studied, 11,354 (42%) tested remotely and 15,761 (58%) in person. Across the parameters of interest (main effect of testing modality and 2-way interactions), the only statistically significant effects were the interaction effects between testing mode (interaction effect: -0.61; 95% confidence interval [CI], -1.01 to -0.21) and PGY (interaction effect: -0.54; 95% CI, -0.95 to -0.13) ( P = .002). Differences between in-person and remote predicted scores were slightly larger for PGY-1 than for PGY-2 and PGY-3 residents, but the magnitude of these differences across residency training was well under one percentage point. Because these statistically significant effects were deemed educationally nonsignificant, the study concluded that performance did not substantively differ across in-person and remote examinees. Residents taking the 2020 IM-ITE performed similarly across in-person and remote proctoring. This study provides evidence of score comparability across the 2 testing modalities and supports continued use of remote proctoring for the IM-ITE.

Impact of the COVID-19 pandemic on internal medicine training in the United States: results from a national survey

BackgroundInternal medicine (IM) residency is a notoriously challenging time generally characterized by long work hours and adjustment to new roles and responsibilities. The COVID-19 pandemic has led to multiple emergent adjustments in training schedules to accommodate increasing needs in patient care. The physician training period, in itself, has been consistently shown to be associated with vulnerability with respect to mental well-being. The impact of the COVID-19 pandemic on the experience of IM trainees is not well established.ObjectiveCharacterize the impact of the COVID-19 pandemic on trainee clinical education, finances, and well-being.MethodsWe developed a survey composed of 25 multiple choice questions, 6 of which had an optional short-answer component. The survey was distributed by the American College of Physicians (ACP) to 23,289 IM residents and subspecialty fellows. We received 1,128 complete surveys and an additional 269 partially completed surveys.ResultsThe majority of respondents reported a disruption in their clinical schedule (76%) and a decrease in both didactic conferences (71%) and protected time for education (56%). A majority of respondents (81%) reported an impact on their well-being with an increase in their level of burnout and 41% of respondents reported a decrease in level of direct supervision. Despite these changes, the majority of trainee respondents (78%) felt well prepared for clinical practice after graduation.ConclusionsThese results outline the vulnerable position of internal medicine physicians in training. Preserving educational experiences, adequate supervision, and humane work hours are essential in protecting trainees from mental illness and burnout during global emergencies.

Abstract 307: In-Situ Simulation-Based Booster ACLS Training to Increase the Confidence and Performance of Internal Medicine Residents as Code Blue Leaders - A Quality Improvement Project

Background: In the United States, nearly 290,000 adult patients develop in-hospital cardiac arrest (IHCA) every year. Delivery of guideline-based resuscitation has improved patient outcomes. During 2022, our hospital had 68 inpatient i.e., approximately 1 code/resident. Residents have reported desire for more exposure. The 2020 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommended: 1) booster training, 2) in-situ simulation-based resuscitation training, and 3) specific teamwork and leadership training for healthcare providers. We aimed to implement such training to achieve an improvement in resident confidence and performance as code blue leaders. Methods: Pre-intervention, residents completed a 5-item 0-100 continuous scale to assess confidence in major code leader skills (Fig 1-A). Interventions included: 1) Calling residents to patient rooms to run simulation-based codes, and 2) a didactic session that discussed common errors during codes. Time to key ACLS steps was recorded during the simulations. At the end of the project, residents completed the post-intervention survey of confidence and balancing measures. Results: 13 residents led simulation-based codes, 20 attended the didactic session, and 25 completed the survey. Resident confidence in the defined skills increased by an average of 30%. (P&lt;0.05) (Fig 1-A). Residents who led codes after the didactic session had shorter times to key ACLS steps (Fig 1-B). Balancing measures included resident-reported satisfaction and perceived disruption to clinical workflow (100% and 0% of responses, respectively). Conclusions: In-situ simulation-based booster ACLS training was associated with an increase in the confidence and performance of IM residents as code blue leaders. Incorporation of such training in IM residency curriculum should be considered as a practical application to sustain the gains of this QI initiative.

