Years Of Internal Medicine Training Research Articles

Comparison of internal medicine applicant and resident characteristics with performance on ACGME milestones

ABSTRACT Internal medicine (IM) residency programs select applicants based on several metrics. Factors predicting success during residency are unclear across studies. To identify whether specific applicant or resident factors are associated with IM resident performance using ACGME milestones. We tested for associations between applicant factors available prior to the start of IM residency and resident factors measured during IM residency training, and resident performance on ACGME milestones across three consecutive years of IM training between 2015-2020. Univariable and multivariable linear regression modeling was used to test associations. Eighty-nine categorical IM residents that completed 3 consecutive years of training were included. Median age was 28 years (IQR 27-29) and 59.6% were male. Mean ACGME milestone scores increased with each post-graduate year (PGY) from 3.36 (SD 0.19) for PGY-1, to 3.80 (SD 0.15) for PGY-2, to 4.14 (SD 0.15) for PGY-3. Univariable modeling suggested referral to the clinical competency committee (CCC) for professionalism concerns was negatively associated with resident performance during each PGY. No applicant or resident factors included in the final multivariable regression models (age at starting residency, USMLE Step scores, interview score, rank list position, ITE scores) were associated with ACGME milestone scores for PGY-1 and PGY-2. Referral to the CCC for professionalism was negatively associated with resident performance during PGY-3. Residency selection factors did not predict resident milestone evaluation scores. Referral to the CCC was associated with significantly worse resident evaluation scores, suggesting professionalism may correlate with clinical performance.

'Just pretending': Narratives of professional identity transitions in internal medicine.

Health professional identity transitions involve a dynamic period of liminality prompting a time of considerable uncertainty and self-doubt. For postgraduate trainees in the United Kingdom, the transition to medical registrar can be a significant deterrent to recruitment and retention. Narrative analysis offers insight into identity work during transitions with potential to inform strategies for developing professional identities. This study aimed to use narrative analysis to explore trainees' experiences and their sense of agency during the liminal phase of this transition. Following ethical approval, internal medicine (IM) trainees in their second year of IM training were interviewed. Transcripts were audio recorded, transcribed verbatim and analysed to identify narratives describing liminality during the transition to the role of medical registrar, including examples of rejecting and claiming identity grants. Narrative analysis, as described by Riessman and influenced by James Gee's units of discourse, was undertaken, with an agentive lens applied to the data. Between January 2021 and February 2022, 19 IM trainees were interviewed. Given the in-depth analysis, four narratives were purposively selected to present, including trainees rejecting and claiming the medical registrar role. Trainees tended to describe negative experiences, but those with a higher sense of agency demonstrated positive reflection and identity construction through narrative. There was often identity dissonance between how trainees defined their stage in the transition to medical registrar and how their narrative illustrated their identity work. This study exemplifies narrative analysis' linguistic and agentive lenses in exploring the experience of the liminal identity transitional period. The findings reflect the identity dissonance experienced by trainees during this time and sheds light on their sense of agency throughout. It heralds a need to acknowledge the significant liminality experienced during transitions throughout medical training and to empower a sense of agency to support identity work.

Healing Through History: a qualitative evaluation of a social medicine consultation curriculum for internal medicine residents

BackgroundSocial context guides care; stories sustain meaning; neither is routinely prioritized in residency training. Healing Through History (HTH) is a social medicine consultation curriculum integrating social determinants of health narrative into clinical care for medically and socially complex patients. The curriculum is part of an internal medicine (IM) residency outpatient clinical rotation at a Veterans Health Administration hospital. Our aim was to explore how in-depth social medicine consultations may impact resident clinical practice and foster meaning in work.MethodsFrom 2017 to 2019, 49 categorical and preliminary residents in their first year of IM training were given two half-day sessions to identify and interview a patient; develop a co-produced social medicine narrative; review it with patient and faculty; and share it in the electronic health record (EHR). Medical anthropologists conducted separate 90-min focus groups of first- and second-year IM residents in 2019, 1–15 months from the experience.Results46 (94%) completed HTH consultations, of which 40 (87%) were approved by patients and published in the EHR. 12 (46%) categorical IM residents participated in focus groups; 6 PGY1, and 6 PGY2. Qualitative analysis yielded 3 themes: patient connection, insight, and clinical impact; clinical skill development; and structural barriers to the practice of social medicine.ConclusionsHTH offers a model for teaching co-production through social and narrative medicine consultation in complex clinical care, while fostering meaning in work. Integration throughout training may further enhance impact.

