Medicine Subspecialty Fellows Research Articles

Learning from our patients: An exploratory study to inform the development of a case tracking dashboard for internal medicine subspecialty fellows

Background Case tracking (following-up prior patient encounters) can help inform future clinical decisions and supplement experiential learning. Internal medicine subspecialty fellows see a high volume of patients and need to become subject matter experts within a short time frame, yet little is known about their specific needs and motivations around case tracking. Objective The objective of this study was to explore internal medicine subspecialty fellows’ motivations, preferences, and practices around case tracking. Methods We conducted interviews with internal medicine subspecialty fellows at a single academic medical center during the 2022–2023 academic year. Interviews were analyzed using qualitative content analysis. Results 22 fellows were interviewed for our study. We found that most fellows engaged in case tracking with lists in the electronic health record (EHR). Fellows primarily tracked cases of clinical uncertainty and patients with specific diseases or conditions of interest. Fellows sought information on patients’ health outcomes, results, and clinical notes. Motivations for tracking were predominantly related to curiosity, professional growth, and development of practice patterns. Barriers to case tracking included time, challenges maintaining patient lists, losing track of patients, and lack of motivation to develop and maintain an organized system. Conclusions Internal medicine subspecialty fellows engaged in and valued case tracking as a way to supplement their experiential learning. Our study highlighted their current practices, motivations, preferences, and challenges related to case tracking. We plan to use these findings to help develop an EHR-embedded dashboard to facilitate case tracking among subspecialty fellows.

A comparison of career plans of gastroenterology fellows compared to fellows in other internal medicine subspecialties

Background The career trajectory of medical professionals, particularly in specialized fields like gastroenterology, can significantly impact healthcare and research. This study aimed to analyze career choices among gastroenterology fellows in the US and investigate the factors influencing these choices. Methods We utilized data from the American Medical Association on internal medicine subspecialty fellows. The study examined career plans of gastroenterology fellows and compared them with those of other subspecialties. A chi-square test was performed to assess differences in career choices and practice settings. Results Among gastroenterology fellows, 46% opted for private practice, 28% pursued further training, and 26% chose academia. Notably, gastroenterology fellows were more inclined toward private practice than their counterparts in other subspecialties (46.3% vs 38.4%) and were less likely to pursue academic careers (25.6% vs 30.7%). Conclusion This study highlights a concerning trend among recent gastroenterology fellowship graduates favoring private practice over academic careers or additional training. To sustain and strengthen academic medicine in gastroenterology, interventions such as scholarships, mentorship programs, and loan repayment initiatives tailored to academic pursuits could play a crucial role.

772. Learning from our patients: An exploratory study to inform the development of a case tracking dashboard for subspecialty fellows

Abstract Background Educators identify case tracking (following-up prior patient encounters) as a valued practice to cultivate physician expertise. Much of the existing research has focused on the practices of general medicine providers, where challenges include insufficient time and difficulty tracking patients in the electronic health record (EHR). Subspecialty fellows constitute a group of advanced learners who see a high volume of patients and need to quickly become subject matter experts, yet little is known about their particular needs and motivations around case tracking. In this study, we performed a needs assessment with fellows to inform the design of an EHR-based case tracking dashboard that can facilitate learning from prior patient encounters. Methods We conducted semi-structured interviews with 22 medicine subspecialty fellows (including 4 Infectious Diseases [ID] fellows) at a single academic medical center that explored participants’ motivations, preferences, and practices around case tracking. Interview transcripts were coded and analyzed with directed qualitative content analysis. Results of this analysis will be used to inform the design of a subspecialist EHR-based case tracking dashboard. Results Participants were motivated to engage in case tracking, with curiosity regarding patient outcomes as a strong motivator. Although some attempted to track all consults, most focused on subsets of patients, feeling that not all encounters were of equal educational value. Participants highlighted particular results, specialty-specific notes, and major outcomes as the most useful information. ID fellows specifically were interested in post-discharge ID clinic encounters, send-out tests, and outcomes of their management decisions. Despite widespread motivation to engage in case tracking, manually adding patients to lists and remembering to follow up poses logistical and time barriers. Conclusion An ideal EHR case-tracking dashboard would automatically keep a list of patients cared for by fellows and provide easy access to own-specialty notes, specific results of interest, and information on the global clinical course. The ability to highlight specific cases anticipated to have more educational value would also be of benefit. Disclosures All Authors: No reported disclosures

Feasibility and Effectiveness of a Quality Improvement Curriculum for Combined Medicine Subspecialty Fellows.

