Internal Medicine Residency Training Research Articles

Transforming Primary Care Training—Patient-Centered Medical Home Entrustable Professional Activities for Internal Medicine Residents

The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice. We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs? The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs). The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs. The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Factors Affecting Learner Satisfaction with an Internet-Based Curriculum

Online curricula are used increasingly for educating physicians, and evaluating educational outcomes can help improve their effectiveness. It is unknown how specific educational outcomes associate with each other among learners using online curricula. We set out to study how two educational outcomes, learner satisfaction and knowledge, and the learner's year of training and training hospital, were associated with one another among learners accessing a widely used online curriculum. Using data from the 2006-2007 academic year, learner satisfaction was compared with pretest knowledge, posttest knowledge, changes in knowledge, module topic, year of training, and training hospital among 3229 residents at 73 internal medicine residency training programs. A multivariable model was used to calculate the odds ratio of learner satisfaction relative to changes in knowledge. Module topic, year of training, and hospital type were associated with learner satisfaction. Second-year residents were more satisfied with training modules (mean rating 4.01) than first- and third-year residents (mean ratings 3.97 and 3.95, respectively; P < 0.05). Learner satisfaction was greater among community hospital residents than university hospital residents (mean rating 4.0 vs 3.92; P < 0.05). Learner satisfaction was greater in residents with high pretest and high posttest knowledge (P < 0.05). In multivariate analyses, greater gains in knowledge were associated with greater learner satisfaction (P < 0.05). Greater learner satisfaction is associated with greater baseline knowledge, greater knowledge after completing a curriculum, and greater improvement in knowledge while enrolled in a curriculum.

Learner feedback and educational outcomes with an internet-based ambulatory curriculum: a qualitative and quantitative analysis

BackgroundOnline medical education curricula offer new tools to teach and evaluate learners. The effect on educational outcomes of using learner feedback to guide curricular revision for online learning is unknown.MethodsIn this study, qualitative analysis of learner feedback gathered from an online curriculum was used to identify themes of learner feedback, and changes to the online curriculum in response to this feedback were tracked. Learner satisfaction and knowledge gains were then compared from before and after implementation of learner feedback.Results37,755 learners from 122 internal medicine residency training programs were studied, including 9437 postgraduate year (PGY)1 residents (24.4 % of learners), 9864 PGY2 residents (25.5 %), 9653 PGY3 residents (25.0 %), and 6605 attending physicians (17.0 %). Qualitative analysis of learner feedback on how to improve the curriculum showed that learners commented most on the overall quality of the educational content, followed by specific comments on the content. When learner feedback was incorporated into curricular revision, learner satisfaction with the instructive value of the curriculum (1 = not instructive; 5 = highly instructive) increased from 3.8 to 4.1 (p < 0.001), and knowledge gains (i.e., post test scores minus pretest scores) increased from 17.0 % to 20.2 % (p < 0.001).ConclusionsLearners give more feedback on the factual content of a curriculum than on other areas such as interactivity or website design. Incorporating learner feedback into curricular revision was associated with improved educational outcomes. Online curricula should be designed to include a mechanism for learner feedback and that feedback should be used for future curricular revision.

Paul Arthur Grayburn, MD: An Interview by Mina Mecheal Benjamin, MD

Dr. Paul Grayburn (Figure ​(Figure11) was born in Cincinnati, Ohio, on July 24, 1954. He graduated from Texas A&M University with a bachelor's degree in chemistry in 1976 and The University of Texas (UT) School of Medicine in Galveston, Texas, in 1981. After an internship and residency training in internal medicine at St. Paul Hospital (a UT Southwestern affiliate) in Dallas, he completed his cardiology and interventional cardiology training at the University of Kentucky Medical Center. He worked for 1 year as an instructor in medicine at the University of Kentucky Medical Center before returning to Dallas in 1988, where he practiced interventional cardiology and served as chief of cardiology at the Veterans Affairs Medical Center and was director of the echocardiography laboratories for UT Southwestern Medical Center. In September 2002, he came to Baylor University Medical Center at Dallas (BUMC) as the medical director of cardiology research. Dr. Grayburn has coauthored >270 articles in medical journals and is author/editor of 9 book chapters. He has participated in several multicenter trials that have changed our understanding and management of cardiovascular diseases. Dr. Grayburn is an expert in echocardiography and valvular heart diseases. He has been a visiting professor and lecturer at numerous institutions in the United States and abroad. Dr. Grayburn is the epitome of what an academic physician should be: an outstanding clinician, teacher, researcher, and mentor.

