The Organization of Academic General Internal Medicine Practice at the Top Primary Care Schools.

BACKGROUND: While prior studies have explored staffing infrastructure for primary care practices in general, little is known about the range of academic primary care practice models and supports available for academic general internists. OBJECTIVE: To characterize the range of practice arrangements and expectations for attending academic physicians in general internal medicine (GIM) practices at the top 22 medical schools across the USA. DESIGN: Cross-sectional survey administered electronically between October 30, 2022, and December 28, 2022. PARTICIPANTS: Clinical leaders in GIM at the top 22 primary care medical schools, as identified by the 2023 US News and World Report Rankings. MAIN MEASURES: Clinical load, productivity expectations, cross-coverage, and team-based care models. KEY RESULTS: Twenty-two leaders responded, representing 68% (15/22) of medical schools surveyed. The practices were mostly in urban locations (18/22, 82%) and 86% (19/22) included residents. Practices ranged from 7 to 200 PCPs and from 3 to 112 clinical FTEs. A full-time (1.0 FTE) clinical role for academic attending GIM physicians entailed a median of 9 (IQR 8, 10) weekly half-day clinic sessions, with a median panel size expectation of 1600 (IQR 1450, 1850) patients and a median yearly RVU expectation of 5200 (IQR 4161, 5891) yearly RVUs generated. Staff support was most commonly present for prescription refills and patient portal message checks. It was less commonly available for time sensitive form completion. Occasional clinical coverage for other physicians was an expectation at all practices. CONCLUSIONS: In this study, we characterize the organization of and supports available in academic GIM practices affiliated with the top primary care medical schools. Our findings provide comparative information for leaders of academic GIM practices seeking to enhance primary care delivery for their faculty and trainees. They also highlight areas where standardization may be beneficial across academic GIM.

A substance use disorder training curriculum for internal medicine residents using resident-empaneled patients.

BACKGROUND: Internal Medicine (IM) residents frequently encounter, but feel unprepared to diagnose and treat, patients with substance use disorders (SUD). This is compounded by negative regard for patients with SUD. Optimal education strategies are needed to empower IM residents to care for patients with SUD. The objective of this study was to evaluate a brief SUD curriculum for IM residents, using resident-empaneled patients as an engaging educational strategy. METHODS: Following a needs assessment, a 2-part SUD curriculum was developed for IM residents at the University of Chicago during the 2018-2019 academic year as part of the ambulatory curriculum. During sessions on Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD), a facilitator covered concepts about screening, diagnosis, and treatment. In session, residents completed structured worksheets applying concepts to one of their primary care patients. A post-session assessment included questions on knowledge, preparedness & attitudes. RESULTS: Resident needs assessment (n = 44/105, 42% response rate) showed 86% characterized instruction received during residency in SUD as none or too little, and residents did not feel prepared to treat SUD. Following the AUD session, all residents (n = 22) felt prepared to diagnose and treat AUD. After the OUD session, all residents (n = 19) felt prepared to diagnose, and 79% (n = 15) felt prepared to treat OUD. Residents planned to screen for SUD more or differently, initiate harm reduction strategies and increase consideration of pharmacotherapy. CONCLUSIONS: A brief curricular intervention for AUD and OUD using resident-empaneled patients can empower residents to integrate SUD diagnosis and management into practice.

An Expanded Primary Care-Based Women's Health Clinic to Improve Resident Education and Patient Care in Resident Continuity Clinic.

BACKGROUND: Internal medicine (IM) residents are underprepared in women's health. Lack of properly trained faculty and clinic culture limits the ability to provide bedside teaching. AIM: Assess the impact of a primary care-based, women's clinic on residents' quality of care for females. SETTING: Large academic, urban primary care clinic with resident and faculty practices PARTICIPANTS: PGY-2 IM and Med-Peds (MP) residents PROGRAM DESCRIPTION: A weekly half-day, women's clinic to provide expanded women's healthcare to primary care group patients. Residents rotate through the clinic to receive bedside teaching. PROGRAM EVALUATION: Chart review was performed for a representative sample of reproductive-aged women seen in primary care before and after the establishment of the women's clinic. A total of 666 charts were reviewed (314 pre, 352 post). Improvement was seen in residents' rate of sexual histories (54% vs 75%, p< 0.01) with a significant decrease in women not asked about contraception (15% vs 3%, p<0.01). Overall there was a decrease in gynecology referrals (18 to 11%, p=0.02). DISCUSSION: After implementing the women's health clinic, more women were asked about sexual health needs, and fewer were referred to gynecology, suggesting increased women's healthcare provided by residents.