The Accreditation Council for Graduate Medical Education (ACGME) requires training in quality improvement (QI) yet many programs struggle to incorporate appropriate content. Small fellowship programs may find it particularly difficult, limited by a lack of well-trained faculty. We report on the feasibility and effectiveness of a consolidated curriculum for subspecialty fellowship programs. Two QI experts were identified to design a curriculum. Interactive didactic sessions were created to guide development and implementation of fellow QI projects. All projects culminated in abstract/poster presentation. Seven of 10 eligible fellowships participated. Twenty-four projects were completed with 70% reaching improvement in process measures. Trainees improved confidence in 11 of 12 QI domains. Program directors stated enhancement in QI education with 100% recommending program continuation. Consolidating teaching efforts with existing QI experts can lead to an effective QI curriculum for fellowship programs. This model can be expanded to other graduate medical education trainees as a means to increase QI proficiency.

Abstract #1003580: Sub-Specialty Fellow Education on Managing After-Hours Pages: A Single Institute Survey

Internal medicine sub-specialty fellows, including those in endocrinology, are often responsible for responding to patients who call after business hours. They are expected to address patient concerns, often without attending physician supervision. Very few specialties train fellows to answer these calls. Our aim was to assess fellows’ training and comfort with after-hours calls to determine if there is an unmet need for more education.

Can You Hear Me Now? Helping Faculty Improve Feedback Exchange for Internal Medicine Subspecialty Fellows.

IntroductionFeedback is an important tool that describes an individual's performance in a specific activity. Trainees at all levels grow from feedback exchanges to develop knowledge, skills, and attitudes in their specialty. However, there is a dearth of faculty development on providing advanced trainees feedback effectively.MethodsWe designed and delivered internal medicine subspecialty-focused 60- or 90-minute interactive workshop to train faculty to improve feedback exchange with fellows. The workshop included addressing barriers to feedback specific to fellowship, tool and skills for feedback exchange, and case-based skills practice specific to scenarios seen in each subspecialty fellowship program. We utilized surveys of faculty assessing comfort with feedback exchange with fellows before and after the workshop.ResultsWe delivered the workshop to two separate specialty sections, gastroenterology and endocrine. Overall, faculty (N = 14) self-reported comfort improved significantly from pretest to posttest (p < .01). Ten participants’ comfort ratings increased, while four remained the same at posttest. The evaluation identified several common themes as important learning points including labeling feedback, setting expectations around feedback exchange, and identifying elements of high-quality feedback exchange.DiscussionThis workshop for faculty was designed to improve the skills, knowledge, and attitudes related to feedback exchange specifically within an internal medicine subspecialty fellowship training program. Analysis of pre- and postsurvey data demonstrated increased faculty comfort providing fellows-in-training with feedback.

1123. Improving Quality Improvement: Increasing QI Competency in Internal Medicine Subspecialty Fellows

BackgroundMedical errors contribute to 44,000 – 98,000 deaths annually, which can result in total national costs upwards of 17-29 billion dollars. The Institute of Medicine suggests the application of QI as on of its five core competencies for all health care providers. ACGME has recognized the importance of QI curriculum in the training of both residents and fellows. To date, most QI curriculums focus on participation rather than application proficiency. A review performed by ACGME found that participants appeared to have a limited understanding of QI even after partaking in QI curricula. An activity that emphasizes practical application and meets the time constraints of residents and fellows would prove more beneficial than standard approaches.MethodsThis study included 13 ID, Allergy and Immunology, and Endocrine fellows from the University of Kansas Medical Center. Utilizing a QIKAT-R assessment tool, fellows were given 3 cases for which they had to develop a QI project. The assessment was made based on the ability to make an aim, find a measurable outcome or process that could easily be tabulated, and propose a change that could be tested. Following this, a 1-hour power point presentation which included active learning prompts in developing a QI project was given to the fellows. At the conclusion of the presentation, 3 additional cases were given to the fellows. Their ability to develop a QI project was again evaluated using the QIKAT-R assessment tool. At the end of the session a 5-question satisfaction survey was completed. As a group mean, scores prior to the 1-hour presentation were compared to those afterwards. A paired, single-tail, t-test was utilized to obtain a p-value in order to determine significance of change.ResultsIn total, there was a 42.2% (p=0.00001) increase in total QIKAT-R score after “QI Power Hour.” 92.3% of participants had a positive perception (Agree/Strongly Agree) of the 1-hour session.ConclusionThe findings suggest that fellows are able to show a higher proficiency in QI understanding as well as development of future QI projects. Fellows satisfaction of “QI Power Hour” was overall favorable. This study shows that it is possible to easily integrate QI understanding for practical application into the time constraints of a fellowship or residency curriculum.Disclosures All Authors: No reported disclosures

