Evaluation of patient health outcomes of a student-run free clinic in East Harlem.

BACKGROUND: Most United States medical schools have affiliated student-run free clinics, but the quality of services provided in such contexts compared to national metrics is unknown. This study determines whether a student-run, attending-supervised free clinic servicing a low-income and minority race patient population in New York City can meet national metrics of care. METHODS: Through chart review from January 1, 2020 to December 31, 2020, patient outcomes and service utilization in the Healthcare Effectiveness Data and Information Set were examined and compared to national rates of patients using Medicaid HMO or Medicare. Patients are ≥ 21 years of age, residents of East Harlem, and ineligible for health insurance because of legal residency requirements. The majority identify as Hispanic and speak Spanish as their primary language. All patients who were seen in the clinic during the 2020 calendar year were included. The primary study outcome is the number of Healthcare Effectiveness Data and Information Set measures in which patients, seen in a student-run free clinic, meet or exceed national comparisons. RESULTS: The healthcare outcomes of 238 patients, mean age 47.8 years and 54.6% female, were examined in 18 Healthcare Effectiveness Data and Information Set measures. The student-run free clinic met or exceeded national metrics in 16 out of 18 categories. CONCLUSIONS: The student-run free clinic met or exceeded the national standard of care according to national metrics. Evidence-based priorities have been clarified for future improvement. Other student-run free clinics should similarly evaluate the quality of their services.

Bias Reporting in the Clinical Learning Environment: A National Survey of Internal Medicine Clerkship Directors.

PURPOSE: Bias exists in the internal medicine (IM) clinical learning environment; however, it is unclear how often bias is identified by clerkship directors (CDs), how bias is addressed, and whether best practices exist for identifying or mitigating bias. This study investigated how IM CDs receive and respond to bias reports in the clinical learning environment. METHOD: In May 2021, the Clerkship Directors in Internal Medicine (CDIM) created an 18-question survey assessing the frequency of bias reports, macroaggressions and microaggressions, and report outcomes. Of the 152 U.S. medical schools that met study accreditation criteria, the final survey population included 137 CDs (90%) whose medical schools held valid CDIM membership. RESULTS: Of the 137 surveys sent, 100 were returned (survey response rate, 73%). Respondents reported a median of 3 bias events (interquartile range, 1-4; range, 0-50) on the IM clerkship in the past year. Among 76 respondents who reported 1 or more event, microaggressions represented 43 of the 75 total events (57%). No mechanism emerged as the most commonly used method for reporting bias. Race/ethnicity (48 of 75 [64%]) and gender (41 of 75 [55%]) were cited most as the basis for bias reports, whereas the most common sources of bias were student interactions with attending physicians (51 of 73 [70%]) and residents (40 of 73 [55%]). Of the 75 respondents, 53 (71%) described the frequency of bias event reports as having increased or remained unchanged during the past year. Only 48 CDs (49%) responded that they were "always" aware of the outcome of bias reports. CONCLUSIONS: Bias reports remain heterogeneous, are likely underreported, and lack best practice responses. There is a need to systematically capture bias events to work toward a just culture that fosters accountability and to identify bias events through more robust reporting.

Roles and Responsibilities of Medicine Subinternship Directors : Medicine Subinternship Director Roles.

BACKGROUND: The internal medicine (IM) subinternship (also referred to as acting internship) plays a crucial part in preparing medical students for residency. The roles, responsibilities, and support provided to subinternship directors have not been described. OBJECTIVE: We sought to describe the current role of IM subinternship directors with respect to their responsibilities, salary support, and reporting structure. DESIGN: Nationally representative, annually recurring thematic survey of IM core clerkship directors with membership in an academic professional association as of September 2017. PARTICIPANTS: A total of 129 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited U.S./U.S.-territory-based medical schools. MAIN MEASURES: Responsibilities, salary support, and reporting structure of subinternship directors. KEY RESULTS: The survey response rate was 83.0% (107/129 medical schools). Fifty-one percent (54/107) of respondents reported overseeing both core clerkship inpatient experiences and/or one or more subinternships. For oversight, 49.1% (28/53) of subinternship directors also reported that they were the clerkship director, 26.4% (14/53) that another faculty member directed all medicine subinternships, and 18.9% (10/53) that each subinternship had its own director. The most frequently reported responsibilities for the subinternship directors were administration, including scheduling, and logistics of student schedules (83.0%, 44/53), course evaluation (81.1%, 43/53), and setting grades 79.2% (42/53). The modal response for estimated FTE per course was 10-20% FTE, with 33.3% (16/48) reporting this level of support and 29.2% (14/54) reporting no FTE support. CONCLUSIONS: The role of the IM subinternship director has become increasingly complex. Since the IM subinternship is critical to preparing students for residency, IM subinternship directors require standard expectations and adequate support. Future studies are needed to determine the appropriate level of support for subinternship directors and to define essential roles and responsibilities.

