US Internal Medicine Residency Research Articles

How Are We Teaching Advocacy? A National Survey of Internal Medicine Residency Program Directors.

Although internal medicine (IM) physicians accept publicadvocacy as a professional responsibility, there is little evidence that IM training programs teach advocacy skills. The prevalence and characteristics of publicadvocacy curricula in US IM residency programs are unknown. To describe the prevalence and characteristics of curricula in US IM residencies addressing public advocacy for communities and populations; to describe barriers to the provision of such curricula. Nationally representative, web-based, cross-sectional survey of IM residency program directors with membership in an academic professional association. A total of 276 IM residency program directors (61%) responded between August and December 2022. Percentage of US IM residency programs that teach advocacy curricula; characteristics of advocacy curricula; perceptions of barriers to teaching advocacy. More than half of respondents reported that their programs offer no advocacy curricula (148/276, 53.6%). Ninety-five programs (95/276, 34.4%) reported required advocacy curricula; 33 programs (33/276, 12%) provided curricula as elective only. The content, structure, and teaching methods of advocacy curricula in IM programs were heterogeneous; experiential learning in required curricula was low (23/95, 24.2%) compared to that in elective curricula (51/65, 78.5%). The most highly reported barriers to implementing or improving upon advocacy curricula (multiple responses allowed) were lack of faculty expertise in advocacy (200/276, 72%), inadequate faculty time (190/276, 69%), and limited curricular flexibility (148/276,54%). Over half of US IM residency programs offer no formal training in public advocacy skills and many reported lack of faculty expertise in public advocacy as a barrier. These findings suggest many IM residents are not taught how to advocate for communities and populations. Further, less than one-quarter of required curricula in public advocacy involves experiential learning.

Finding the right combination for self-directed learning: A focus group study of residents' choice and use of digital resources to support their learning.

There has been a shift in postgraduate medical education towards digital educational resources-podcasts, videos, social media and other formats consumed asynchronously and apart from formal curricula. It is unclear what drives residents to select and use these resources. Understanding how and why residents choose digital resources can aid programme directors, faculty and residents in optimising residents' informal learning time. This focus group study was conducted with residents at two US internal medicine residency programmes. The authors used the framework approach to content analysis using self-determination theory as guide for deductive coding and iteratively assessing connections among codes and identifying themes. Trustworthiness was addressed through use of analytic memos, reflexive practice and member checking. The authors conducted eight virtual focus groups (n = 23) from 5/27/20 to 6/11/20. Residents described that a feeling of 'should know' drove initial choices towards self-directed learning outside of work. Regular use of a resource was influenced by how the resource fit into a resident's lifestyle, the personal cognitive energy and the perceived 'activation energy' of using a particular resource. Familiarity, increased confidence and in-person social networks gained from digital resources served to reinforce and further guide resource choice. The selection of digital resources for self-directed learning is driven by multiple factors, suggesting an interdependent relationship between the learning environment and a residents' cognitive capacity. Understanding these interconnections can help residents and clinical educators explicitly choose resources that fit their lifestyle and learning needs.

Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors.

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

Evaluation of an Individualized Learning Plan Template for the Transition to Residency.

Background Specialty-specific individualized learning plans (ILPs) have been promoted to improve the undergraduate to graduate medical education transition, yet few pilots have been described. Objective To create and report on the feasibility and acceptability of a pilot internal medicine (IM) ILP template. Methods The ILP was created by a group of diverse IM expert stakeholders and contained questions to stimulate self-reflection and collect self-reported readiness data from incoming interns. US IM residency programs were invited to pilot the ILP with interns in spring 2022. Data was used at the programs' discretion. The pilot was evaluated by a post-pilot survey of programs to elicit perceptions of the impact and value of the ILP and analyze anonymous ILP data from 3 institutions. Results Fifty-two IM residency programs agreed to participate with a survey response rate of 87% (45 of 52). Of responding programs, 89% (40 of 45) collected ILPs, thus we report on data from these 40 programs. A total of 995 interns enrolled with 782 completing ILPs (79%). One hundred eleven ILPs were analyzed (14%). Most programs found the ILP valuable to understand incoming interns' competencies (26 of 40, 65%) and areas for improvement (24 of 40, 60%) and thought it should continue (29 of 40, 73%). Programs estimated the ILP took interns 29.2±14.9 minutes and 21.6±10.3 minutes for faculty mentors to complete. The most common barrier was faculty mentor participation. Conclusions An ILP based on interns' self-reported data was feasible and valuable to IM residency programs in understanding interns' competencies and areas for improvement.

