From Race to Racism: Teaching a Tool to Critically Appraise the Use of Race in Medical Research.

INTRODUCTION: Despite the ubiquitous use of race within scientific literature, medical trainees are not taught how to critically appraise the use of racial categories. We developed a tool to appraise the use of race in medical literature and a workshop to teach this approach. METHODS: Third-year medical students and second- and third-year residents participated in workshops between 2015 and 2018. We evaluated our UME workshop with a postworkshop survey. We evaluated our GME workshop with a pretest, immediate posttest, and 6-month posttest on self-assessed knowledge, skills, and use of the Critical Appraisal of Race in Medical Literature (CARMeL) tool in subsequent journal clubs. RESULTS: We delivered this workshop to 560 students and 82 residents. Of the initial 140-student cohort evaluating the workshop, 99 (71% response rate) highly rated clarity of presentation, quality of teaching, and quality of slides. Of PGY 2 and PGY 3 residents, 67 (82% response rate) rated the workshop greater than 4.5 out of 5 on quality, clarity, and appropriateness of content. Residents had significant improvements in self-assessed knowledge and skills immediately after the session and 6 months later. Of residents, 74% reported using the CARMeL tool in subsequent presentations. DISCUSSION: We designed the CARMeL tool and a workshop to teach it. Trainees rated this workshop as useful, with the majority of residents later applying the tool. Limitations included a lack of objective assessment of knowledge acquisition. We recommend that institutions invest time in faculty development and pair new faculty with those experienced in anti-oppressive facilitation.

Advance care planning clinic: A structured clinical experience for internal medicine residents.

BACKGROUND: Advance care planning (ACP) is an important step to provide medical care consistent with patients' preferences and values. Nationally, rates of ACP completion are low, and internal medicine residency clinics face additional barriers. To address this need, we implemented an ACP clinic for internal medicine residents. METHODS: An ACP clinical experience was created for PGY2 residents beginning in 2018, with 6 total sessions, consisting of consolidated didactics, protected time to identify, outreach, and schedule patients, and two half days of dedicated ACP visits. Residents were surveyed before (end of PGY1) and after (end of PGY2) the intervention. The preceding residency class, serving as a historic control, only received the curriculum and were surveyed at the end of their PGY2 year. Electronic medical record (EMR) data was accessed to track ACP documentation. RESULTS: The overall survey response rate was 124/134 (93%). Comparing the intervention cohort before and after the intervention, there was a significant increase in self-assessed confidence in completing ACP (2.1/4.0 vs 3.5/4.0, p < 0.01). Comparing the intervention and historic cohorts (end of PGY2), the intervention was associated with improved confidence in ability to complete ACP for their patients (3.5/4.0 vs 2.7/4.0, p < 0.01). The historic control had no increase in ACP documentation rates over time, while the intervention cohort had a 13.9% absolute increase in ACP documentation for their patients over the course of residency (p < 0.01). CONCLUSION: The creation of an ACP-specific clinical experience, in conjunction with existing curricula, resulted in significant improvements in knowledge, self-assessed skills and behavior, and EMR documentation.

A Personalized Approach to Chronic Kidney Disease and Cardiovascular Disease: JACC Review Topic of the Week.

Cardiovascular disease is the most common cause of death in patients with end-stage renal disease (ESRD). The initiation of dialysis for treatment of ESRD exacerbates chronic electrolyte and hemodynamic perturbations. Rapid large shifts in effective intravascular volume and electrolyte concentrations ultimately lead to subendocardial ischemia, increased left ventricular wall mass, and diastolic dysfunction, and can precipitate serious arrhythmias through a complex pathophysiological process. These factors, unique to advanced kidney disease and its treatment, increase the overall incidence of acute coronary syndrome and sudden cardiac death. To date, risk prediction models largely fail to incorporate the observed cardiovascular mortality in the CKD population; however, multimodality imaging may provide an additional prognostication and risk stratification. This comprehensive review discusses the cardiovascular risks associated with hemodialysis, and explores the pathophysiology and the novel utilization of multimodality imaging in CKD to promote a personalized approach for these patients with implications for future research.

Resident as Preceptor: An Ambulatory Internal Medicine Curriculum for Third-Year Resident Precepting.

Introduction: The role of outpatient preceptor is a core component of many careers within internal medicine (both general internal medicine and subspecialty practice), yet opportunities to learn and practice this skill during residency training are limited. The purpose of this initiative was to introduce outpatient clinic precepting into the third-year ambulatory experience with a didactic and experiential curriculum. Methods: Internal medicine third-year residents received a 1-hour didactic on outpatient precepting and participated in a precepting session in their ambulatory block rotation during the 2017-2018 academic year. During this session, third-year residents precepted their first- and second-year colleagues in the residency clinic with faculty supervision. Residents were surveyed before the didactic and after the precepting experience to assess precepting comfort level, preparedness to supervise others, and satisfaction with the initiative in the ambulatory curriculum. Results: A total of 38 third-year residents were eligible to participate in the initiative, and 36 (94%) participated in the precepting session. Survey response rates were 76% and 78% for pre- and postsurveys, respectively. Resident survey scores of self-assessed teaching, precepting, and supervision skills increased from a mean of 25 out of 42 to 34 out of 42 (p < .001), with an average enjoyment score of 10.3 out of a possible 12, suggesting high learner satisfaction. Discussion: The introduction of outpatient clinic precepting into the third-year internal medicine residency ambulatory curriculum was met with high participation and satisfaction and can be a successful approach to augmenting the outpatient residency experience.