Telehealth Attitudes, Training, and Preparedness Among First-Year Internal Medicine Residents in the COVID-19 Era.

Introduction: Telehealth, especially the use of real-time video and phone visits in ambulatory care, is increasingly important in the wake of the COVID-19 pandemic. The current state of internal medicine (IM) interns' telehealth training at the start of residency is unknown. Objective: To characterize the attitudes, training, and preparedness of IM interns regarding the use of telehealth video and phone visits in ambulatory care. Materials and Methods: We conducted a cross-sectional survey of IM interns at four IM residency programs in the United States in 2020. Results: One hundred fifty-six surveys were analyzed (response rate 82%). Seventy-five percent of interns rated training in the use of real-time video and phone visits for ambulatory care as important or very important. The vast majority received no training (74%) or clinical experience (90% no prior video visits, 81% no prior phone visits) during medical school. More interns believed that primary care may be effectively delivered via video visits compared with phone visits (77% vs. 35%). Most interns (69%) missed clinical time during medical school due to the COVID-19 pandemic; 41% felt that the pandemic negatively affected their ambulatory care preparation. Overall, the majority of interns (58%) felt prepared for primary care; only 12% felt prepared to deliver primary care using either video or phone visits. Conclusions: Although IM interns had favorable attitudes toward video and phone visits, few had training or clinical experience; most felt unprepared. Residency programs may need to close training gaps for current interns in conducting telehealth video and phone visits.

Time for Clinic: Fourth-Year Primary Care Exposure and Clinic Preparedness Among Internal Medicine Interns.

BACKGROUND: Internal medicine (IM) residency graduates consistently report being less prepared for outpatient practice than inpatient medicine. Although an initial study suggested interns arriving for IM residency reported low levels of preparedness for continuity clinic, the impact of education and experience during the undergraduate medical education to graduate medical education transition on ambulatory training is unclear. OBJECTIVE: To describe end of medical school primary care exposure among entering IM interns and its association with self-assessed preparedness for residency continuity clinic. DESIGN: Cross-sectional survey of 161 entering IM interns in 2019. PARTICIPANTS: Entering interns at four geographically diverse IM residency programs (University of Chicago, University of North Carolina, University of Pennsylvania, and University of Washington), representing 81 US medical schools. RESULTS: A total of 139 interns (86%) responded to the survey. Surveyed interns reported a median of zero days of general internal medicine (GIM) clinic (interquartile range [IQR]: 0-20 days) and 2.5 days of multispecialty adult primary care (IQR: 0-26.5 days) during fourth year of medical school. The median last exposure to primary care was 13 months prior to internship (IQR: 7-18 months). Interns who rated themselves as prepared for primary care clinic reported a median of twenty more multispecialty adult primary care days (20 vs. 0 days; p < 0.01) and fourteen more GIM clinic days (14 vs. 0 days; p < 0.01) than their unprepared counterparts. The experiences were also more recent, with six fewer months between their last multispecialty adult primary care exposure and the start of internship (9 vs. 15 months; p < 0.01). CONCLUSIONS: The majority of incoming IM interns had no primary care training during the fourth year of medical school. At the start of residency, IM interns who felt more prepared for their primary care clinic reported more recent and more numerous primary care experiences.

Health systems science education: The new post-Flexner professionalism for the 21st century.