Teaching Telemedicine in the COVID-19 Era: a National Survey of Internal Medicine Clerkship Directors.

BACKGROUND: Prior to the COVID-19 pandemic, telemedicine (TM) experiences in undergraduate medical education were uncommon. When students' clinical experiences were interrupted due to the pandemic, TM education provided opportunities for students to participate in clinical care while adhering to social distancing guidelines. OBJECTIVE: To assess the prevalence of TM experiences in the internal medicine (IM) core clerkship experience prior to the COVID-19 pandemic, during interruption in clinical clerkships, and following the return to in-person activities at US medical schools. DESIGN: The Clerkship Directors in Internal Medicine (CDIM) survey is a national, annually recurring thematic survey of IM core clerkship directors. The 2020 survey focused on effects of the COVID-19 pandemic, including a section about TM. The survey was fielded online from August through October 2020. PARTICIPANTS: A total of 137 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited US/US territory-based medical schools. MAIN MEASURES: A 10-item thematic survey section assessing student participation in TM and assessment of TM-related competencies. KEY RESULTS: The response rate was 73.7% (101/137 medical schools). No respondents reported TM curricular experiences prior to the pandemic. During clinical interruption, 39.3% of respondents reported TM experiences in the IM clerkship, whereas 24.7% reported such experiences occurring at the time they completed the survey. A higher percentage of clerkships with an ambulatory component reported TM to be an important competency compared to those without an ambulatory component. CONCLUSIONS: The extent to which TM was used in the IM clinical clerkship, and across clinical clerkships, increased substantially when medical students were removed from in-person clinical duties as a response to COVID-19. When students returned to in-person clinical duties, experiences in TM continued, suggesting the continued value of TM as part of the formal education of students during the medicine clerkship. Curricula and faculty development will be needed to support TM education.

Clerkship Roles and Responsibilities in a Rapidly Changing Landscape: a National Survey of Internal Medicine Clerkship Directors.

BACKGROUND: In the rapidly changing landscape of undergraduate medical education (UME), the roles and responsibilities of clerkship directors (CDs) are not clear. OBJECTIVE: To describe the current roles and responsibilities of Internal Medicine CDs. DESIGN: National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred twenty-nine clerkship directors at all Liaison Committee on Medical Education accredited US medical schools with CDIM membership as of September 1, 2017. MAIN MEASURES: Responsibilities of core CDs, including oversight of other faculty, and resources available to CDs including financial support and dedicated time. KEY RESULT: The survey response rate was 83% (107/129). Ninety-four percent of the respondents oversaw the core clerkship inpatient experience, while 47.7% (n = 51) and 5.6% (n = 6) oversaw the outpatient and longitudinal integrated clerkships respectively. In addition to oversight, CDs were responsible for curriculum development, evaluation and grades, remediation, scheduling, student mentoring, and faculty development. Less than one-third of CDs (n = 33) received the recommended 0.5 full-time equivalent (FTE) support for their roles, and 15% (n = 16) had less than 20% FTE support. An average 0.41 FTE (SD .2) was spent in clinical work and 0.20 FTE (SD .21) in administrative duties. Eighty-three percent worked with other faculty who assisted in the oversight of departmental UME experiences, with FTE support varying by role and institution. Thirty-five percent of CDs (n = 38) had a dedicated budget for managing their clerkship. CONCLUSIONS: The responsibilities of CDs have increased in both number and complexity since the dissemination of previous guidelines for expectations of and for CDs in 2003. However, resources available to them have not substantially changed.

Pediatric resident perceptions of shift work in ward rotations.

Although the long working hours of physicians are considered to be a social issue, no effective policies such as duty hour regulations have so far been proposed in Japan. We implemented an overnight call shift (OCS) system for ward rotations to improve the working environment for residents in a pediatric residency program. We later conducted a cross-sectional questionnaire asking the residents to compare this system with the traditional overnight call system. Forty-one pediatric residents participated in this survey. The residents felt that the quality of patient care improved (80.4% agreed). Most felt that there was less emphasis on education (26.8%) and more emphasis on service (31.7%). Overall, the residents reported that the OCS was beneficial (90.2%). In conclusion, the pediatric residents considered the OCS system during ward rotations as beneficial. Alternative solutions are vital to balance improvements in resident work conditions with the requirement for a high quality of education.

Evaluating the Clinical Learning Environment: Resident and Fellow Perceptions of Patient Safety Culture.

