Resident Burnout, Wellness, Professional Development, and Engagement Before and After New Training Schedule Implementation.

Importance: Burnout is a work-related syndrome of depersonalization (DP), emotional exhaustion (EE), and low personal achievement (PA) that is prevalent among internal medicine resident trainees. Prior interventions have had modest effects on resident burnout. The association of a new 4 + 4 block schedule (4 inpatient weeks plus 4 outpatient weeks) with resident burnout has not previously been evaluated. Objective: To evaluate the association of a 4 + 4 block schedule, compared with a 4 + 1 schedule, with burnout, wellness, and self-reported professional engagement and clinical preparedness among resident physicians. Design, Setting, and Participants: This nonrandomized preintervention and postintervention survey study was conducted in a single academic-based internal medicine residency program from June 2019 to June 2021. The study included residents in the categorical, hospitalist, and primary care tracks in postgraduate years 1 and 2 (PGY1 and PGY2). Data analysis was conducted from October to December 2022. Intervention: In the 4 + 4 structure, resident schedules alternated between 4-week inpatient call-based rotations and 4-week ambulatory non-call-based rotations. Main Outcomes and Measures: The primary outcome was burnout, assessed using the Maslach Burnout Inventory subcategories of EE (range, 0-54), DP (range, 0-30), and PA (range, 0-48), adjusted for sex and PGY. Secondary outcomes included In-Training Examination (ITE) scores and a questionnaire on professional, educational, and health outcomes. Multivariable logistic regression was used to assess the primary outcome, 1-way analysis of variance was used to compare ITE percentiles, and a Bonferroni-adjusted Kruskal Wallis test was used for the remaining secondary outcomes. The findings were reexamined with several sensitivity analyses, and Cohen's D was used to estimate standardized mean differences (SMDs). Results: Of the 313 eligible residents, 216 completed the surveys. A total of 107 respondents (49.5%) were women and 109 (50.5%) were men; 119 (55.1%) were PGY1 residents. The survey response rates were 78.0% (85 of 109) in the preintervention cohort and 60.6% (63 of 104) and 68.0% (68 of 100) in the 2 postintervention cohorts. The PGY1 residents had higher response rates than the PGY2 residents (119 of 152 [78.2%] vs 97 of 161 [60.2%]; P < .001). Adjusted EE scores (mean difference [MD], -6.78 [95% CI, -9.24 to -4.32]) and adjusted DP scores (MD, -3.81 [95% CI, -5.29 to -2.34]) were lower in the combined postintervention cohort. The change in PA scores was not statistically significant (MD, 1.4 [95% CI, -0.49 to 3.29]). Of the 15 items exploring professional, educational, and health outcomes, a large positive association was observed for 11 items (SMDs >1.0). No statistically significant change in ITE percentile ranks was noted. Conclusions and Relevance: In this survey study of internal medicine resident physicians, a positive association was observed between a 4 + 4 block training schedule and internal medicine resident burnout scores and improved self-reported professional, educational, and health outcomes. These results suggest that specific 4 + 4 block combinations may better improve resident burnout than a 4 + 1 combination used previously.

Exploring US internal medicine resident career preferences: a Q-methodology study.

Career selection in medicine is a complex and underexplored process. Most medical career studies performed in the U.S. focused on the effect of demographic variables and medical education debt on career choice. Considering ongoing U.S. physician workforce shortages and the trilateral adaptive model of career decision making, a robust assessment of professional attitudes and work-life preferences is necessary. The objective of this study was to explore and define the dominant viewpoints related to career choice selection in a cohort of U.S. IM residents. We administered an electronic Q-sort in which 218 IM residents sorted 50 statements reflecting the spectrum of opinions that influence postgraduate career choice decisions. Participants provided comments that explained the reasoning behind their individual responses. In the final year of residency training, we ascertained participating residents' chosen career. Factor analysis grouped similar sorts and revealed four distinct viewpoints. We characterized the viewpoints as "Fellowship-Bound-Academic," "Altruistic-Longitudinal-Generalist," "Inpatient-Burnout-Aware," and "Lifestyle-Focused-Consultant." There is concordance between residents who loaded significantly onto a viewpoint and their ultimate career choice. Four dominant career choice viewpoints were found among contemporary U.S. IM residents. These viewpoints reflect the intersection of competing priorities, personal interests, professional identity, socio-economic factors, and work/life satisfaction. Better appreciation of determinants of IM residents' career choices may help address workforce shortages and enhance professional satisfaction.

A Quality Improvement Approach to Modification of a Point-of-Care Ultrasound Curriculum.