An Educational Needs Assessment of Telehealth in Primary Care Among US Internal Medicine Residents.

As a result of the coronavirus disease 2019 pandemic, many Internal Medicine (IM) residency programs converted to telehealth for primary care. Our objectives in this study were to better understand resident past and present telehealth education, their perceived barriers to telehealth practice, and their perceived solutions to improving telehealth use and education. We performed a cross-sectional needs assessment survey between November 2020 and February 2021 among residents at 10 IM residency programs across the United States. Our primary measures were telehealth use in resident continuity clinics before and during the coronavirus disease 2019 pandemic, telehealth training, and confidence and barriers in using telehealth. Of 857 residents contacted, 314 (36.6%) responded. Residents reported low rates of education in telehealth prepandemic with significant improvements after the start of the pandemic across all visit domains (range of 10.7%-19.6% prepandemic compared with 25.6%-55.7% postpandemic, all P < 0.001). Resident confidence levels were significantly lower (P < 0.001) for video visits and telephone visits compared with in-person visiting across domains of communication, history taking, using an interpreter, making a diagnosis, counseling patients, providing psychosocial support, performing medical management, and coordinating after-visit care. Reported barriers included patient resources, clinic resources, lack of preceptor feedback, and lack of observation. Reported resources for improvement included tutorials on physical examination techniques, clinical space for telehealth, and patient resources for telehealth. To effectively address the educational needs for telehealth practice by IM residents, educators must consider not only curricular needs but also clinical, preceptor, and patient barriers to the high-quality use of telehealth for primary care.

Reported Visa Acceptance or Sponsorship for Non-US Citizen Applicants to US Internal Medicine Residency Programs.

Non-US citizen international medical graduates (IMGs) make up a significant proportion of the physician workforce, especially in physician shortage areas and specialties. IMGs face barriers matriculating in US residency programs. Whether a program reports accepting J-1 visas and sponsoring H-1B visas influences their decision to apply, it remains unclear which institutional factors shape programs' likelihood to consider visa-seeking applicants. We investigated factors associated with programs reporting accepting J-1 visas or sponsoring H-1B visas for non-citizen applicants in internal medicine, the specialty most sought after by IMGs. We performed multivariable regression analyses using publicly available data to identify characteristics associated with reported visa acceptance (J-1 and or H-1B). Covariates included university affiliation, program size, program type (academic, university-affiliated community, or community), and Doximity reputation ranking. We identified 419 programs: 267 (63.7%) reported accepting J-1 visas. Among programs that accepted J-1 visas, 65.6% (n=175) accepted only J-1 visas while 34.5% (n=92) sponsored H-1B and accepted J-1 visas. Ranking in the third quartile (vs first quartile) was associated with lower odds of accepting J-1 (aOR 0.12; 95% CI 0.02-0.87; P=.04) and sponsoring H-1B visas (aOR 0.19; 95% CI 0.05-0.76; P=.02). Community status (vs academic) was associated with lower odds of accepting J-1 visas (aOR 0.2; 95% CI 0.06-0.64; P=.007), as was county hospital affiliation vs non-county hospitals (aOR 0.22; 95% CI 0.11-0.42; P<.001). While prior evidence shows that most internal medicine programs that substantially enroll IMGs are low ranking, high-ranking internal medicine programs are paradoxically more likely to report that they consider and sponsor visa-seeking applicants.