Industry Payments Received by Residents During Training

Those responsible for medical education-specialties, sponsoring institutions, and program directors (PD)-are independently associated with the professional identity formation of the trainees with respect to potential conflicts of interest. To identify the relative degree to which factors in the training environment are associated with resident acceptance of payments from pharmaceutical and medical device companies. Cross-sectional, retrospective study of residents enrolled in the 3 largest primary-care specialties (internal medicine [IM], family medicine [FM], obstetrics and gynecology [OBGYN]) and 3 largest surgical disciplines (general surgery [GS], orthopedic surgery, and urology) during academic year 2020 to 2021. All analyses were conducted January through August 2023. Specialty, sponsoring institutions' ownership (nonprofit, for-profit, federal government, local government, or state government), and the number of payments PDs accepted. Modified Poisson regression assessed the relative risk of ownership, specialty, and PD behavior on residents' acceptance of industry payments as recorded in the Open Payments Program (OPP) database. In total, there were 124 715 residents in all training programs during 2020 to 2021, 12% of whom received payments totaling $6.4 million. There were 65 992 residents in training during 2020 to 2021 in the 6 specialties evaluated in this study, with 4438 in orthopedics, 1779 in urology, 9177 in GS, 5819 in OBGYN, 14 493 in FM, and 30 286 in IM. OPP records $3.9 million in payments to the 8750 residents (13.4%) who received at least 1 industry payment. The record of all payments to residents in OPP totals $6.4 million. Compared with residents in federal sponsoring institutions, those affiliated with for-profit institutions were 3.50 (95% CI, 2.32-5.28) times more likely to accept industry payments, while those affiliated with nonprofit organizations were 2.00 (95% CI, 1.36-2.93) times more likely to accept payments. Compared with IM, residents in each of the following specialties have an elevated risk of accepting payments: orthopedics, 3.21 (95% CI, 2.73-3.77) times; urology, 2.95 (95% CI, 2.44-3.56) times; GS, 1.21 (95% CI, 1.00-1.45) times; OBGYN, 1.30 (95% CI, 1.05-1.62) times. The difference in the risk of accepting a payment between FM and IM residents was not statistically significant. The number of payments PDs accepted slightly elevated the risk of residents to accept a payment by 1.01 (95% CI, 1.01-1.01). In this cross-sectional, retrospective study, receipt of industry payments by residents was associated with specialty, institutional control, and PD behavior.

A single center pilot study: assessing resident needs and faculty perceptions to improve training in rheumatology

BackgroundInternal medicine (IM) residents lack confidence in rheumatology. Due to the wide variety of topics in rheumatology, identifying the most important subjects to learn during training is vital to create future interventions to increase confidence and knowledge. The preferred teaching modality for both attendings/fellows and residents is not known.MethodsAn electronic survey was distributed to all IM residents, rheumatology fellows, and rheumatology faculty at the University of Chicago during the 2020–2021 academic year. Residents reported self-confidence levels on 10 rheumatology topics, while rheumatology attendings/fellows were asked to rank these from most to least important to learn during IM residency. All groups were asked preferred teaching modality.ResultsMedian confidence level [interquartile range] among residents for caring for patients with rheumatological conditions was 6 [3.6–7.5] for inpatient and 5 [3.7–6.5] for outpatient settings (10 being very confident). Attendings and fellows identified the most important topics to learn during the rheumatology rotation as ordering and interpreting autoimmune serologies and musculoskeletal exam. Both attendings/fellows and residents preferred bedside teaching in the inpatient setting and case-based learning in the outpatient setting.ConclusionsWhile some disease-specific topics such as autoimmune serologies were identified as important rheumatology topics for IM residents to learn, more practical topics like musculoskeletal exam skills were also deemed important. This highlights the need for comprehensive interventions that focus on more than standardized exam topics alone to improve rheumatology confidence in IM residents. There are different preferences of teaching styles in various clinical settings.

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.

Exploring US internal medicine resident career preferences: a Q-methodology study.