A Randomized Controlled Trial of the Impact of a Teaching Procedure Service on the Training of Internal Medicine Residents

Academic medical centers must provide safe inpatient procedures while balancing resident autonomy and education. We performed a randomized, controlled trial to evaluate the effect of a 2-week hospitalist procedure service (HPS) rotation on interns' self-perceived procedure ability, knowledge, and autonomy versus the standard curriculum. We randomly selected 16 of 57 internal medicine interns (28%) to participate in the intervention group rotation, with 29 interns in the control group. All interns were surveyed before the start of residency and at the end of the postgraduate year-1 (PGY-1) and PGY-2years to evaluate self-reported knowledge and ability to (1) safely perform procedures, (2) supervise procedures, and (3) use bedside ultrasound. Ninety-four percent of HPS interns (15/16) and 71% of control interns (29/41) completed all surveys. Baseline knowledge and experience did not differ significantly between the groups. The intervention group performed significantly more paracentesis (9 versus 4; P < .001), thoracentesis (6 versus 2; P < .001), and lumbar puncture (4 versus 3; P < .001) procedures than did the control group. After their first year, residents who completed the HPS rotation rated their ability to safely perform and supervise all of the assessed procedures as higher (P < .05 for all procedures) and were more likely to rate self-perceived knowledge as very good or excellent in all surveyed aspects of procedure performance (P < .05). A 2-week hospitalist-supervised procedure service rotation substantially improved residents' experience, confidence, and knowledge in performing bedside procedures early in their training, with this effect sustained through the PGY-2year. Standardized procedure service rotations are a viable solution for programs seeking to improve their procedure-based education.

Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination

Despite the future potential of using ultrasound stethoscopes to augment the bedside cardiac physical, few data exist on a general cardiovascular imaging protocol that can be taught to physicians on a perpetual basis as a curriculum in graduate medical education. During the past decade, we developed and integrated a cardiovascular limited ultrasound training program within the confines of an internal medicine residency. The evidence-based rationale for the exam, the teaching methods, and curriculum are delineated, and subsequent observations regarding program requirements, proficiency, and academic outcomes are explored. Analysis of variance and linear regression assessed for relationships between academic scores, chief resident selection, and gender to proficiency in ultrasound. A brief, 5-minute cardiovascular limited ultrasound exam (CLUE) was taught using both didactic and bedside methods, and practiced primarily within the cardiology consult, outpatient clinic, and intensive care rotations. Program costs were minimized by employing readily available institutional resources. After a 2-year lead-in training phase, the subsequent 4 years of senior resident performance (n = 41 residents) showed an 81% pass rate in CLUE competency. Resident ultrasound performance did not relate to academic scores (r = 0.05, P = 0.75), chief resident selection, nor gender. Observations regarding resident pitfalls in CLUE practice and increased participation in extracurricular research are described. We report our initial experience in developing and implementing a training program for bedside cardiovascular ultrasound examination that employed evidence-based techniques, set proficiency goals, and assessed resident performance. It may be feasible to teach future internist-hospitalists the technique of bedside ultrasound during residency.

“Problem Residents”: Prevalence, Problems and Remediation in the Era of Core Competencies

The American Board of Internal Medicine (ABIM) has defined the “problem resident” as a learner who demonstrates problem behaviors significant enough to require intervention by program leadership, typically the residency program director or chief resident.1 It has been over a decade since Yao and Wright's report2 on the prevalence of “problem residents” in internal medicine residency training programs. Their survey of program directors reported performance problems in 6.9% of residents. We are unaware of any subsequent large studies in internal medicine of this important topic.

What does the Allergist/Clinical Immunologist do?