Characterization of Internal Medicine Chief Resident Administrative, Educational, and Clinical Experiences

The internal medicine (IM) chief residency is a position of leadership and honor common in IM programs, but the goals, responsibilities, and experiences of those who undertake it can be highly variable. Studies assessing the experience and impressions of the chief resident (CR) position from the viewpoint of the IM CRs are lacking. To describe the structure, responsibilities, and perceptions of the IM CR role across IM residency programs. A cross-sectional, simple descriptive electronic survey for current CRs was administered between April and June 2018 across US IM residency programs accredited by US Accreditation Council for Graduate Medical Education. A 2-step nonrandom sampling approach was used: first, snowball sampling was performed using the authors' professional networks, and second, the survey was sent to the Association of Program Directors in Internal Medicine (APDIM) CR listserv. Data analysis was performed from June 2020 to August 2020. Participation as a CR for an IM residency program in the 2017 to 2018 academic year. Descriptive CR personal and program characteristics and CR perceptions of administrative, clinical, and leadership experiences. Among 169 unique responses, 77 participants (46%) were female and 89 (53%) were White. The response rate was 57% (70 of 122 surveys) in the snowball sample and 12% (99 of 842 surveys) in the APDIM listserv. The 2 sampled groups were combined for analysis. Most respondents (125 CRs [74%]) were from academic or university-based programs. Common across CR responses was responsibility for administrative tasks, clinical work, and educational efforts. Most CRs (111 of 157 respondents [71%]) reported being the primary schedulers for the residency program. Clinical work differed widely across respondents. Only 70 of 156 respondents (45%) reported having an academic title associated with the CR role. CRs reported inconsistent evaluation throughout the year, with high percentages reporting never receiving feedback on teaching (34 respondents [23%]), clinical abilities (67 respondents [45%]), or leadership abilities (60 respondents [40%]). Most CRs (107 respondents [69%]) agreed that they find work as a CR fulfilling and 117 (74%) agreed they would do chief residency again. Despite its ubiquity in training programs across the US, the IM CR experience is very different across programs. Recommendations are provided to consider for improvement of the CR experience, including structured feedback opportunities, maximizing educational and clinical experiences, and standardizing policies.

Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors

Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors

Training in Safe Opioid Prescribing and Treatment of Opioid Use Disorder in Internal Medicine Residencies: a National Survey of Program Directors.

BackgroundTraining future clinicians in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD) is critical to address the opioid epidemic. The Accreditation Council on Graduate Medical Education requires all programs to provide instruction and experience in pain management and will mandate addiction medicine clinical experiences for internal medicine trainees.ObjectiveAssess residents’ training in SOP and treatment of OUD and identify training barriers.DesignCross-sectional nationally representative survey was emailed in 2019.ParticipantsFour hundred twenty-two Association of Program Directors in Internal Medicine members in US internal medicine residency programs.Main MeasuresProgram opportunities and challenges to developing or implementing training in SOP, treatment of OUD, and buprenorphine waiver training, and perceived curricular effectiveness.Key ResultsThe response rate was 69.4% (293/422). Most programs required didactics in SOP (94.2%) and treatment of OUD (71.7%). Few programs required clinical experiences including addiction medicine clinics (28/240, 11.7%), inpatient consult services (11/240, 4.6%), or offsite treatment rotations (8/240, 3.3%). Lack of trained faculty limited developing or implementing curricula (61.5%). Few respondents reported that their program was “very effective” in teaching SOP (80/285, 28.1%) or treatment of OUD (43/282, 15.3%). Some programs offered buprenorphine waiver training to residents (83/286, 29.0%) and faculty (94/286, 32.9%) with few mandating training (11.7% (28/240) and 5.4% (13/240) respectively). Only 60 of 19,466 (0.3%) residents completed buprenorphine waiver training. Primary care programs/tracks were more likely to offer waiver training to residents (odds ratio [OR], 3.07; 95% CI, 1.68–5.60; P < 0.001) and faculty (OR, 1.08; 95% CI, 1.01–3.22; P = 0.05).ConclusionsIn this nationally representative survey, few internal medicine residency programs provided clinical training in SOP and treatment of OUD, and training was not viewed as very effective. Lack of effective training may have adverse implications for patients, clinicians, and society.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07102-y.

Perspectives of Internal Medicine Residency Program Directors on the Accreditation Council for Graduate Medical Education (ACGME) Diversity Standards.