Developing internal medicine subspecialty fellows\u2019 teaching skills: a needs assessment

BackgroundFor academic physicians, teaching represents an essential skill. The proliferation of educator training programs aimed at residents and medical students signals the increasing commitment of training programs to develop teaching skills in their trainees as early as possible. However, clinical fellowships represent an important opportunity to advance training as educators. In addition to enriching the pipeline of future teachers, developing fellows as teachers augments the training experience for more junior trainees and may impact patient care. Fellows’ needs for programs to improve teaching skills have been largely unexplored.MethodsWe conducted a multi-institutional needs assessment of internal medicine (IM) subspecialty fellows to gauge interest in teaching and improvement of teaching skills. We surveyed IM subspecialty fellows at three academic medical centers about their access to fellow-as-teacher programs and other mechanisms to improve their teaching skills during fellowship. We also elicited their attitudes towards teaching and interest in training related to teaching skills.ResultsOne hundred eighty-three fellows representing 20 programs and nine different subspecialties responded to the survey (48% response rate). The majority of participants (67%) reported having no specific training focused on teaching skills and only 12% reported receiving regular feedback about their teaching during their fellowship. Seventy-nine percent of fellows anticipated teaching to be part of their careers, and 22% planned to participate in medical education scholarship. Fellows reported a strong interest in teaching and programs aimed at improving their teaching skills.ConclusionsThe majority of fellows reported a lack of mechanisms to advance their teaching skills as fellows, despite anticipating teaching to be an important aspect of their future careers and having strong interest in such programs. Our findings at three academic medical centers confirm a lost opportunity among subspecialty fellowships to accelerate teaching skills development for future educators.

New Roadmap for the Journey From Internist to Rheumatologist.

Measurement is necessary to gauge improvement. US training programs have not previously used shared standards to assess trainees' mastery of the knowledge, skills, and attitudes necessary to practice rheumatology competently. In 2014, the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System began requiring semiannual evaluation of all medicine subspecialty fellows on 23 internal medicine subspecialty reporting milestones. Since these reporting milestones are not subspecialty specific, rheumatology curricular milestones were needed to guide rheumatology fellowship training programs and fellows on the training journey from internist to rheumatologist. Rheumatology curricular milestones were collaboratively composed by expanding the internal medicine reporting milestones to delineate the specific targets of rheumatology fellowship training within 6 ACGME core competencies. The 2006 American College of Rheumatology core curriculum for rheumatology training programs was updated. A total of 80 rheumatology curricular milestones were created, defining progressive learning through training; most focus on patient care and medical knowledge. The core curriculum update incorporates the new curricular milestones and rheumatology entrustable professional activities. Rheumatology curricular milestones are now available for implementation by rheumatology fellowship training programs, providing a clear roadmap for specific training goals and a guide to track each fellow's achievement over a 2-year training period. The comprehensive core curriculum delineates the essential breadth of knowledge, skills, and attitudes that define rheumatology, and provides a guide for educational activities during fellowship training. These guiding documents are now used to train and assess fellows as they prepare for independent rheumatology practice as the next generation of rheumatologists.

Self-Assessment Scores Improve After Simulation-Based Palliative Care Communication Skill Workshops.

We conducted a randomized trial of a simulation-based multisession workshop to improve palliative care communication skills (Codetalk). Standardized patient assessments demonstrated improved communication skills for trainees receiving the intervention; however, patient and family assessments failed to demonstrate improvement. This article reports findings from trainees' self-assessments. To examine whether Codetalk resulted in improved self-assessed communication competence by trainees. Trainees were recruited from the University of Washington and the Medical University of South Carolina. Internal medicine residents, medicine subspecialty fellows, nurse practitioner students, or community-based advanced practice nurses were randomized to Codetalk, a simulation-based workshop, or usual education. The outcome measure was self-assessed competence discussing palliative care needs with patients and was assessed at the start and end of the academic year. We used robust linear regression models to predict self-assessed competency, both as a latent construct and as individual indicators, including randomization status and baseline self-assessed competency. We randomized 472 trainees to the intervention (n = 232) or usual education (n = 240). The intervention was associated with an improvement in trainee's overall self-assessment of competence in communication skills ( P < .001). The intervention was also associated with an improvement in trainee self-assessments of 3 of the 4 skill-specific indicators-expressing empathy, discussing spiritual issues, and eliciting goals of care. Simulation-based communication training was associated with improved self-assessed competency in overall and specific communication skills in this randomized trial. Further research is needed to fully understand the importance and limitations of self-assessed competence in relation to other outcomes of improved communication skill.