The foundations of medical education have drawn from the Flexner Report to prepare students for practice for over a century. These recommendations relied, however, upon a limited set of competencies and a relatively narrow view of the physician's role. There have been increasing calls and recommendations to expand those competencies and the professional identity of the physician to better meet the current and future needs of patients, health systems, and society. We propose a framework for the twenty-first century physician that includes an expectation of new competency in health systems science (HSS), creating 'system citizens' who are effective stewards of the health care system. Experiential educational strategies, in addition to knowledge-centered learning, are critically important for students to develop their professional identity as system citizens working alongside interprofessional colleagues. Challenges to HSS adoption range from competing priorities for learners, to the need for faculty development, to the necessity for buy-in by medical schools and their associated health care systems. Ultimately, success will depend on our ability to articulate, encourage, support, and evaluate system citizenship and its impact on health care and health care systems.

"Ms. B changes doctors": using a comic and patient transition packet to engineer patient-oriented clinic handoffs (EPOCH).

BACKGROUND: Few patient-centered interventions exist to improve year-end residency clinic handoffs. AIM: Our purpose was to assess the impact of a patient-centered transition packet and comic on clinic handoff outcomes. SETTING: The study was conducted at an academic medicine residency clinic. PARTICIPANTS: Participants were patients undergoing resident clinic handoff 2011-2013 PROGRAM DESCRIPTION: Two months before the 2012 handoff, patients received a "transition packet" incorporating patient-identified solutions (i.e., a new primary care provider (PCP) welcome letter with photo, certificate of recognition, and visit preparation tool). In 2013, a comic was incorporated to stress the importance of follow-up. PROGRAM EVALUATION: Patients were interviewed by phone with response rates of 32 % in 2011, 43 % in 2012 and 36 % in 2013. Most patients who were interviewed were aware of the handoff post-packet (95 %). With the comic, more patients recalled receiving the packet (44 % 2012 vs. 64 % 2013, p< 0.001) and correctly identified their new PCP (77 % 2012 vs. 98 % 2013, p< 0.001). Among patients recalling the packet, most (70 % 2012; 65 % 2013) agreed it helped them establish rapport. Both years, fewer patients missed their first new PCP visit (43 % in 2011, 31 % in 2012 and 26 % in 2013, p< 0.001). DISCUSSION: A patient-centered transition packet helped prepare patients for clinic handoffs. The comic was associated with increased packet recall and improved follow-up rates.

Development and Implementation of an Experiential Longitudinal Health Systems Science Thread Into an Existing Medical School Curriculum.

PROBLEM: Medical school graduates enter a complex health care delivery system involving interprofessional teamwork and multifaceted value-based patient care decisions. However, current curricula on health systems science (HSS) are piecemeal, lecture based, and confined to preclinical training. APPROACH: The VISTA program is a longitudinal, immersive learning curriculum integrated into the University of Chicago Pritzker School of Medicine curriculum between 2016 and 2018. Key components include a unit-based nursing interprofessional team experience, a discharge objective structured clinical examination (OSCE), a patient safety simulation, and the implementation of a Choosing Wisely SmartPhrase. Graduates before 2016-2017 and after 2018-2020 VISTA implementation completed a Likert-style survey assessing attitudes, knowledge, and behaviors on HSS topics. A free response question solicited improvement areas. The Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) was also examined. OUTCOMES: The overall VISTA survey response rate was 59%, with 126 fourth-year medical student respondents before VISTA and 120 after VISTA. Compared with pre-VISTA graduates, post-VISTA graduates reported a significantly higher rate of competence on the HSS questions, with the greatest increases seen in effective communication at discharge (n = 73/126 [57.9%] to 116/120 [96.7%], P < .001), knowledge on safety event reporting (n = 53/126 [42.1%] to 96/120 [79.8%], P < .001), and considering costs in making health care decisions (n = 76/126 [60.3%] to 117/120 [97.5%], P < .001). All were directly addressed through experiential learning interventions, and 2 were intended practice behaviors. VISTA graduate responses to free-text questions demonstrated a more nuanced understanding of HSS compared with pre-VISTA responses. The AAMC GQ data showed increased agreement with an item that mapped to HSS understanding. NEXT STEPS: The VISTA program provides a model for institutions to enhance HSS education between curricular overhauls. Next steps include implementing value-added roles and additional immersive learning exercises.