An allergist or clinical immunologist is a medical doctor with specialty training in the diagnosis, treatment and prevention of allergic diseases and diseases of the immune system. To become an allergist, a person must attained a bachelor degree from a Faculty of Medicine, and undergo residency training in either internal medicine or pediatrics (3 years each). Once board-certified, the internist or pediatrician may decide to obtain additional specialty training in allergy and clinical immunology, called a fellowship (2-3 years). An allergist or clinical immunologist who is board-certified has also passed an additional examination showing competence in the fields of allergy and clinical immunology. SAUDI JOURNAL OF INTERNAL MEDICINE V 1 N . 2 1432 H 2011 G EDITORIAL

A Curriculum in Health Systems and Public Health for Internal Medicine Residents

Medical educators and accreditation organizations recognize that healthcare professionals in the future will depend on working knowledge of the larger contexts and systems of health care, including population and public health. Little published guidance on medical education in health systems and public health exists, particularly for graduate medical education. This study describes the evaluation of a curriculum in health systems and public health which was successfully implemented in an internal medicine residency training program. A pilot program consisting of a week-long didactic curriculum for senior residents, including ten half-day seminars. Two cycles of the pilot curriculum were implemented in September and November, 2007. The participants were third-year residents in an internal medicine training program at a large, urban academic medical center. The 1-week curriculum was fully implemented and evaluated in the academic years 2008-2010. It included seminars on health policy and economics, health insurance, technology and cost assessment, legal medicine, public health, community-oriented primary care, and local health department initiatives. Residents evaluated the quality and impact of the seminars and overall curriculum, retrospectively assessed their knowledge of topics presented before and after the seminars, and rated the seminars that were most valuable to them. The seminars were highly rated by the participating residents, and the curriculum was judged by them to be valuable in their clinical activities and professional development. Key lessons learned included the importance of accessing resources external to the residency program and the challenge of making learning in health systems and public health active and relevant to clinical practice.

Developing cardiac auscultation skills among physician trainees

Erica S. Spatz ⁎, Darlene LeFrancois , Robert J. Ostfeld c,d a Department of Medicine, Section of Cardiolovascular Medicine, Yale University School of Medicine, New Haven, CT, USA b Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA c Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA d Department of Medicine, Internal Medicine Residency Training Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

Using a Web-Based Survey for the Annual Internal Medicine Residency Evaluation

The Accreditation Council for Graduate Medical Education requires annual surveys of residency programs. We switched from a paper-based to a web-based survey and report on the efficiency and quality improvement gains from this change. To determine the prevalence of web-based surveys, we conducted a web-based and telephone survey of 17 internal medicine residency training programs in Southern California. Fifteen programs provided data (88% response rate). By making the switch, our internal medicine residency program was able to save over 50 administrative hours and over 1000 pieces of paper. A total investment of $20 for the Surveymonkey.com account (Palo Alto, CA) and approximately 15hours to migrate the survey was made. The program administrators were able to more rapidly analyze and respond to the feedback from the residents with this system. Our survey of other programs showed that of 15 programs, 12 used a web-based survey system (80%) and 3 used a paper-based system (20%). Surveymonkey.com was the most popular system used. We feel that the quality of response to resident feedback was enhanced by the real-time reaction to comments and assessments. Residents also appreciated the benefits of such a change. We recommend this approach to other programs that are still using paper-based surveys.

Creating a Geriatric Medicine Fellowship Program in 10 “Easy” Steps

The aging of the U.S. population poses one of the greatest future challenges for family medicine and internal medicine residency training. One important barrier to providing quality education and training in geriatric medicine to residents is a serious and growing shortage of practicing geriatricians and geriatrics faculty. The Accreditation Council for Graduate Medical Education currently accredits 45 family medicine-based and 107 internal medicine-based geriatric medicine fellowships in the United States. There are 13 American Osteopathic Association-certified geriatric medicine fellowship programs. In this article, the authors examine the rationale for the development of additional geriatric medicine fellowship programs and offer some practical suggestions and pointers for those interested in developing their own geriatric medicine fellowships. The authors write from the perspective of their own recent experiences with the development and accreditation of a family medicine residency-affiliated fellowship in geriatrics. Other residencies may find this article useful in determining the feasibility of developing a geriatric medicine fellowship for their programs and communities and will find practical guidance for beginning the process.