Career selection in medicine is a complex and underexplored process. Most medical career studies performed in the U.S. focused on the effect of demographic variables and medical education debt on career choice. Considering ongoing U.S. physician workforce shortages and the trilateral adaptive model of career decision making, a robust assessment of professional attitudes and work-life preferences is necessary. The objective of this study was to explore and define the dominant viewpoints related to career choice selection in a cohort of U.S. IM residents. We administered an electronic Q-sort in which 218 IM residents sorted 50 statements reflecting the spectrum of opinions that influence postgraduate career choice decisions. Participants provided comments that explained the reasoning behind their individual responses. In the final year of residency training, we ascertained participating residents' chosen career. Factor analysis grouped similar sorts and revealed four distinct viewpoints. We characterized the viewpoints as "Fellowship-Bound-Academic," "Altruistic-Longitudinal-Generalist," "Inpatient-Burnout-Aware," and "Lifestyle-Focused-Consultant." There is concordance between residents who loaded significantly onto a viewpoint and their ultimate career choice. Four dominant career choice viewpoints were found among contemporary U.S. IM residents. These viewpoints reflect the intersection of competing priorities, personal interests, professional identity, socio-economic factors, and work/life satisfaction. Better appreciation of determinants of IM residents' career choices may help address workforce shortages and enhance professional satisfaction.

Association of Gender and Race/Ethnicity with Internal Medicine In-Training Examination Performance in Graduate Medical Education.

Disparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern. Examine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity. Longitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014-2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square. A total of 689 IM residents, including 330 women and URiM residents (48%). ITE score KEY RESULTS: There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F(2, 1321) 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p<0.001). Women and URiM residents had greater odds of being at potential risk for not passing the ABIM-CE (OR 1.75, 95% CI 1.10 to 2.78) with greatest odds in PGY3 (OR 3.13, 95% CI 1.54 to 6.37). Differences in ITE over training were associated with resident gender and race/ethnicity. Women and URiM residents had smaller ITE score gains across PGY translating into greater odds of potentially being seen as at-risk for not passing the ABIM-CE. Differences in ITE over training may reflect differences in experiences of women and URiM residents during training and may lead to further disparities.

A Novel Hospital Medicine Training Track for Internal Medicine Residents: Description and Program Evaluation of the First 15 Years.

The growth of hospital medicine has resulted in a parallel growth of hospital medicine training within internal medicine residency programs (IMRPs), but the experience and outcomes of these training offerings have not yet been described. To describe the first dedicated hospitalist track and the program evaluation data. The University of Colorado Hospitalist Training Track (HTT) is a 3-year track within the IMRP with robust inpatient clinical training, specialized didactics, experiential improvement work, and career mentorship. We collected data on graduates' current practices and board certification pass rates. To further evaluate the track, we electronically sent a cross-sectional survey to 124 graduates from 2005 to 2019 to identify current practice settings, graduate roles, and assessment of the training track. Among 124 graduates, 97 (78.2%) practice hospital medicine, and the board certification pass rate was slightly higher than the overall IMRP pass rate for those graduating classes. Sixty-two (50%) graduates responded to the survey. Among respondents, 50 (80.6%) currently practice hospital medicine and 34 (54.8%) practice in an academic setting. The majority (50, 80.6%) hold leadership roles and are involved in a variety of scholarship, educational, and operational projects. Dedicated clinical training, didactics, and mentorship were valued by respondents. This represents the first description and program evaluation of a HTT for IM residents. A dedicated HTT produces graduates who choose hospital medicine careers at high rates and participate in a wide variety of leadership and nonclinical roles.

Internal medicine residents' and program directors' perception of virtual interviews during COVID-19: a national survey.