Outcomes for resident-identified high-risk patients and resident perspectives of year-end continuity clinic handoffs.

BACKGROUND: Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff. OBJECTIVE: To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff DESIGN: Retrospective cohort PARTICIPANTS: Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009-2011. PGY2 IM residents surveyed from 2010-2011. MEASUREMENTS: Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff. RESULTS: Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P<0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p<0.001) and those lost to follow-up (21 % vs. 17 % NSR, p=0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as "theirs" until they are seen by them in clinic. CONCLUSIONS: While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.

Leadership Experiences of Internal Medicine Residents: A Needs Assessment for Leadership Curricula.

Purpose: Leadership development during medical training is critical. Accrediting bodies strongly recommend and residents desire leadership training. However, limited needs assessment data exist regarding trainee perceptions of and experiences with leadership training. Our objective is to describe residents' perceptions of leadership and desires for leadership training with the goal of informing effective curricular development. Patients and Methods: In 2019 a trained qualitative interviewer conducted semi-structured interviews with volunteer second-year categorical internal medicine residents recruited via email across four institutions. Interviews were audio-recorded, transcribed, and inductively coded by two independent coders. After adjudicating discrepancies, coders synthesized codes into broader themes. Final thematic analysis was triangulated with the entire author group. Results: Fourteen residents were interviewed (50% female). Few reported prior leadership training. Thematic analysis yielded six main themes. First, residents perceive "leadership" to be related to formal, assigned, hierarchical roles. Second, residents identify their own leadership primarily in the inpatient clinical setting. Third, residents identify clinical competence, emotional intelligence, and communication as important skills for effective leadership. Fourth, residents struggle to identify where leadership is currently being taught. Fifth, residents desire additional leadership development. Finally, residents prefer well-labeled, interactive methods for leadership development. Conclusion: Although residents desire leadership development, these skills are not often explicitly taught, labeled, or assessed. Curriculum developers may consider explicitly contextualizing leadership training within an "everyday leadership" framework, dovetailing leadership coaching with daily teaching workflow and feedback structures, and implementing faculty development initiatives to allow for appropriate feedback and assessment of these skills.

Teaching internal medicine residents to sustain their improvement through the quality assessment and improvement curriculum.

INTRODUCTION: Although sustainability is a key component in the evaluation of continuous quality improvement (CQI) projects, medicine resident CQI projects are often evaluated by immediate improvements in targeted areas without addressing sustainability. AIM/SETTING: To assess the sustainability of resident CQI projects in an ambulatory university-based clinic. PROGRAM DESCRIPTION: During their ambulatory rotation, all second year internal medicine residents use the American Board of Internal Medicine's Clinical Preventive Services (CPS) Practice Improvement Modules (PIM) to complete chart reviews, patient surveys, and a system survey. The residents then develop a group CQI project and collect early post data. Third year residents return to evaluate their original CQI project during an ambulatory rotation two to six months later and complete four plan-do-study-act (PDSA) cycles on each CQI project. PROGRAM EVALUATION: From July 2006 to June 2009, 64 (100%) medicine residents completed the CQI curriculum. Residents completed six group projects and examined their success using early (2 to 6 weeks) and late (2 to 6 months) post-intervention data. Three of the projects demonstrated sustainable improvement in the resident continuity clinic. DISCUSSION: When residents are taught principles of sustainability and spread and asked to complete multiple PDSA cycles, they are able to identify common themes that may contribute to success of QI projects over time.

Teaching Telemedicine: The Next Frontier for Medical Educators.