Associations between quality indicators of internal medicine residency training programs.

BackgroundSeveral residency program characteristics have been suggested as measures of program quality, but associations between these measures are unknown. We set out to determine associations between these potential measures of program quality.MethodsSurvey of internal medicine residency programs that shared an online ambulatory curriculum on hospital type, faculty size, number of trainees, proportion of international medical graduate (IMG) trainees, Internal Medicine In-Training Examination (IM-ITE) scores, three-year American Board of Internal Medicine Certifying Examination (ABIM-CE) first-try pass rates, Residency Review Committee-Internal Medicine (RRC-IM) certification length, program director clinical duties, and use of pharmaceutical funding to support education. Associations assessed using Chi-square, Spearman rank correlation, univariate and multivariable linear regression.ResultsFifty one of 67 programs responded (response rate 76.1%), including 29 (56.9%) community teaching and 17 (33.3%) university hospitals, with a mean of 68 trainees and 101 faculty. Forty four percent of trainees were IMGs. The average post-graduate year (PGY)-2 IM-ITE raw score was 63.1, which was 66.8 for PGY3s. Average 3-year ABIM-CE pass rate was 95.8%; average RRC-IM certification was 4.3 years. ABIM-CE results, IM-ITE results, and length of RRC-IM certification were strongly associated with each other (p < 0.05). PGY3 IM-ITE scores were higher in programs with more IMGs and in programs that accepted pharmaceutical support (p < 0.05). RRC-IM certification was shorter in programs with higher numbers of IMGs. In multivariable analysis, a higher proportion of IMGs was associated with 1.17 years shorter RRC accreditation.ConclusionsAssociations between quality indicators are complex, but suggest that the presence of IMGs is associated with better performance on standardized tests but decreased duration of RRC-IM certification.

About the Authors

About the Authors

A Qualitative Analysis of Career Transitions Made by Internal Medicine–Pediatrics Residency Training Graduates

Physicians who complete combined residency training in internal medicine and pediatrics (med-peds) have a variety of career options after training. Little is known about career transitions among this group or among other broadly trained physicians. To better understand these career transitions, we conducted semistructured, in-depth, telephone interviews of graduates of the University of North Carolina-Chapel Hill School of Medicine med-peds program who self-identified as having had a career transition since completing training. We qualitatively analyzed interview transcripts, to develop themes describing their career transitions. Of 106 physicians who graduated during 1980-2007, 20 participated in interviews. Participants identified factors such as personality, work environment, lifestyle, family, and finances as important to career transition. Five other themes emerged from the data; the following 4 were confirmed by follow-up interviews: (1) experiences during residency were not sufficient to predict future job satisfaction; work after the completion of training was necessary to discover career preferences; (2) a major factor motivating job change was a perceived lack of control in the workplace; (3) participants described a sense of regret if they did not continue to see both adult and pediatric patients as a result of their career change; (4) participants appreciated their broad training and, regardless of career path, would choose to pursue combined residency training again. We included only a small number of graduates from a single institution. We did not interview graduates who had no career transitions after training. There are many professional opportunities for physicians trained in med-peds. Four consistent themes surfaced during interviews about med-peds career transitions. Future research should explore how to use these themes to help physicians make career choices and employers retain physicians.

A core competence-based objective structured clinical examination (OSCE) in evaluation of clinical performance of postgraduate year-1 (PGY 1) residents

Background Clinical competency certifications are important parts of internal medicine residency training. This study aims to evaluate a composite objective structured clinical examination (OSCE) that assesses postgraduate year-1 (PGY 1) residents’ acquisition of the six core competencies defined by the Accreditation council for Graduate Medical Education (ACGME). Methods Six-core-competency-based OSCE was used as examination of the clinical performance of 192 PGY 1 residents during their 3-month internal medicine training between 2007 January and 2009 December. For each year, the reliability of the entire examination was calculated with Cronbach’s alpha. Results The reliability of six-core-competency-based OSCE was acceptable, ranging from 0.69 to 0.87 between 2007 and 2009. In comparison with baseline scores, the summary scores and core-competency subscores all showed significant increase after PGY 1 residents finished their 3-month internal medicine training program. Conclusion By using a structured development process, the authors were able to create reliable evaluation items for determining PGY 1 residents’ acquisition of the ACGME core competencies.