Why I Wrote the New Royal College General Internal Medicine Exam: Redefining Our Identity and Revalidation

In 2010, the Royal College of Physicians and Surgeons of Canada (RCPSC) recognized General Internal Medicine (GIM) as a distinct subspecialty. Soon after this recognition came a new written certificationexam, the successful completion of which awards the applicant the title of General Internist. For those of us who trained prior to the new status and examination, GIM was the default designation after four years of internal medicine training if a subspecialty was not pursued.What does this new subspecialty status mean for our professional identity, qualifications, and public credibility? Twelve years aftermy successful completion of the Internal Medicine (IM) certification exams, I voluntarily applied for consideration to write the first RCPSC exam in GIM, without a clear reason why. My reflection on the days leading up to the exam and writing the exam itself led me to understand why I did it. The process addressed my skepticism around designating GIM as a unique subspecialty, and through this I have come to appreciate the need for our profession to embrace revalidation.

English

In 2010, the Royal College of Physicians and Surgeons of Canada (RCPSC) recognized General Internal Medicine (GIM) as a distinct subspecialty. Soon after this recognition came a new written certificationexam, the successful completion of which awards the applicant the title of General Internist. For those of us who trained prior to the new status and examination, GIM was the default designation after four years of internal medicine training if a subspecialty was not pursued.What does this new subspecialty status mean for our professional identity, qualifications, and public credibility? Twelve years aftermy successful completion of the Internal Medicine (IM) certification exams, I voluntarily applied for consideration to write the first RCPSC exam in GIM, without a clear reason why. My reflection on the days leading up to the exam and writing the exam itself led me to understand why I did it. The process addressed my skepticism around designating GIM as a unique subspecialty, and through this I have come to appreciate the need for our profession to embrace revalidation.

International Issues: Obtaining an adult neurology residency position in the United States

Around the world, there are marked differences in neurology training, including training duration and degree of specialization. In the United States, adult neurology residency is composed of 1 year of internal medicine training (preliminary year) and 3 years of neurology-specific training. Child neurology, which is not the focus of this article, is 2 years of pediatrics and 3 years of neurology training. The route to adult neurology residency training in the United States is standardized and is similar to most other US specialties. Whereas US medical graduates often receive stepwise guidance from their medical school regarding application for residency training, international graduates often enter this complex process with little or no such assistance. Despite this discrepancy, about 10%-15% of residency positions in the United States are filled by international medical graduates.(1,2) In adult neurology specifically, 35% of matched positions were filled by international graduates in 2013, 75% of whom were not US citizens.(1) In an effort to provide a preliminary understanding of the application process and related terminology (table 1) and thereby encourage international residency applicants, we describe the steps necessary to apply for neurology residency in the United States.

The Relationship Between Communication Scores From the USMLE Step 2 Clinical Skills Examination and Communication Ratings for First-Year Internal Medicine Residents

This study extends available evidence about the relationship between scores on the Step 2 Clinical Skills (CS) component of the United States Medical Licensing Examination and subsequent performance in residency. It focuses on the relationship between Step 2 CS communication and interpersonal skills scores and communication skills ratings that residency directors assign to residents in their first postgraduate year of internal medicine training. It represents the first large-scale evaluation of the extent to which Step 2 CS communication and interpersonal skills scores can be extrapolated to examinee performance in supervised practice. Hierarchical linear modeling techniques were used to examine the relationships among examinee characteristics, residency program characteristics, and residency-director-provided ratings. The sample comprised 6,306 examinees from 238 internal medicine residency programs who completed Step 2 CS for the first time in 2005 and received ratings during their first year of internal medicine residency training. Although the relationship is modest, Step 2 CS communication and interpersonal skills scores predict communication skills ratings for first-year internal medicine residents after accounting for other factors. The results of this study make a reasonable case that Step 2 CS communication and interpersonal skills scores provide useful information for predicting the level of communication skill that examinees will display in their first year of internal medicine residency training. This finding demonstrates some level of extrapolation from the testing context to behavior in supervised practice, thus providing validity-related evidence for using Step 2 CS communication and interpersonal skills scores in high-stakes decisions.

Association of Volume of Patient Encounters with Residents’ In-Training Examination Performance

Patient care and medical knowledge are Accreditation Council for Graduate Medical Education (ACGME) core competencies. The correlation between amount of patient contact and knowledge acquisition is not known. To determine if a correlation exists between the number of patient encounters and in-training exam (ITE) scores in internal medicine (IM) and pediatric residents at a large academic medical center. Retrospective cohort study Resident physicians at Mayo Clinic from July 2006 to June 2010 in IM (318 resident-years) and pediatrics (66 resident-years). We tabulated patient encounters through review of clinical notes in an electronic medical record during post graduate year (PGY)-1 and PGY-2. Using linear regression models, we investigated associations between ITE score and number of notes during the previous PGY, adjusted for previous ITE score, gender, medical school origin, and conference attendance. For IM, PGY-2 admission and consult encounters in the hospital and specialty clinics had a positive linear association with ITE-3 % score (β = 0.02; p = 0.004). For IM, PGY-1 conference attendance is positively associated with PGY-2 ITE performance. We did not detect a correlation between PGY-1 patient encounters and subsequent ITE scores for IM or pediatric residents. No association was found between IM PGY-2 ITE score and inpatient, outpatient, or total encounters in the first year of training. Resident continuity clinic and total encounters were not associated with change in PGY-3 ITE score. We identified a positive association between hospital and subspecialty encounters during the second year of IM training and subsequent ITE score, such that each additional 50 encounters were associated with an increase of 1 % correct in PGY-3 ITE score after controlling for previous ITE performance and continuity clinic encounters. We did not find a correlation for volume of encounters and medical knowledge for IM PGY-1 residents or the pediatric cohort.