The COVID-19 pandemic has pushed telemedicine to the forefront of health care delivery, and for many clinicians, virtual visits are the new normal. Although telemedicine has allowed clinicians to safely care for patients from a distance during the current pandemic, its rapid adoption has outpaced clinician training and development of best practices. Additionally, telemedicine has pulled trainees into a new virtual education environment that finds them oftentimes physically separated from their preceptors. Medical educators are challenged with figuring out how to integrate learners into virtual workflows while teaching and providing patient-centered virtual care. In this viewpoint, we review principles of patient-centered care in the in-person setting, explore the concept of patient-centered virtual care, and advocate for the development and implementation of patient-centered telemedicine competencies. We also recommend strategies for teaching patient-centered virtual care, integrating trainees into virtual workflows, and developing telemedicine curricula for graduate medical education trainees by using our TELEMEDS framework as a model.

Clinician Perspectives on Telemedicine: Observational Cross-sectional Study.

BACKGROUND: Since the COVID-19 pandemic onset, telemedicine has increased exponentially across numerous outpatient departments and specialties. Qualitative studies examining clinician telemedicine perspectives during the pandemic identified challenges with physical examination, workflow concerns, burnout, and reduced personal connection with patients. However, these studies only included a relatively small number of physicians or were limited to a single specialty, and few assessed perspectives on integrating trainees into workflows, an important area to address to support the clinical learning environment. As telemedicine use continues, it is necessary to understand a range of clinician perspectives. OBJECTIVE: This study aims to survey pediatric and adult medicine clinicians at the University of Chicago Medical Center to understand their telemedicine benefits and barriers, workflow impacts, and training and support needs. METHODS: In July 2020, we conducted an observational cross-sectional study of University of Chicago Medical Center faculty and advanced practice providers in the Department of Medicine (DOM) and Department of Pediatrics (DOP). RESULTS: The overall response rate was 39% (200/517; DOM: 135/325, 42%; DOP: 65/192, 34%); most respondents were physicians (DOM: 100/135, 74%; DOP: 51/65, 79%). One-third took longer to prepare for (65/200, 33%) and conduct (62/200, 32%) video visits compared to in-person visits. Male clinicians reported conducting a higher percentage of telemedicine visits by video than their female counterparts (P=.02), with no differences in the number of half-days per week providing direct outpatient care or supervising trainees. Further, clinicians who conducted a higher percentage of their telemedicine by video were less likely to feel overwhelmed (P=.02), with no difference in reported burnout. Female clinicians were "more overwhelmed" with video visits compared to males (41/130, 32% vs 12/64, 19%; P=.05). Clinicians 50 years or older were "less overwhelmed" than those younger than 50 years (30/85, 35% vs 23/113, 20%; P=.02). Those who received more video visit training modalities (eg, a document and webinar on technical issues) were less likely to feel overwhelmed by the conversion to video visits (P=.007) or burnt out (P=.009). In addition, those reporting a higher ability to technically navigate a video visit were also less likely to feel overwhelmed by video visits (P=.02) or burnt out (P=.001). The top telemedicine barriers were patient-related: lack of technology access, lack of skill, and reluctance. Training needs to be focused on integrating learners into workflows. Open-ended responses highlighted a need for increased support staff. Overall, more than half "enjoyed conducting video visits" (119/200, 60%) and wanted to continue using video visits in the future (150/200, 75%). CONCLUSIONS: Despite positive telemedicine experiences, more support to facilitate video visits for patients and clinicians is needed. Further, clinicians need additional training on trainee education and integration into workflows. Further work is needed to better understand why gender and age differences exist. In conclusion, interventions to address clinician and patient barriers, and enhance clinician training are needed to support telemedicine's durability.

A Novel Contraception Counseling and Shared Decision-Making Curriculum for Internal Medicine Residents.