In memoriam Prof. Peter T. Macklem, 1931–2011: a tribute from the European Respiratory Society

It is our sad duty to announce the passing of Prof. Peter T. Macklem to the readers of the European Respiratory Journal ( ERJ ) and the members of the European Respiratory Society (ERS). Peter Macklem passed away suddenly at home on Friday February 11, 2011, at the age of 79 years. His passing is an immense loss to the ERS and to the whole respiratory community, for which he was one of the main sources of inspiration, creativity and innovation. Getting to know him as both a person and a scientist was an exquisite experience and he will be sadly missed by everyone who came in contact with him. Born in 1931, Peter grew up in Kingston, ON, Canada where he attended Queen's University and obtained a Bachelor's degree in 1952. He then entered McGill University Medical School (Montreal, QC, Canada), where he obtained an MDCM in 1956. Following residency training in internal medicine at the Royal Victoria Hospital (Montreal), he became a research fellow in the Cardio-Pulmonary Service then headed by David Bates, where he was introduced to the study of lung mechanics by Dr Margo Becklake. This subject rapidly became the scientific love of his life and a constant theme of the many areas of pulmonary medicine and physiology that he contributed to. He became a fellow of the Royal College of Physicians and Surgeons of Canada by examination in 1963 and was appointed an Instructor in Medicine and Clinical Assistant at the Royal Victoria Hospital, after a fellowship with Jere Mead at the Harvard School of Public Health in Boston, MA, USA, with whom he maintained lifelong contact and whom he greatly respected. Following this seminal experience, Peter returned to Montreal where he quickly developed into an outstanding clinical scientist with deep interests in both basic research and …

Standards for Education and Credentialing in Critical Care Medicine

HE PROVISION OF INTENSIVE CARE TO PATIENTS IN THE throes of life-threatening acute illness is one of the most important and most expensive parts of US health care. Today, adults in the United States are increasingly likely to receive intensive care unit (ICU) care compared with previous generations, with the greatest ICU resource use occurring among older patients and those at the end of life. 1 Several million individuals are admitted to ICUs in the United States each year at a cost approaching 1% of the nation’s gross domestic product. 2,3 A large body of evidence suggests that the likelihood a patient will survive an episode of critical illness is exquisitely dependent on how the ICU is staffed. 4 In particular, care led by physicianstrainedandcertifiedincriticalcaremedicine(CCM) isstronglyassociatedwithimprovedoddsofsurvival.Inthe rest of the developed world, ICUs are staffed exclusively by physicians trained in CCM. However, in the United States, only a third of patients in the ICU are managed by critical care physicians. 5 There is no coordinated effort to train an expanded workforce of CCM physicians. In the United States, CCM is recognized neither as an independent discipline such as surgery, internal medicine, or anesthesiology, nor as a conjoined subspecialty with uniform education, training, and credentialing. Rather, there are now 6 separate adult intensive care training pathways following residency training in anesthesiology, emergency medicine, internal medicine (either as critical care alone or jointly with training in pulmonary medicine), neurology, and surgery, leading to an array of training programs with separate credentialing criteria. No other medical subspecialty has such an inconsistent approach. Criticalcaremedicineseemstobemovingawayfromuniformstandardsevenasitmaturesasaspecialty.Criticalcare medicine arose in the United States during the 1960s just as ICUs emerged. In the United States, CCM has been regarded as a “niche” specialty in that training is undertaken by a minority of physicians within a primary specialty. 6 In

Internal Medicine Residency Training on Topics in Ambulatory Care: A Status Report

Internal Medicine Residency Training on Topics in Ambulatory Care: A Status Report

First Do No Harm: Preserving Patient Safety Without Sacrificing Procedural Education

First Do No Harm: Preserving Patient Safety Without Sacrificing Procedural Education