To increase diversity and inclusion in graduate medical education, the Accreditation Council for Graduate Medical Education (ACGME) issued a revision to their Common Program Requirements during the 2019-2020 academic year mandating that all residency programs must have policies and practices to achieve appropriate diversity among trainees and faculty. To explore the perspectives of internal medicine program directors (PDs) and associate program directors (APDs) on the ACGME diversity standard. Qualitative study of internal medicine residency program leadership from academic and community programs across the USA. Current PDs (n = 12) and APDs (n = 8) of accredited US internal medicine residency programs. We conducted semi-structured, in-depth qualitative interviews. Data was analyzed using the constant comparative method to extract recurrent themes. Three main themes, described by participants, were identified: (1) internal medicine PDs and APDs had limited knowledge of the new Common Program Requirement relating to diversity; (2) program leaders expressed concern that the diversity standard reaches beyond the PDs' scope of influence and lack of institutional commitment to the successful implementation of diversity standards; (3) participants described narrow view of diversity and inclusion efforts focusing on recruitment strategies during the interview season. Our findings of lack of familiarity with the new diversity standards, and limited institutional investment in diversity and inclusion efforts raise a concern about successful implementation across GME programs. Nevertheless, our finding suggests that structured implementation in the form of education, guideposts, and financial allocation can alleviate some of the concerns of program leadership in meeting the new ACGME diversity standard in a meaningful way.

Trends in US Internal Medicine Residency and Fellowship Applications During the COVID-19 Pandemic vs Previous Years

This cross-sectional study evaluates the number of applicants and number of applications submitted per applicant to internal medicine residency and subspecialty fellowships for 2021 compared with 5 prior application cycles.

Assessment of Training in Health Disparities in US Internal Medicine Residency Programs

Health disparities continue to exist despite the call to increase education of health care practitioners. An assessment of health disparities education has not been previously studied in a national cohort. To describe and compare the curriculum on health disparities from the perspective of program directors and perceptions of training among internal medicine residents. This cross-sectional survey study used a survey of US internal medicine program directors, the 2015 Association of Program Directors in Internal Medicine annual survey, which included questions about health disparities curriculum, and a 1-time survey of US internal medicine residents that asked questions related to their training in health disparities on the American College of Physicians 2015 Internal Medicine In-Training Examination. All internal medicine program directors who were members of Association of Program Directors in Internal Medicine (368 of 396 accredited programs), and internal medicine residents who took the Internal Medicine In-Training Examination were eligible. Final analysis of the merged data set was completed in 2018. Questions were included on the annual Association of Program Directors in Internal Medicine survey and the Internal Medicine In-Training Examination. Program directors reported on presence of health disparities curriculum, educational methods, quality, barriers and challenges to curriculum, and Clinical Learning Environment Review. Residents reported whether they received training and quality of the training in health disparities. A total of 227 program directors (response rate, 61.7%) and 22 723 residents (response rate, 87.2%) responded to the surveys. A total of 90 program directors (39.6%) reported a curriculum in health disparities, but among these, only 16 program directors (17.8%) felt quality of their education was very good or excellent. In more than half of the programs (52 programs [55.9%]), outcomes of the curriculum were not measured. After merging, the combined data set included 18 883 residents from 366 APDIM member programs with 225 program director responses. Among these, 13 251 residents (70.2%) reported some training in caring for patients at risk for health disparities. Of residents who reported receiving training, 10 494 (79.2%) rated the quality as very good or excellent. These findings suggest that that despite the Clinical Learning Environment Review mandate and Accreditation Council for Graduate Medical Education required competencies for training in health disparities, relatively few internal medicine programs in the US provided educational curriculum. Additionally, the existence of health disparities curricula in internal medicine training programs was not associated with resident's perception of training or its quality.

Training and Performance Differences in US Internal Medicine Residents Trained in Community- and University-Based Programs – a Systematic Review

Introduction:Residents’ learning and performance depends on program structures, clinical setting and faculty mentors; however,performance differences between and community based vs. university based residents have not been exploredsystematically.Objectives:To systematically review the performance differences between internal medicine residents trained in community-basedprograms [CBPs] versus university-based programs [UBPs] in the US.Methods:Eligible studies were identified in Medline and Embase databases from 1990- June 2018. Eligible studies comparedlearning and performance differences between UBP and CBP internal medicine residency programs aligned withACGME recommendations.Results:Out of 4916 titles, 14 cross-sectional studies were included in the analysis. Diverse reporting among the includedstudies precluded meta-analysis. Significant differences were found in specific practice areas, such as knowledge aboutHIV, nutrition training, and program accreditation cycle. Residents in UBPs participated more often in hypothesisdriven research and had higher publication rates than residents in CBPs. Residents trained in CBPs experienced moreburnt out than those in UBPs and had higher prevalence of residents with problematic behaviors and deficiencies.Nonsignificant differences were found among residents regarding ABIM pass rate, medical procedures, and publichealth training.Conclusion:Our review reports inconsistent trends in residents’ learning and performances following RRC- IM and ACGMErecommendations. Significant differences were noted in areas that required more practice and system based learning,non-procedural skills and patient care. Future studies with larger sample sizes and adjusted analyses are needed toevaluate the difference between residents’ performance and learning in UBPs versus CBPs.