BACKGROUND: The Accreditation Council for Graduate Medical Education has begun to evaluate teaching institutions' learning environments with Clinical Learning Environment Review visits, including trainee involvement in institutions' patient safety and quality improvement efforts. OBJECTIVE: We sought to address the dearth of metrics that assess trainee patient safety perceptions of the clinical environment. METHODS: Using the Hospital Survey on Patient Safety Culture (HSOPSC), we measured resident and fellow perceptions of patient safety culture in 50 graduate medical education programs at 10 hospitals within an integrated health system. As institution-specific physician scores were not available, resident and fellow scores on the HSOPSC were compared with national data from 29 162 practicing providers at 543 hospitals. RESULTS: Of the 1337 residents and fellows surveyed, 955 (71.4%) responded. Compared with national practicing providers, trainees had lower perceptions of patient safety culture in 6 of 12 domains, including teamwork within units, organizational learning, management support for patient safety, overall perceptions of patient safety, feedback and communication about error, and communication openness. Higher perceptions were observed for manager/supervisor actions promoting patient safety and for staffing. Perceptions equaled national norms in 4 domains. Perceptions of patient safety culture did not improve with advancing postgraduate year. CONCLUSIONS: Trainees in a large integrated health system have variable perceptions of patient safety culture, as compared with national norms for some practicing providers. Administration of the HSOPSC was feasible and acceptable to trainees, and may be used to track perceptions over time.

Impact of web-based review on long-term retention of simulation-acquired knee and shoulder aspiration and injection skills.

BACKGROUND: Musculoskeletal problems are the reason for one-quarter of primary care visits. Opportunities for internal medicine residents to perform joint aspirations and injections have declined. Simulation has been shown to improve procedure skills post completion of simulation courses, yet controversy exists about the durability of simulation-acquired skills. OBJECTIVE: To investigate whether web-based review preserves residents' joint procedure skills 6 to 30 months after a simulation course. METHODS: Postgraduate year-1 internal medicine residents participated in a simulation-based Joint Aspiration Injection Course consisting of web-based instructional material, guided practice on joint models, and a multiple-choice test. Procedure proficiency was scored by using a 3-component skills checklist. Six to 30 months later, residents who had participated in the simulation were randomly assigned to review or not to review the original web-based instructional material before retesting. The groups were compared by using Wilcoxon rank sum and matched pairs signed rank tests. RESULTS: Compared to the performance at the end of the simulation course, scores of all 3 procedure components declined (informed consent, 64.7-43.0 versus 30.6-23.8, P < .001; procedure proficiency, 63.4-61.7 versus 46.4-44.3, P < .001; and postprocedure instructions, 58.0-54.1 versus 29.9-29.4, P < .001). However, the review group outperformed the nonreview group on informed consent (shoulder: 37.1 versus 24.6, P  =  .01) and postprocedure instructions (shoulder: 34.0 versus 25.2, P  =  .01; knee: 35.5 versus 24.8, P < .001). Residents who reported doing actual procedures maintained a higher confidence level, compared with those reporting none (6.8-5.1 versus 4.1-3.6, P < .001). CONCLUSION: Shoulder and knee simulation-acquired skills declined 6 to 30 months after a simulation course. However, rereview of web-based instructional material improved proficiency in informed consent, shoulder, and postprocedure instructions, shoulder and knee.

Randomized trial of web-based training about opioid therapy for chronic pain.

OBJECTIVES: The treatment of chronic noncancer pain with chronic opioid therapy has increased rapidly, but medicine residents receive little training concerning this therapy. Therefore we conducted a trial to determine if an interactive web-based training focusing on shared decision-making for chronic opioid therapy improves knowledge and competence compared with exposure to practice guidelines. METHODS: A randomized controlled educational trial of 213 internal medicine residents from 5 medicine residencies participating in the Residency Review Committee for Internal Medicine's Educational Innovations Project comparing access to interactive web-based training (COPE: Collaborative Opioid Prescribing Education) or access to the Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. Pretraining and immediate posttraining knowledge test; pretraining and 60-day posttraining self-reported competence, satisfaction, patient-centeredness, and selected clinical behaviors were analyzed using t tests, Pearson chi, and Generalized Estimating Equations. RESULTS: The web training group had greater increase in knowledge with training (chi(2)=72.06, P<0.00001) and greater self-rated competence in the management of outpatients with chronic pain (chi(2)=6.48, P=0.01), and specifically in the use of opioids in this management (chi(2)=5.17, P=0.02). Residents in both groups reported more satisfaction with managing chronic pain care after training (chi(2)=52.72, P<0.0001), though the web training was superior on subscales concerning training adequacy (chi(2)=4.94, P=0.026) and relationship quality (chi(2)=5.79, P=0.016). CONCLUSIONS: Exposure to an interactive web-based training focused on shared decision-making and communication skills was more effective than exposure to compatible practice guidelines for knowledge and self-reported competence in the management of chronic noncancer pain.

Residents' perceptions of a night float system.