PurposeDue to the coronavirus disease 2019 pandemic, all Canadian Resident Matching Service interviews for internal medicine subspecialty programs were conducted virtually for the first time. This study explored the perceptions and experiences of internal medicine residents, subspecialty medicine program directors, and interviewers during virtual interviews.MethodsWe invited all Canadian third-year IM residents, subspecialty program directors, and interviewers who participated in the 2020 medical subspecialty medicine interviews to complete a branching survey with a section for residents and one for program directors and interviewers. We distributed the anonymous survey after the submission of the rank order lists, to not affect residency match outcomes. Qualitative data were open-coded thematically and quantitative data were cleaned and then statistically analyzed using descriptive statistics and Analysis of Variance tests.Results62 residents, 59 program directors, and 113 interviewers responded to the survey with representation from almost all Canadian medical faculties and medical subspecialties. Strengths of virtual interviews included reduced cost, stress, pandemic infection risk, and carbon footprint. Weaknesses of virtual interviews included decreased ability to connect personally and informally, and inability to tour medical facilities and cities. A majority of both resident respondents (59.6%) and program directors/interviewer respondents (54.6%) supported conducting interviews virtually in the future.ConclusionsThis study showed that the majority of both sampled residents and program directors/interviewers would prefer to conduct medicine subspecialty match interviews virtually in the future, and provides suggestions on how to improve the virtual interviews for the next iteration.

972. Antimicrobial Stewardship Educational Needs of Residents in an Internal Medicine Program

BackgroundAntibiotic stewardship continues to be health concern that physicians often acknowledge, but whose real-life practices do not reflect that awareness. There is a wide range of opinions on the efficacy of the type of modality that is most effective to teach stewardship. Our project addresses resident needs specifically, with coverage in four topics—proper antibiotic dosing, IV to PO transitioning, duplicate coverage, and antibiotic time outs.MethodsCategorical Internal Medicine residents in PGY 1-3 were sent an optional 48-question Likert survey querying needs in the above four topics.ResultsGeneral Demographics. Resident response was 35%, with equal representation from all PGY years. Over half reported no ID or stewardship elective exposure and 74% agreed they could benefit from further education on stewardship (Figure 1). Proper Dosing Educational Needs. Of residents, 68% reported feeling confident about where to find information on dosing antibiotics for a given condition/organism (Figure 2a), but only 37% were comfortable with establishing an initial dose. When a range was suggested, 55% of respondents admitted to at least “sometimes, often, or always” choosing the highest suggested dose by default. IV to PO transition. Residents preferred (76%) and used (89%) IV antibiotics by default in an inpatient setting. Nearly 45% of respondents reported “sometimes or rarely” feeling comfortable in making an IV to PO transition, and 40% “often or always” avoid PO transition until discharge (Figure 2b). Duplicate Coverage. Over 70% of residents reported they “sometimes, rarely, or never” felt confident in stopping double coverage themselves when started by the primary team (Figure 3a). Antibiotic Time Out. Only 17% of respondents had heard of an antibiotic timeout, and only 8% have ever used one (Fig.3b); 80% of residents had no structured way to review usage and 53% reported “sometimes or often” forgetting about assessing for de-escalation daily.Figure 1. Resident Demographics Our anonymous, optional survey attracted a 35% response rate from the categorical residents at our suburban program spread over two tertiary hospitals with >1200 beds total. Most had not received prior training in infectious disease or stewardship, yet most recognized antibiotic overuse and resistance as a major, ongoing problem.Figure 2. Resident responses on proper dosing and IV to PO questions. (A) Residents appear most uncomfortable with initial antibiotic dosing and seeking additional sources for best dosage when commonly used sources suggest a range of possible doses. (B) Majority of residents preferred and used IV antibiotics, and commonly transitioned to PO only at patient discharge. Some residents reported discomfort with establishing equivalent IV to PO transition dosages.Figure 3. Resident responses to questions regarding duplication of therapy and antibiotic time outs. (A) Though many could and had recognized duplication of therapy on the wards, several participants reported at least some discomfort in independently stopping double coverage. (B) Most residents had not heard of or utilized an antibiotic time-out or any other structured method to re-assess their antibiotic use on daily rounds. As such, 41% of respondents admitted they would likely just continue initial, broad-spectrum therapy.ConclusionOur analysis aimed to establish resident educational needs in four major topics in stewardship. Gaps in knowledge include timing transition from IV to PO, initial antibiotic dosing, stopping double-coverage, and lack of awareness of timeouts. This needs assessment will be used to build an antibiotic stewardship curriculum for IM residents.Disclosures All Authors: No reported disclosures