Meritorious Contributions to Neuropathology:

The Award for Meritorious Contributions to Neuropathology recognizes members who have made significant contributions to the advancement of knowledge in neuropathology and have provided service to the American Association of Neuropathologists. Each recipient of the award is nominated by the president in conjunction with the Nominating Committee and with the approval of the Executive Council. The qualities of outstanding scientific achievement and service are embodied in this year s recipients, Drs Donald L. Price and Bernd Walter Scheithauer. They join the rich roster of distinguished former award recipients. Dr Scheithauer's award is presented posthumously. Donald Lowell Price was born in Stamford, Connecticut. He began his academic career at Wesleyan University in Connecticut where he studied English literature and received a Bachelor of Arts. He then entered the Albany Medical School from which he graduated in 1961. After 2 years of internal medicine training at the New England Medical Center, he became a neurology resident at the Massachusetts General Hospital. After 2 years as staff neurologist at the National Naval Medical Center in Bethesda, Dr Price returned to Boston as a fellow in Neuropathology under the mentorship of Dr E. P. Richardson, Jr., at the Massachusetts General Hospital. Subsequently, he worked in cell and molecular …

How confident are internal medicine residents in rheumatology versus other common internal medicine clinical skills: an issue of training time or exposure?

The objective of this study was to determine self-confidence of internal medicine (IM) residents regarding rheumatology clinical skills and factors that may affect their confidence. Permission was sought to e-mail a web-based survey to IM residents at all 13 English language Canadian internal medicine programs. Residents were asked to rank self-confidence in rheumatology, cardiology, respirology, and gastroenterology skills. Further questions included site and year of training, career interests, rheumatology experiences, learning opportunities, and assessment frequency. These factors were analyzed by univariate and multivariate analyses. Two hundred sixteen residents (21.8%) from all 13 sites responded to the survey. Resident self-confidence in rheumatology diagnoses was 5.24/10, lower than all three comparator subspecialties. Increasing teaching exposure had a more significant impact on confidence in rheumatology than on comparator subspecialties. Increasing year of training had no association with higher self-confidence for rheumatology, in contrast to the increase in confidence seen with increased year of training for each comparator subspecialty. Further analysis demonstrated that the completion of a rheumatology rotation, increasing learning opportunities, annual assessment, and career interest were associated with greater resident self-confidence. Resident self-confidence for rheumatology skills is cautious at best and is lower than other common subspecialties. Self confidence improves with targeted rheumatology clinical experience and teaching, but does not improve solely with higher year of IM training. Furthermore, the impact of rheumatology teaching is greater than that of other common IM subspecialties. This information is critical to the planning and implementation of effective rheumatology curricula within internal medicine residency programs.

Attracting Internal Medicine Trainees to Rheumatology: Where and When Programs Should Focus Efforts

To determine where and when efforts should be focused to increase recruitment of rheumatology trainees from internal medicine (IM) programs. (1) We calculated the percentage of trainees at each of the 13 English-speaking Canadian IM-accredited programs who entered a rheumatology training program in Canada from 2005 to 2007. We then correlated this with the opportunity they would have had to do a rheumatology rotation in each of their 3 postgraduate years of IM training. (2) We calculated the overall percentage of residents who remained at the same training institution after their IM program, 2005-2007, comparing this to 4 similar-size subspecialty training programs. Among IM trainees, 3.5% began rheumatology training in Canada. There was a positive relationship at the postgraduate year 1 (PGY1) level between more rheumatology opportunities and chance of entering rheumatology (r(2) = 0.35, p < 0.05), but not at the PGY2 or PGY3 level. Among rheumatology trainees, 78% remained at the training institution where they completed IM training, more than the 70% of gastroenterology trainees, 68% of nephrology trainees, 67% of endocrinology trainees, and 76% of infectious diseases trainees. The opportunity for a rheumatology rotation in the first year of IM training increases the likelihood the trainee may choose rheumatology as a career. Further, most rheumatology trainees continue at the same institution as their IM training, more than other subspecialties. This information may assist recruitment efforts to increase numbers of rheumatology trainees and the overall rheumatology workforce. These data warrant reevaluation of IM programs of study in order to influence trainee career choices and plan better for future workforce requirements in all IM fields.