BACKGROUND: A Night Float (NF) system has been implemented by many institutions to address increasing concerns about residents' work hours. The purpose of our study was to examine the perceptions of residents towards a NF system. METHODS: A 115-item questionnaire was developed to assess residents' perceptions of the NF rotation as compared with a regular call month. The categories included patient care, education, medical errors, and overall satisfaction. Internal Medicine housestaff (post-graduate years 1-3) from three hospital settings at the University of Pittsburgh completed the questionnaire. RESULTS: The response rate was 90% (n = 149). Of these, 74 had completed the NF rotation. The housestaff felt that the quality of patient care was improved because of NF (41% agreed and 18% disagreed). A majority also felt that better care was provided by a rested physician in spite of being less familiar with the patient (46% agreed and 21% disagreed). Most felt that there was less emphasis on education (65%) and more emphasis on service (52%) during NF. Overall, the residents felt more rested during their call months (83%) and strongly supported the 80-hour workweek requirement (77%). CONCLUSION: Housestaff felt that the overall quality of patient care was improved by a NF system. The perceived improved quality of care by a rested physician coupled with a perceived decrease in the emphasis on education may have significant implications in housestaff training.

Assessing patient safety culture of internal medicine house staff in an academic teaching hospital.

PURPOSE: Patient safety culture (PSC) examines how individuals perceive an organization's commitment and proficiency in health and safety management. The primary objective of this study was to assess hospital PSC from the perspective of internal medicine house staff, and to compare the results by postgraduate year (PGY) of training and to national hospital benchmark data. METHODS: The authors modified and used a version of the Hospital Survey on Patient Safety Culture (HSOPSC), which has 12 PSC dimensions. Each dimension uses a 5-level Likert scale of agreement ("Strongly disagree" to "Strongly agree") or frequency ("Never" to "Always"). The survey was distributed to 68 PGY-2 and PGY-3 internal medicine house staff at an academic medical center between December 2006 and February 2007. Composite scores were created for each respondent by calculating the proportion of positive responses for each domain. Domain score means were compared between PGYs and to survey data from hospitals that administered the HSOPSC (ie, benchmark data). RESULTS: The overall response rate was 85.3% (58/68). House staff scored lower on 6 and 4 of the 12 PSC dimensions, when compared with the overall national hospital and medicine unit benchmarks, respectively (P < .05). PGY-3 staff scored lower than PGY-2 staff in 2 dimensions (P < .05). CONCLUSIONS: PGY-2 and PGY-3 internal medicine house staff at our institution were in agreement on most of the PSC dimensions. Overall, house staff PSC was significantly lower than national hospital benchmark data for half of the dimensions. The results of this study will be used to establish internal PSC benchmarks and to identify targets for interventions to further improve PSC.

Causes and risk factors for rehospitalization of patients hospitalized with community-acquired pneumonia.

BACKGROUND: Rehospitalization after inpatient treatment of community-acquired pneumonia occurs in one-tenth of all hospitalizations, but the clinical circumstances surrounding readmission to the hospital have not been well studied. The objective of this study was to identify the causes and risk factors for rehospitalization of inpatients with community-acquired pneumonia. METHODS: This project was performed as part of a randomized, multicenter, controlled trial of the implementation of practice guidelines to reduce the duration of intravenous antibiotic therapy and duration of hospitalization for patients who have received a clinical and radiographic diagnosis of pneumonia. The trial was conducted at 7 hospitals in Pittsburgh, Pennsylvania, from February 1998 through March 1999. The primary outcome for these analyses was rehospitalization within 30 days after the index hospitalization. Two physicians independently assigned the cause of rehospitalization as pneumonia related, comorbidity related, or both; consensus was reached for all assignments. Patient demographic characteristics and clinical factors independently associated with rehospitalization were identified using multiple logistic regression analysis. RESULTS: Of the 577 patients discharged after hospitalization for community-acquired pneumonia, 70 (12%) were rehospitalized within 30 days. The median time to rehospitalization was 8 days (interquartile range, 4-13 days). Overall, 52 rehospitalizations (74%) were comorbidity related, and 14 (20%) were pneumonia related. The most frequent comorbid conditions responsible for rehospitalization were cardiovascular (n = 19), pulmonary (n = 6) and neurological (n = 6) in origin. Less than a high school education (odds ratio, 2.0; 95% confidence interval, 1.1-3.4), unemployment (odds ratio, 3.7; 95% confidence interval, 1.1-12.3), coronary artery disease (odds ratio, 2.7; 95% confidence interval, 1.5-4.7), and chronic obstructive pulmonary disease (odds ratio, 2.3; 95% confidence interval, 1.3-4.1) were independently associated with rehospitalization. CONCLUSIONS: The majority of rehospitalizations following pneumonia are comorbidity related and are the result of underlying cardiopulmonary and/or neurologic diseases. Careful attention to the clinical stability of patients with these coexisting conditions at and following hospital discharge may decrease the frequency of rehospitalization of patients with community-acquired pneumonia.