1118. Development of a Curriculum for Internal Medicine Residents on Latent and Active Pulmonary TB: A Targeted Needs Assessment

BackgroundInternal medicine (IM) residents have previously been found to have significant knowledge and practice gaps in tuberculosis (TB) diagnosis, but it is unknown whether these gaps vary based on geography or TB incidence. San Francisco has the highest incidence of TB of any US city. UCSF IM residents encounter TB throughout their clinical training; however, the residency program does not have a dedicated TB curriculum. Following the Kern model of curriculum development, the aim of this project was to conduct a targeted needs assessment of UCSF IM residents regarding the need for and format of a TB curriculum.MethodsAn anonymous survey was sent to residents in February 2020 to assess their confidence in multiple domains in the diagnosis and management of latent and active pulmonary TB and gauge their preferences for the format and timing for delivery of a TB curriculum. All questions used a five-point Likert scale. Chi-squared test was used to compare confidence levels between interns and residents. The study received UCSF IRB approval.ResultsSeventy-five IM residents completed the survey (41% of residency; 32% interns and 68% residents). More than 50% of respondents reported that they were quite or extremely confident in only 1 of 14 domains assessed. Residents demonstrated significantly increased confidence compared to interns in only 4 of 14 domains. IM residents felt that a TB curriculum of a short video series, online videos interspersed with questions, or a house-staff handbook would be most useful, with more than 50% stating that these formats would be quite or extremely useful. While lectures and Powerpoint slides are common teaching methods, residents felt these formats were less useful. IM residents also felt they would be more likely to access a TB curriculum during ID elective or while caring for patients on wards and less likely on own time.ConclusionIM residents demonstrated lack of confidence in multiple domains in the diagnosis and management of latent and active pulmonary TB. Confidence did not markedly improve between interns and residents despite increased experience in a high TB incidence clinical setting, highlighting the need for a TB curriculum to address this gap. This curriculum should avoid lecture format and be integrated within relevant clinical time to maximize utility.Disclosures All Authors: No reported disclosures

Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomized Clinical Trial.

This is the first randomized controlled trial evaluating the impact of note template design on note quality using a simulated patient encounter and a validated assessment tool. To compare note quality between two different templates using a novel randomized clinical simulation process. A randomized non-blinded controlled trial of a standard note template versus redesigned template. PGY 1-3 IM residents. Residents documented the simulated patient encounter using one of two templates. The standard template was modeled after the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment, and deemphasized less useful elements. Note length; time to note completion; note template evaluation by resident authors; note evaluation by faculty reviewers. 36 residents participated, 19 randomized to standard template, 17 to new. New template generated shorter notes (103 vs 285 lines, p < 0.001) that took the same time to complete (19.8 vs 21.6 min, p = 0.654). Using a 5-point Likert scale, residents considered new notes to have increased visual appeal (4 vs 3, p = 0.05) and less redundancy and clutter (4 vs 3, p = 0.006). Overall template satisfaction was not statistically different. Faculty reviewers rated the standard note more up-to-date (4.3 vs 2.7, p = 0.001), accurate (3.9 vs 2.6, p = 0.003), and useful (4 vs 2.8, p = 0.002), but less organized (3.3 vs 4.5, p < 0.001). Total quality was not statistically different. Residents rated the new note template more visually appealing, shorter, and less cluttered. Faculty reviewers rated both note types equivalent in the overall quality but rated new notes inferior in terms of accuracy and usefulness though better organized. This study demonstrates a novel method of a simulated clinical encounter to evaluate note templates before the introduction into practice. ClinicalTrials.gov ID: NCT04333238.

Resident Physician Prescribing Variability Demonstrates Need for Antimicrobial Stewardship in Continuity Clinic: A Pilot Study.