Background: There is increasing emphasis on resident involvement in quality improvement (QI) efforts, yet resident engagement in QI has remained low for many reasons. Although QI methods are classically applied to clinical processes, there are many opportunities to incorporate QI principles into curricular design and implementation. Objective: Demonstrate the utility of QI methods when applied to curricular design and the implementation of a novel point-of-care ultrasound portfolio development and quality assurance program at a large internal medicine residency program. Methods: We applied foundational QI methods, including process mapping, plan-do-study-act (PDSA) cycles, time-trap identification, run-chart analysis, and qualitative interviews throughout the curricular design and implementation phases to rapidly identify areas for improvement and perform timely tests of change. Results: Fifty-one interns participated in the curriculum, submitting 731 images in the first trimester. Process mapping and submission review revealed that 29% of images were saved to the incorrect digital archive. Resident-reviewer interpretation concordance was present in 80.7% of submissions. In 95.2% of completed quality assurance cards, the same information was provided in the commentary feedback and the evaluator's checklists, representing a time trap. Interventions included restricting access to image archives and removing redundant fields from quality assurance cards. The time to feedback fell from 69.5 to 6.5 days, demonstrating nonrandom variation via run-chart analysis. Conclusion: This pilot study demonstrates the successful application of QI methods to a novel point-of-care ultrasound curriculum. The systematic use of these methodologies in curricular design and implementation allows expeditious curricular improvement. Emphasizing the relevance of QI methods to subject matter beyond clinical processes may increase resident engagement in QI efforts.

Development of a National Academic Boot Camp to Improve Fellowship Readiness.

Background: Pulmonary and critical care medicine (PCCM) fellowship requires a high degree of medical knowledge and procedural competency. Gaps in fellowship readiness can result in significant trainee anxiety related to starting fellowship training.Objective: To improve fellowship readiness and alleviate anxiety for PCCM-bound trainees by improving confidence in procedural skills and cognitive domains.Methods: Medical educators within the American Thoracic Society developed a national resident boot camp (RBC) to provide an immersive, experiential training program for physicians entering PCCM fellowships. The RBC curriculum is a 2-day course designed to build procedural skills, medical knowledge, and clinical confidence through high-fidelity simulation and active learning methodology. Separate programs for adult and pediatric providers run concurrently to provide unique training objectives targeted to their learners' needs. Trainee assessments include multiple-choice pre- and post-RBC knowledge tests and confidence assessments, which are scored on a four-point Likert scale, for specific PCCM-related procedural and cognitive skills. Learners also evaluate course material and educator effectiveness, which guide modifications of future RBC programs and provide feedback for individual educators, respectively.Results: The American Thoracic Society RBC was implemented in 2014 and has grown annually to include 132 trainees and more than 100 faculty members. Mean knowledge test scores for participants in the 2019 RBC adult program increased from 55% (±14% SD) on the pretest to 72% (±11% SD; P < 0.001) after RBC completion. Similarly, mean pretest scores for pediatric course attendees increased from 54% (±13% SD) to 62% (±19% SD; P = 0.17). Specific content domains that improved by 10% or more between pre- and posttests included airway management, bronchoscopy, pulmonary function testing, and code management for adult course participants, and airway management, pulmonary function testing, and extracorporeal membrane oxygenation for pediatric course participants. Trainee confidence also significantly improved across all procedural and cognitive domains for adult trainees and in 10 of 11 domains for pediatric course attendees. Course content for the 2019 RBC was overwhelmingly rated as "on target" for the level of learner, with <4% of respondents indicating any specific session was "much too basic" or "much too advanced."Conclusion: RBC participation improved PCCM-bound trainee knowledge, procedural familiarity, and confidence. Refinement of the RBC curriculum over the past 7 years has been guided by educator and course evaluations, with the ongoing goal of meeting the evolving educational needs of rising PCCM trainees.

Factors Associated With Discharge Home Among Medical ICU Patients in an Early Mobilization Program.

OBJECTIVES: One goal of early mobilization programs is to facilitate discharge home after an ICU hospitalization, but little is known about which factors are associated with this outcome. Our objective was to evaluate factors associated with discharge home among medical ICU patients in an early mobilization program who were admitted to the hospital from home. DESIGN: Retrospective cohort study of medical ICU patients in an early mobilization program. SETTING: Tertiary care center medical ICU. PATIENTS: Medical ICU patients receiving early mobilization who were community-dwelling prior to admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A comprehensive set of baseline, ICU-related, and mobilization-related factors were tested for their association with discharge home using multivariable logistic regression. Among the analytic cohort (n = 183), the mean age was 61.9 years (sd 16.67 yr) and the mean Acute Physiology and Chronic Health Evaluation II score was 23.5 (sd 7.11). Overall, 65.0% of patients were discharged home after their critical illness. In multivariable analysis, each incremental increase in the maximum level of mobility achieved (range, 1-6) during the medical ICU stay was associated with nearly a 50% greater odds of discharge home (odds ratio, 1.46; 95% CI, 1.13-1.88), whereas increased age (odds ratio, 0.95; 95% CI, 0.93-0.98) and greater hospital length of stay (odds ratio, 0.94; 95% CI, 0.90-0.99) were associated with decreased odds of discharge home. Prehospital ambulatory status was not associated with discharge home. CONCLUSIONS: Among medical ICU patients who resided at home prior to their ICU admission, the maximum level of mobility achieved in the medical ICU was the factor most strongly associated with discharge back home. Identification of this factor upon ICU-to-ward transfer may help target mobilization plans on the ward to facilitate a goal of discharge home.