Monroe Cole, MD (1933–2008)

Dr. Monroe Cole, Emeritus Professor of Neurology at Case Western Reserve University (CWRU) School of Medicine, died of congestive heart failure on January 28, 2008, at the age of 74. Monroe received his BA from Amherst College and MD from Georgetown University in 1957. He had 2 years of Internal Medicine training at Seton Hall before becoming a resident in Neurology and Neuropathology at Massachusetts General Hospital, where he stayed until 1962. While at the MGH, he participated in clinical studies that resulted in several seminal publications.1–3 He then entered the US Army Medical Corps and spent 3 years doing neuroanatomic research under the legendary W.J.H. Nauta at the Walter Reed Army Institute of Research. Following his military obligation, he joined the faculty of Bowman Gray School of Medicine. He was elected to membership in the American …

Medical Dermatology: A View to the Future

Medical Dermatology: A View to the Future

Mood Change and Empathy Decline Persist during Three Years of Internal Medicine Training

To examine longitudinal changes in mood and empathy over the course of the internal medicine residency. The authors conducted a cohort study of 61 residents who completed the Profile of Mood States (POMS) and the Interpersonal Reactivity Index (IRI) at six time points during their internal medicine residency at a university-based program. (POMS was administered five times, and IRI was administered six times.) The main outcomes measured were trends in mood disturbances and multiple domains of empathy over the three-year residency, and comparisons to norms. Response rates varied from Time 1 to Time 6 (98%, 72%, 79%, 79%, 94%, and 95%, respectively). Interns had better scores on four POMS subscales: Depression-Dejection (p = .0031), Anger-Hostility (p < .0001), Fatigue-Inertia (p < .0001), and Vigor-Activity (p < .0001) compared with later administrations, especially midinternship. By the end of residency all POMS scores were returning towards baseline (effects sizes in the .20 s), but only depression was no longer significantly different. IRI scores showed the decline in Empathic Concern remained over residency whereas Personal Distress peaked midinternship year but approached baseline at the end of residency. Compared with the general population, the graduating residents were less tense, depressed, and confused. Personal Distress was significantly lower than the norm group. Internal medicine residency presents challenges resulting in common mood disturbances. Although graduating residents appear to be better off than the population norms, some domains of their mood disturbances and empathy never fully recover from their internship year.

Assessment of empathy in different years of internal medicine training

The operational measurement of physician empathy, as well as the question of whether empathy could change at different levels of medical education, is of interest to medical educators. To address this issue, 98 internal medicine residents from all 3 years of training were studied. The Jefferson Scale of Physician Empathy was administered, and residents' empathy scores correlated with ratings on humanistic attributes made by postgraduate program directors. No statistically significant differences in scores were found among residents of different training levels. Empathy scores remained also stable during internship (test-retest reliability = 0.72). Correlation between empathy and ratings on humanism was 0.17. Thus, the findings suggest that empathy is a relatively stable trait that is not easily amenable to change in residency training programs. The issue of whether targeted educational activities for the purpose of cultivating empathy can improve empathy scores awaits empirical scrutiny.

Canadian Dermatology

Canadian dermatology differs from the American system by a predominant referral system in most provinces and by universal health care scheme. Canadian certification requires 1 year of internal medicine training in addition to 3 years of clinical training. The Canadian Dermatology Association has formed several links with the American Academy of Dermatology and sponsors a similar sun awareness campaign.

It's Over, Debbie

To the Editor. —I was distressed by the article in the Jan 8,1988, issue of JAMA entitled It's Over, Debbie. 1 I, too, was a tired gynecologic resident rotating through large hospitals and I saw similar situations and, perhaps, responded no better than our nameless physician. After that, I did three years of internal medicine training that did not help me prepare for managing such difficult problems. I went to the United Kingdom to study how things are done at the University of Edinburgh and at St Christopher's Hospice in London and then became medical director of a hospice. During the past five years I have treated some 2000 terminally ill patients to the times of their deaths, mostly in their own homes but sometimes in our inpatient facility. I have learned that patients like Debbie do not need to be killed by their physicians to be relieved of their

Attitudes of departments of medicine in the United States toward provision of internal medicine training for prospective neurologists.

A questionnaire was sent to directors of training programs in internal medicine to assess attitudes towards providing a year of internal medicine training for prospecitve neurologists. Such applicants are handled in a variety of ways. Among the 92 responding institutions with neurology training programs, three were not willing to accept prospective neurologists for 1 year of internal medicine. Seventy-three percent would either reserve places for prospective neurologists, arrange with neurology for a position through the intern matching program, or arrange medical rotations for candidates accepted by neurology. Twenty-four percent would accept neurologists for a single year without specifying any special arrangement.