Inappropriate antimicrobial use is common in the outpatient setting but often goes unaddressed by stewardship education. Residents might benefit from directed stewardship education. We conducted a needs assessment of resident knowledge, attitudes, and behaviors regarding antibiotic use and stewardship in outpatient continuity clinics. Internal medicine (IM) residents with continuity clinic at Minneapolis Veterans Affairs Health Care System were eligible. Antimicrobial prescriptions and number of visits were extracted from the Computerized Patient Record System (July 1, 2017-March 31, 2018). Antimicrobial rate (prescriptions per 1000 visits) was calculated for each resident. Results from a resident survey that included demographics, attitudes, and case-based multiple-choice knowledge questions were linked by unique identifier to antimicrobial rate. Prescription and visit data were available for 37 residents. Mean monthly antimicrobial rate was 51 prescriptions per 1000 visits (range 8-239). Surveys were completed by 19 residents (51%). Respondents were 32% female, 32% interns, and 11% international medical graduates. An online resource was most commonly used for prescribing guidance, whereas lectures and small group sessions for residents were rated as the most helpful educational modalities. Many respondents reported being unprepared to perform basic tasks related to antimicrobial stewardship. Median percentage correct was 57% of case-based knowledge questions (interquartile range 50%-71%). Antimicrobial rates among IM residents at a VA outpatient continuity clinic are low and vary by provider. Residents agree with key antimicrobial stewardship concepts but lack preparation in tasks related to antimicrobial stewardship. Knowledge regarding antimicrobial prescribing was low.

MON-122 Introduction of an Ambulatory Curriculum in Endocrinology Diabetes and Metabolism for Internal Medicine Trainees

Internal Medicine (IM) training programs are disproportionately weighted to inpatient learning opportunities. IM residents‘ exposure to outpatient internal medicine subspecialties, such as Endocrinology, Diabetes and Metabolism (EDM), is limited. This may contribute to gaps in medical knowledge in these content areas in spite of the frequent occurrence of EDM disorders. Further, reduced exposure during training may adversely impact interest in pursuing fellowship training in these fields, in spite of increased societal need.In July 2015 the IM residency program at the University of Pennsylvania switched to a “6 + 2” training model. In this training module, trainees are grouped into four cohorts, each of which have 6 weeks of inpatient rotations, followed by 2 weeks of an ambulatory experience. This model allowed the introduction of an organized ambulatory curriculum during the 2-week outpatient blocks, which was named the Interactive Learning Module (ILM). This creates the opportunity to deliver a standardized curriculum to all residents. Through this module we coordinate an immersive experience in five distinct outpatient themes: General Internal Medicine, Infectious Disease, EDM, Nephrology, and Rheumatology. The EDM ILM is co-led by a core faculty member and senior endocrinology fellow with interest in pursuing a career in medical education.During the EDM ILM, IM interns receive 12 hours of interactive didactics in high yield content areas including: Diabetes Workshop, Adrenal and Pituitary Diseases, Osteoporosis, Thyroid Diseases, Women’s Health, Calcium Disorders, Obesity and Endocrine Emergencies.Interns are given 3-4 opportunities to work with an EDM faculty member in the outpatient setting. Interns are also asked to read and review three publications within the field, which are discussed as a group.The EDM ILM has been consistently praised by IM interns, and feedback for the curriculum has been overwhelmingly positive. 97% of interns agreed the breadth of content was comprehensive and 94% agreed that the content was applicable to their delivery of ambulatory primary care. The quality of the teaching was rated high among 96% of interns. 89% reported improved understanding of EDM. Four years after the institution of the curriculum, we have not yet noted an increase in graduating IM residents choosing fellowship in EDM. However, all three of our IM residents who have matched into EDM fellowship over the past four years have chosen to stay at our institution.Faculty have thrived with these teaching opportunities: their consistently high evaluations have been an important criterion for academic promotion.Co-leading this course has been an important opportunity for senior EDM fellows to build expertise in medical education; three out of four participating fellows accepted academic positions with GME support.

Do USMLE steps, and ITE score predict the American Board of Internal Medicine Certifying Exam results?