Knowledge of HIV Testing Guidelines Among US Internal Medicine Residents: A Decade After the Centers for Disease Control and Prevention's Routine HIV Testing Recommendations.

Ten years after the Centers for Disease Control and Prevention recommended universal HIV screening, rates remain low. Internal medicine residents are the front-line medical providers for large groups of patients. We evaluated the knowledge of internal medicine residents about HIV testing guidelines and examined adherence to universal HIV testing in an outpatient setting. A cross-sectional survey of internal medicine residents at four residency programs in Chicago was conducted from January to March 2016. Aggregate data on HIV screening were collected from 35 federally qualified community health centers in the Chicago area after inclusion of an HIV testing best practice alert in patients' electronic medical records. Of the 192 residents surveyed, 130 (68%) completed the survey. Only 58% were aware of universal HIV screening and 49% were aware that Illinois law allows for an opt-out HIV testing strategy. Most of the residents (64%) ordered no more than 10 HIV tests in 6 months. The most frequently reported barriers to HIV testing were deferral because of urgent care issues, lack of time, and the perception that patients were uncomfortable discussing HIV testing. From July 2015 to February 2016, the average HIV testing adherence rate in the 35 health centers was 18.2%. More effort is needed to change HIV testing practices among internal medicine residents so that they will adopt this approach in their future clinical practice. Improving knowledge about HIV testing and addressing other HIV testing barriers are essential for such a successful change.

US Internal Medicine Program Director Perceptions of Alignment of Graduate Medical Education and Institutional Resources for Engaging Residents in Quality and Safety.

Alignment between institutions and graduate medical education (GME) regarding quality and safety initiatives (QI) has not been measured. The objective was to determine US internal medicine residency program directors' (IM PDs) perceived resourcing for QI and alignment between GME and their institutions. A national survey of IM PDs was conducted in the Fall of 2013. Multivariable linear regression was used to test association between a novel Integration Score (IS) measuring alignment between GME and the institution via PD perceptions. The response rate was 72.6% (265/365). According to PDs, residents were highly engaged in QI (82%), but adequate funding (14%) and support personnel (37% to 61%) were lower. Higher IS correlated to reports of funding for QI (76.3% vs 54.5%, P = .012), QI personnel (67.3% vs 41.1%, P < .001), research experts (70.5% vs 50.0%, P < .001), and computer experts (69.0% vs 45.8%, P < .001) for QI assistance. Apparent mismatch between GME and institutional resources exists, and the IS may be useful in measuring GME-institutional leadership alignment in QI.

Gaps in Radiation Therapy Awareness: Results From an Educational Multi-institutional Survey of US Internal Medicine Residents

Internists and primary care providers play a growing role in cancer care. We therefore evaluated the awareness of radiation therapy in general and specifically the clinical utility of stereotactic body radiation therapy (SBRT) for early-stage non-small cell lung cancer (NSCLC) among current US internal medicine residents. A web-based institutional review board-approved multi-institutional survey was distributed to US internal medicine residency programs. The survey evaluated trainee demographic characteristics, baseline radiation oncology awareness, knowledge of the role of SBRT for early-stage NSCLC, and whether the survey successfully improved awareness. Thirty US internal medicine programs participated, with an overall participant response rate of 46% (1177 of 2551). Of the trainees, 93% (n=1076) reported no radiation oncology education in their residency, 39% (n=452) reported confidence in knowing when to consult radiation oncology in an oncologic emergency, and 26% (n=293) reported confidence in knowing when to consult radiation oncology in the setting of a newly diagnosed cancer. Of the participants, 76% (n=850) correctly identified that surgical resection is the standard treatment in operable early-stage NSCLC, but only 50% (n=559) of participants would recommend SBRT to a medically inoperable patient, followed by 31% of participants (n=347) who were unsure of the most appropriate treatment, and 10% (n=117) who recommended waiting to offer palliative therapy. Ninety percent of participants (n=1029) agreed that they would benefit from further training on when to consult radiation oncology. Overall, 96% (n=1072) indicated that the survey increased their knowledge and awareness of the role of SBRT. The majority of participating trainees received no education in radiation oncology in their residency, reported a lack of confidence regarding when to consult radiation oncology, and overwhelmingly agreed that they would benefit from further training. These findings should serve as a call to increase the educational collaboration between internal medicine and radiation oncology departments to ensure optimal cancer care.