Protocol-Based Care versus Individualized Management of Patients in the Intensive Care Unit.

The delivery of evidence-based care in the high-acuity environment of the intensive care unit can be challenging. In an effort to help turn guidelines and standards of care into consistent and uniform practice, physicians and hospitals turn toward protocol-based medical care. A protocol can help guide a practitioner to make correct interventions, at the right time, and in the proper order when managing a given disease. But to be considered a success, a protocol must meet several standards. A protocol must facilitate consistent practice, guiding the practitioner to deliver care more consistently than without the protocol. A good protocol must also be in alignment with the provider's general practice and beliefs to assure wide adoption and complete penetrance. Finally, the protocol must deliver the most medically correct care-neither simplifying nor overcomplicating health care delivery. In addition to the care the protocol delivers, it must overcome other barriers to gain acceptance. These include concerns about protocol usage among medical trainees, physician concern regarding loss of autonomy, and the ceiling effect protocol-driven care places on expert practitioners, among other concerns. The aim of this article is to critically appraise what it means for a protocol to be considered successful with an aim toward improving protocol design and implementation in the future.

Barriers and Challenges to the Successful Implementation of an Intensive Care Unit Mobility Program: Understanding Systems and Human Factors in Search for Practical Solutions.

ICU-acquired weakness is a common problem and carries significant morbidity. Despite evidence that early mobility can mitigate this, implementation outside of the research setting is lagging. Understanding barriers at the systems as well as individual level is a crucial step in successful implementation of an ICU mobility program. This includes taking inventory of waste, overburden and inconsistencies in the work environment. Appreciating regulative, normative as well as cultural forces at work is critical. Finally, key personnel, which include organizational leaders, innovation champions and end users of the proposed change need to be accounted for at each step during program implementation.

Clinical Reasoning and Risk in the Intensive Care Unit.

Clinical reasoning in medicine describes the process whereby a clinician gathers, assimilates, and assesses information about a person and their illness to assign a diagnosis and institute therapy. Care of patients in the intensive care unit involves managing a substantial quantity of incomplete, novel, and rapidly changing data. A modified nine-step bayesian approach to clinical reasoning comports well with this complex environment and is useful for assisting and educating novice learners to apply clinical reasoning accurately and consistently. When combined with a sophisticated approach to risk-benefit analysis to modify the treatment threshold, it becomes a useful and insightful tool for clinicians and those working in medical education.

Interstitial lung disease associated with the idiopathic inflammatory myopathies: what progress has been made in the past 35 years?

Interstitial lung disease is commonly associated with the autoimmune inflammatory myopathies dermatomyositis and polymyositis and accounts for significant morbidity and mortality in these conditions. In the 35 years since the association between inflammatory myopathy and interstitial lung disease was initially described, there has been progress in diagnosing and treating this dis-order. Nevertheless, there remains much about pathogenesis and therapeutics to be learned. This review examines the changes in the understanding of this complex condition, highlighting recent advances and areas deserving of further study.

Respiratory symptoms and disease characteristics as predictors of pulmonary function abnormalities in patients with rheumatoid arthritis: an observational cohort study.

INTRODUCTION: Lung involvement is a common extra-articular manifestation of rheumatoid arthritis (RA) that confers significant morbidity and mortality. The objective of the present study is to assess which respiratory symptoms and patient and disease characteristics are most highly associated with pulmonary function test (PFT) abnormalities in an RA patient cohort without clinical cardiovascular disease. METHODS: A total of 159 individuals with RA and without clinically evident cardiovascular disease were evaluated. Respiratory symptoms were assessed with the Lung Tissue Research Consortium questionnaire and all patients underwent evaluation with PFTs. Demographic, lifestyle, RA disease and treatment characteristics were collected. Subclinical coronary artery disease was assessed by cardiac computed tomography. Multivariable regression analysis was used to identify pulmonary symptoms and nonpulmonary parameters associated with PFT abnormalities. Areas under the receiver operating characteristic curves (AUC) were calculated to evaluate the discrimination of these variables for identifying patients with PFT abnormalities. RESULTS: Respiratory symptoms were reported by 42% of the patient population. Although only 6% carried a prior diagnosis of lung disease, PFT abnormalities were identified in 28% of the subjects. Symptoms combined with other patient and RA characteristics (body mass index, current smoking, anti-cyclic citrullinated peptide antibodies, and current prednisone use) performed satisfactorily in predicting the PFT abnormalities of obstruction (AUC=0.91, 95% confidence interval=0.78 to 0.98), restriction (AUC=0.79, 95% confidence interval=0.75 to 0.93) and impaired diffusion (AUC=0.85, 95% confidence interval=0.59 to 0.92). Co-morbid subclinical coronary artery disease did not modify these relationships. CONCLUSIONS: Assessment of respiratory symptoms along with a limited number of clinical parameters may serve as a useful and inexpensive clinical tool for identifying RA patients in need of further pulmonary investigation.