BackgroundTo evaluate if United States Medical Licensing Examination (USMLE) Step 1, USMLE Step 2 CK, USMLE Step 3, and residency third-year in-service training exam (ITE) scores predict the results of American Board of Internal Medicine Certifying Exam (ABIM-CE).MethodsWe performed a retrospective review of USMLE Step 1, USMLE Step 2 CK, USMLE Step 3, third-year residency ITE scores and ABIM-CE results of IM residents at our residency program from 2004 through 2017. Statistical analysis was perfrormed using Pearson correlation coefficient, and logistic regression to assess the relationship between USMLE Step 1, USMLE Step 2CK, USMLE Step 3, 3rd year ITE scores and ABIM-CE results. We used Multivariate logistic regression to predict pass or fail results in ABIM-CE based on USMLE and third-year ITE test scores controlling for other covariates.ResultsAmong 114 Internal Medicine MD residents included in the study, 92% (n = 105) passed the ABIM-CE. The OR of passing ABIM-CE was 2.70 (95% CI = 1.38–5.29), 2.31 (95% CI = 1.33–4.01), and 1.63 (95% CI = 0.81–3.29) with a ten-point increase in USMLE Step 1, USMLE Step 2 CK and USMLE Step 3 scores respectively. The OR of ABIM-CE passing chance was 2.96 (95% CI = 0.95–9.20), with a ten-point increase in the average score of the above three exams. A 5 % increase in ITE percentage raised the likelihood of passing ABIM-CE (OR 2.92, 95% CI 1.15–7.38). All residents who failed ABIM-CE had Step 1 scores < 220. Among 31 residents with Step 2 CK score < 220, 20% (n = 6) failed ABIM. Similarly, 9% of residents with USMLE Step 3 score < 220 failed ABIM-CE; all residents who failed had scored < 220. The probability curve predicted that the chance of passing ABIM- CE was around 80% with USMLE scores greater than 200 and increased to almost 100% with USMLE scores of 250 or more.ConclusionUSMLE Step 1, USMLE Step 2 CK, and third-year ITE scores can predict the chances of passing ABIM-CE. The third-year ITE score has a higher preditive value compared to USMLE Step 1 and USMLE Step 2 scores. USMLE Step 1 scores more predictive of ABIM-CE results compared to USMLE Step 2CK scores. Thus, residency programs can identify internal medicine residents at risk of failing ABIM-CE and formulate interventions at an early stage during residency training. Measures such as enrolling them in question banks or board review courses can be helpful in improving their chances of passing ABIM-CE.

Learning Styles of Internal Medicine Residents and Association With the In-Training Examination Performance

IntroductionAssessment of how medical residents learn and the impact on standardized test performance is important for effective training. Kolb's learning study inventory categorizes learning into accommodating, assimilating, converging and diverging based on the four stages of learning: active experimentation, abstract conceptualization, concrete experience and reflective observation. The American College of Physicians (ACP) Internal Medicine In-Training Examination (IM-ITE) has been shown to positively correlate with successful performance on clinical assessments and board certification. We sought to evaluate the association between the individual learning styles of IM residents and performance on the ACP IM-ITE. MethodsThe Kolb LSI questionnaire was administered to IM residents during the 2016/2017 academic year. Logistic regression was used to analyze the association between residents preferred learning styles and performance on the ACP IM – ITE. Results53 residents in the IM Residency Program of Morehouse School of Medicine completed the questionnaire. The predominant learning style was assimilating (49%), followed by converging (26%). There was no significant difference between the learning styles of residents when compared across gender, age, race, and PGY levels. Residents with a diverging learning style had the highest mean IM-ITE percentage score followed by assimilating and converging respectively (P = 0.14) ConclusionsThe predominant learning styles among our IM residents are assimilating and converging, which is consistent with previous studies. Residents with a diverging style of learning appeared to perform better on the IM-ITE. We suggest that future studies should evaluate the feasibility of integrating brainstorming and group work sessions into the IM residency teaching curriculum and the impact on academic performance.