Residency Practice Transformation: Implementation of Team-Based Care in an Academic Continuity Clinic.

BACKGROUND: Team-based primary care has the potential to improve care delivery. However, residency scheduling and precepting models make creating functional ambulatory teams challenging. OBJECTIVE: We describe the team-based care transformation at a large academic internal medicine residency practice. METHODS: On July 1, 2016, the program transitioned to a 6+2 schedule and the clinic was divided into teams. Residents were precepted by 2 team preceptors, social work and care coordination needs were met by team-specific staff, and front desk staff were trained on maintaining primary care physician (PCP) and team continuity. Weekly team meetings provided opportunities for proactive patient and panel management, and preclinic huddles incorporated staff into team functions. Pre-transformation (June 2016) and post-transformation (June 2017) surveys were distributed to residents (n = 131), faculty (n = 14), and staff (n = 65) to assess team functioning. Patient-PCP continuity was monitored on a quarterly basis. RESULTS: Three hundred sixty-two of 420 surveys were returned (86%). The intervention was associated with significant improvements in resident satisfaction (from 3.05 baseline to 4.07 of 5, P < .001) and perceptions of teamwork (4.14 to 4.61 of 6, P < .001), with moderate to large effect sizes. Patient-PCP continuity significantly increased (45% to > 70%). While domain-specific improvements were seen for faculty and staff, no overall changes were noted in their perceptions of teamwork or team-based care. CONCLUSIONS: Team-based care was implemented with significant improvements in continuity and resident satisfaction and perceptions of teamwork; however, the impact on faculty and staff was limited.

Empanelment in a Resident Teaching Practice: A Cornerstone to Improving Resident Outpatient Education and Patient Care.

BACKGROUND: Improving continuity is challenging in residency training practices. Studies have shown that empanelment enables high-performing primary care and is foundational to improve accountability and continuity. OBJECTIVE: An empanelment process was created in a large, urban, residency training practice as an effective approach to enhancing continuity among residents and their patients. METHODS: In 2016, we formed an empanelment committee that included stakeholders from the department of medicine, the internal medicine residency program, and hospital and IT leadership. This committee set goal panel sizes, selected an empanelment algorithm, determined which patients needed re-empanelment, and facilitated medical record integration. Empanelment was followed and reassessed quarterly for 2 years. We measured anticipated visit demand using visits in the prior year and continuity using the continuity for physician formula. RESULTS: Of 18 495 active patients in July 2016, 8411 (45%) were assigned a new PCP in the empanelment process. At baseline, panel sizes and expected visit demand were highly variable among residents (from 40 to 107 and 120 to 480, respectively). Empanelment led to more equivalent panel sizes and expected visit demand across same year residents (eg, PGY-3: 80-100 and 320-440, respectively). Continuity for all PCPs in the practice improved from 63% before empanelment to over 80% after empanelment, and improved from 55% to 72% for individual residents. CONCLUSIONS: In a large and complex practice environment, we were able to empanel resident clinic patients to improve continuity and maintain it over 2 years.

A Decade of Teaching and Learning in Internal Medicine Ambulatory Education: A Scoping Review.

BACKGROUND: Ambulatory training in internal medicine residency programs has historically been considered less robust than inpatient-focused training, which prompted a 2009 revision of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Internal Medicine. This revision was intended to create a balance between inpatient and outpatient training standards and to spur innovation in the ambulatory setting. OBJECTIVE: We explored innovations in ambulatory education in internal medicine residency programs since the 2009 revision of the ACGME Program Requirements in Internal Medicine. METHODS: The authors conducted a scoping review of the literature from 2008 to 2017, searching PubMed, ERIC, and Scopus databases. Articles related to improving educational quality of ambulatory components of US-based internal medicine residency programs were eligible for inclusion. Articles were screened for relevance and theme categorization and then divided into 6 themes: clinic redesign, curriculum development, evaluating resident practice/performance, teaching methods, program evaluation, and faculty development. Once a theme was assigned, data extraction and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI) score were completed. RESULTS: A total of 967 potentially relevant articles were discovered; of those, 182 were deemed relevant and underwent full review. Most articles fell into curriculum development and clinic redesign themes. The majority of included studies were from a single institution, used nonstandardized tools, and assessed outcomes at the satisfaction or knowledge/attitude/skills levels. Few studies showed behavioral changes or patient-level outcomes. CONCLUSIONS: While a rich diversity of educational innovations have occurred since the 2009 revision of the ACGME Program Requirements in Internal Medicine, there is a significant need for multi-institution studies and higher-level assessment.

Likelihood Ratios for the Emergency Physician.

The concept of likelihood ratios was introduced more than 40 years ago, yet this powerful metric has still not seen wider application or discussion in the medical decision-making process. There is concern that clinicians-in-training are still being taught an oversimplified approach to diagnostic test performance and have limited exposure to likelihood ratios. Even for those familiar with likelihood ratios, they might perceive them as mathematically cumbersome in application, if not difficult to determine for a particular disease process. This article takes a conceptual approach to likelihood ratios and applies them to two clinical settings: 1) severe intracranial injury after minor head trauma and 2) suspected pulmonary embolism with shortness of breath. Likelihood ratios are the most appropriate metric for efficient rational clinical examination and can prevent unnecessary and wasteful treatments and procedures.