Why Not Nephrology? A Survey of US Internal Medicine Subspecialty Fellows

There is a decreased interest in nephrology such that the number of trainees likely will not meet the upcoming workforce demands posed by the projected number of patients with kidney disease. We conducted a survey of US internal medicine subspecialty fellows in fields other than nephrology to determine why they did not choose nephrology. A web-based survey with multiple choice, yes/no, and open-ended questions was sent in summer 2011 to trainees reached through internal medicine subspecialty program directors. 714 fellows responded to the survey (11% response rate). All non-nephrology internal medicine subspecialties were represented, and 90% of respondents were from university-based programs. Of the respondents, 31% indicated that nephrology was the most difficult physiology course taught in medical school, and 26% had considered nephrology as a career choice. Nearly one-fourth of the respondents said they would have considered nephrology if the field had higher income or the subject were taught well during medical school and residency training. The top reasons for not choosing nephrology were the belief that patients with end-stage renal disease were too complicated, the lack of a mentor, and that there were insufficient procedures in nephrology. Most non-nephrology internal medicine subspecialty fellows never considered nephrology as a career choice. A significant proportion were dissuaded by factors such as the challenges of the patient population, lack of role models, lack of procedures, and perceived difficulty of the subject matter. Addressing these factors will require the concerted effort of nephrologists throughout the training community.

Why Not Nephrology? A Survey of US Internal Medicine Subspecialty Fellows

Why Not Nephrology? A Survey of US Internal Medicine Subspecialty Fellows

Training satisfaction for subspecialty fellows in internal medicine: Findings from the Veterans Affairs (VA) Learners' Perceptions Survey

BackgroundLearner satisfaction assessment is critical in the design and improvement of training programs. However, little is known about what influences satisfaction and whether trainee specialty is correlated. A national comparison of satisfaction among internal medicine subspecialty fellows in the Department of Veterans Affairs (VA) provides a unique opportunity to examine educational factors associated with learner satisfaction. We compared satisfaction across internal medicine fellows by subspecialty and compared factors associated with satisfaction between procedural versus non-procedural subspecialty fellows, using data from the Learners' Perceptions Survey (LPS), a validated survey tool.MethodsWe surveyed 2,221 internal medicine subspecialty fellows rotating through VA between 2001 and 2008. Learners rated their overall training satisfaction on a 100-point scale, and on a five-point Likert scale ranked satisfaction with items within six educational domains: learning, clinical, working and physical environments; personal experience; and clinical faculty/preceptor.ResultsProcedural and non-procedural fellows reported similar overall satisfaction scores (81.2 and 81.6). Non-procedural fellows reported higher satisfaction with 79 of 81 items within the 6 domains and with the domain of physical environment (4.06 vs. 3.85, p <0.001). Satisfaction with clinical faculty/preceptor and personal experience had the strongest impact on overall satisfaction for both. Procedural fellows reported lower satisfaction with physical environment.ConclusionsInternal medicine fellows are highly satisfied with their VA training. Nonprocedural fellows reported higher satisfaction with most items. For both procedural and non-procedural fellows, clinical faculty/preceptor and personal experience have the strongest impact on overall satisfaction.

Internal Medicine and Primary Care

To the Editor.—I will not be the only reader to see a connection between the reports of Earp and others1and Napodano and others2in your February issue. Although more than one interpretation can be made from Earp's data, it is reasonable to conclude that the internal medicine subspecialty fellows they interviewed did not have ideal attitudes for primary care. When I read that only three of 34 respondents (9%) felt that they should be responsible for their patient's psychosocial problems and that only nine (27%) would like their patients to call them personally for medical advice when needed after hours, I can only hope that few of these fellows will later find themselves with primary responsibility for a patient's care. But I know, as documented in the references accompanying the article by Earp et al, that this will not be the case. The kind of training

Attitudes of internal medicine subspecialty fellows toward primary care

Attitudes of internal medicine subspecialty fellows toward primary care

Attitudes of Internal Medicine Subspecialty Fellows Toward Primary Care

Subspecialists deliver a substantial proportion of primary care but little is known about how their training affects their attitudes toward this role. We surveyed a department of medicine to determine fellows' (N = 34) attitudes toward primary care and how these compared with the attitudes of house staff (N = 45) and faculty (N = 66). Continuous, coordinated, and accessible care as departmental policy was almost unanimously endorsed by all physicians. In contrast, fellows less often supported the provision of such care for their own patients in actual clinical situations. Fellows were also less likely than either house staff or faculty to endorse primary care attributes for their own patients. Departments of medicine should examine how negative attitudes toward primary care develop in subspecialty fellows and whether these attitudes persist after fellowship.