Correlations Between Ratings on the Resident Annual Evaluation Summary and the Internal Medicine Milestones and Association With ABIM Certification Examination Scores Among US Internal Medicine Residents, 2013-2014

US internal medicine residency programs are now required to rate residents using milestones. Evidence of validity of milestone ratings is needed. To compare ratings of internal medicine residents using the pre-2015 resident annual evaluation summary (RAES), a nondevelopmental rating scale, with developmental milestone ratings. Cross-sectional study of US internal medicine residency programs in the 2013-2014 academic year, including 21 284 internal medicine residents (7048 postgraduate-year 1 [PGY-1], 7233 PGY-2, and 7003 PGY-3). Program director ratings on the RAES and milestone ratings. Correlations of RAES and milestone ratings by training year; correlations of medical knowledge ratings with American Board of Internal Medicine (ABIM) certification examination scores; rating of unprofessional behavior using the 2 systems. Corresponding RAES ratings and milestone ratings showed progressively higher correlations across training years, ranging among competencies from 0.31 (95% CI, 0.29 to 0.33) to 0.35 (95% CI, 0.33 to 0.37) for PGY-1 residents to 0.43 (95% CI, 0.41 to 0.45) to 0.52 (95% CI, 0.50 to 0.54) for PGY-3 residents (all P values <.05). Linear regression showed ratings differed more between PGY-1 and PGY-3 years using milestone ratings than the RAES (all P values <.001). Of the 6260 residents who attempted the certification examination, the 618 who failed had lower ratings using both systems for medical knowledge than did those who passed (RAES difference, -0.9; 95% CI, -1.0 to -0.8; P < .001; milestone medical knowledge 1 difference, -0.3; 95% CI, -0.3 to -0.3; P < .001; and medical knowledge 2 difference, -0.2; 95% CI, -0.3 to -0.2; P < .001). Of the 26 PGY-3 residents with milestone ratings indicating deficiencies on either of the 2 medical knowledge subcompetencies, 12 failed the certification examination. Correlation of RAES ratings for professionalism with residents' lowest professionalism milestone ratings was 0.44 (95% CI, 0.43 to 0.45; P < .001). Among US internal medicine residents in the 2013-2014 academic year, milestone-based ratings correlated with RAES ratings but with a greater difference across training years. Both rating systems for medical knowledge correlated with ABIM certification examination scores. Milestone ratings may better detect problems with professionalism. These preliminary findings may inform establishment of the validity of milestone-based assessment.

Nikolaos Frangogiannis: Preventing Dangerous Remodeling After Myocardial Infarction.

Nikolaos G. Frangogiannis, MD, is the Edmond J. Safra/Republic National Bank of New York Professor of Cardiovascular Medicine at the Albert Einstein College of Medicine in the Bronx. Frangogiannis graduated from the University of Athens School of Medicine in 1990 and two years later left his native Greece to pursue a residency in Internal Medicine at Baylor College of Medicine in Houston. Accepted into the Clinical Investigator Pathway, he got his first research experience in the laboratory of Mark L. Entman, MD, working with a strong group of investigators exploring myocardial inflammation in response to injury. Frangogiannis remained in Houston for 18 years, joining the faculty and establishing an independent laboratory in 1999 to expand on previous concepts on the role of inflammation in cardiac injury and repair, by probing numerous signaling pathways. The laboratory investigated whether the chemokine monocyte chemoattractant protein (MCP)-1/CCL2 was a critical regulator of myocardial infarct healing, using MCP-1 knockout mice to show that the absence of MCP-1 results in attenuated postinfarction left ventricular remodeling, but at the high cost of a prolonged inflammatory phase and delayed replacement of injured cardiomyocytes with granulation tissue.1 Using a closed-chest model of coronary infarction/reperfusion in mice, Frangogiannis’ laboratory discovered that transforming growth factor (TGF)-β/Smad3 signaling, while having antiproliferative effects, actually promotes fibrogenic actions, particularly in the infarct border zone and in the adjacent remodeling myocardium following infarction, expanding the fibrotic process into noninfarcted areas and contributing to diastolic dysfunction.2 In 2010, Frangogiannis moved to New York, where he has deployed new tools to study the cell biology of cardiac remodeling in vivo, whether following infarction or in response to other injurious stimuli, such as metabolic disease. For example, in 2013 his laboratory demonstrated that the matricellular protein thrombospondin-1 has both direct and indirect effects on the cardiac …