Introduction: Many women of reproductive age with complex medical conditions receive primary care through an internal medicine (IM) physician rather than an obstetrician/gynecologist. Long-acting reversible contraception methods are the most effective form of contraception; however, IM residents are not routinely trained in them. Infrequent training in, inadequate knowledge of, and discomfort with contraception counseling limit the counseling performed by IM residents. Shared decision-making (SDM) is a method of patient-centered communication that can improve communication about patient preferences and increase patient satisfaction with and adherence to contraception. We developed a curriculum to teach contraception counseling under the framework of SDM for IM residents. Methods: The curriculum focused on contraception counseling through the lens of SDM designed for IM and medicine/pediatrics residents (PGY 2-PGY 4). We adapted an existing seven-step model of SDM to fit elements of contraception counseling. The curriculum consisted of a didactic teaching session with integration of an instructional video and structured interactive discussion. The session lasted 60 minutes. Results: Fifty-eight residents participated in the curriculum. On pre- and postcurriculum surveys, residents reported improvement in contraception knowledge (overall mean precurriculum = 57%, postcurriculum = 70%, p < .001) and comfort with contraception counseling (overall mean precurriculum = 3.2, postcurriculum = 3.6, p < .01). Residents expressed strong support for SDM before and after the curriculum. Discussion: Based on the survey results, the curriculum successfully addressed gaps in residents' comfort with contraception counseling and knowledge of contraception side effects and efficacy.

Teaching internal medicine residents quality improvement techniques using the ABIM's practice improvement modules.

INTRODUCTION/AIM: Standard curricula to teach Internal Medicine residents about quality assessment and improvement, important components of the Accreditation Council for Graduate Medical Education core competencies practiced-based learning and improvement (PBLI) and systems-based practice (SBP), have not been easily accessible. PROGRAM DESCRIPTION: Using the American Board of Internal Medicine's (ABIM) Clinical Preventative Services Practice Improvement Module (CPS PIM), we have incorporated a longitudinal quality assessment and improvement curriculum (QAIC) into the 2 required 1-month ambulatory rotations during the postgraduate year 2. During the first block, residents complete the PIM chart reviews, patient, and system surveys. The second block includes resident reflection using PIM data and the group performing a small test of change using the Plan-Do-Study-Act (PDSA) cycle in the resident continuity clinic. PROGRAM EVALUATION: To date, 3 resident quality improvement (QI) projects have been undertaken as a result of QAIC, each making significant improvements in the residents' continuity clinic. Resident confidence levels in QI skills (e.g., writing an aim statement [71% to 96%, P < .01] and using a PDSA cycle [9% to 89%, P < .001]) improved significantly. DISCUSSION: The ABIM CPS PIM can be used by Internal Medicine residency programs to introduce QI concepts into their residents' outpatient practice through encouraging practice-based learning and improvement and systems-based practice.

Bridging the Gap: Interdepartmental Quality Improvement and Patient Safety Curriculum Created by Hospital Leaders, Faculty, and Trainees.

BACKGROUND: The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review recommends that quality improvement/patient safety (QI/PS) experts, program faculty, and trainees collectively develop QI/PS education. OBJECTIVE: Faculty, hospital leaders, and resident and fellow champions at the University of Chicago designed an interdepartmental curriculum to train postgraduate year 1 (PGY-1) residents on core QI/PS principles, measuring outcomes of knowledge, attitudes, and event reporting. METHODS: The curriculum consisted of 3 sessions: PS, quality assessment, and QI. Faculty and resident and fellow leaders taught foundational knowledge, and hospital leaders discussed institutional priorities. PGY-1 residents attended during protected conference times, and they completed in-class activities. Knowledge and attitudes were assessed using pretests and posttests; graduating residents (PGY-3-PGY-8) were controls. Event reporting was compared to a concurrent control group of nonparticipating PGY-1 residents. RESULTS: From 2015 to 2017, 140 interns in internal medicine (49%), pediatrics (33%), and surgery (13%) enrolled, with 112 (80%) participating and completing pretests and posttests. Overall, knowledge scores improved (44% versus 57%, P < .001), and 72% of residents demonstrated increased knowledge. Confidence comprehending quality dashboards increased (13% versus 49%, P < .001). PGY-1 posttest responses were similar to those of 252 graduate controls for accessibility of hospital leaders, filing event reports, and quality dashboards. PGY-1 residents in the QI/PS curriculum reported more patient safety events than PGY-1 residents not exposed to the curriculum (0.39 events per trainee versus 0.10, P < .001). CONCLUSIONS: An interdepartmental curriculum was acceptable to residents and feasible across 3 specialties, and it was associated with increased event reporting by participating PGY-1 residents.