Examining the July Effect: A National Survey of Academic Leaders in Medicine

BackgroundWhether the “July Effect” affects perspectives or has prompted changes in US Internal Medicine residency programs is unknown. MethodsWe designed a survey-based study to assess views and efforts aimed at preventing harm in July. A convenience sampling strategy (email listserv and direct messages to program leaders via the Electronic Residency Application Service) was used to disseminate the survey. ResultsThe response rate was 16% (65/418 programs); however, a total of 262 respondents from all 50 states where residency programs are located were included. Most respondents (n = 201; 77%) indicated that errors occur more frequently in July compared with other months. The most common identified errors included incorrect or delayed orders (n = 183, 70% and n = 167, 64%, respectively), errors in discharge medications (n = 144, 55%), and inadequate information exchange at handoffs (n = 143, 55%). Limited trainee experience (n = 208, 79%), lack of understanding hospital workflow, and difficulty using electronic medical record systems (n = 194; 74% and n = 188; 72%, respectively) were reported as the most common factors contributing to these errors. Programs reported instituting several efforts to prevent harm in July: for interns, additional electronic medical record training (n = 178; 68%) and education on handoffs and discharge processes (n = 176; 67% and n = 108; 41%, respectively) were introduced. Similarly, for senior residents, teaching sessions on how to lead a team (n = 158; 60%) and preferential placement of certain residents on harder rotations (n = 103; 39%) were also reported. Most respondents (n = 140; 53%) also solicited specific “July attendings” using a volunteer system or highest teaching ratings. ConclusionResidency programs in Internal Medicine appear to have instituted various changes to mitigate harm in July. Further evaluation to understand the impact of these interventions on trainee education and patient safety is necessary.

How faculty members experience workplace-based assessment rater training: a qualitative study.

Direct observation of clinical skills is a common approach in workplace-based assessment (WBA). Despite widespread use of the mini-clinical evaluation exercise (mini-CEX), faculty development efforts are typically required to improve assessment quality. Little consensus exists regarding the most effective training methods, and few studies explore faculty members' reactions to rater training. This study was conducted to qualitatively explore the experiences of faculty staff with two rater training approaches - performance dimension training (PDT) and amodified approach to frame of reference training (FoRT) - to elucidate how such faculty development can be optimally designed. In a qualitative study of a multifaceted intervention using complex intervention principles, 45 out-patient resident faculty preceptors from 26 US internal medicine residency programmes participated in a rater training faculty development programme. All participants were interviewed individually and in focus groups during and after the programme to elicit how the training influenced their approach to assessment. A constructivist grounded theory approach was used to analyse the data. Many participants perceived that rater training positively influenced their approach to direct observation and feedback, their ability to use entrustment as the standard for assessment, and their own clinical skills. However, barriers to implementation and change included: (i) a preference for holistic assessment over frameworks; (ii) challenges in defining competence; (iii) difficulty in changing one's approach to assessment, and (iv) concerns about institutional culture and buy-in. Rater training using PDT and a modified approach to FoRT can provide faculty staff with assessment skills that are congruent with principles of criterion-referenced assessment and entrustment, and foundational principles of competency-based education, while providing them with opportunities to reflect on their own clinical skills. However, multiple challenges to incorporating new forms of training exist. Ongoing efforts to improve WBA are needed to address institutional and cultural contexts, and systems of care delivery.