Internal Medicine Resident Perspectives on Virtual Recruitment.

This survey study describes the perceived implications of virtual-only recruitment and the preferred application process for residents and fellows.

Residency Program Responses to Early COVID-19 Surges Highlight Tension as to Whether Residents Are Learners or Essential Workers.

PURPOSE: To quantify the extent to which internal medicine (IM) residents provided care for patients with COVID-19 and examine characteristics of residency programs with or without plans (at some point) to exclude residents from COVID-19 care during the first 6 months of the pandemic. METHOD: The authors used data from a nationally representative, annually recurring survey of U.S. IM program directors (PDs) to quantify early (March-August 2020) resident participation in COVID-19 care. The survey was fielded from August to December 2020. PDs reported whether they had planned to exclude residents from COVID-19 care (i.e., PTE status). PTE status was tested for association with program and COVID-19 temporal characteristics, resident schedule accommodations, and resident COVID-19 cases. RESULTS: The response rate was 61.5% (264/429). Nearly half of PDs (45.4%, 118/260) reported their program had planned at some point to exclude residents from COVID-19 care. Northeastern U.S. programs represented a smaller percentage of PTE than non-PTE programs (26.3% vs 36.6%; P = .050). PTE programs represented a higher percentage of programs with later surges than non-PTE programs (33.0% vs 13.6%, P = .048). Median percentage of residents involved in COVID-19 care was 75.0 (interquartile range [IQR]: 22.5-100.0) for PTE programs, compared with 95.0 (IQR: 60.0-100.0) for non-PTE programs ( P < .001). Residents participated most in intensive care units (87.6%, 227/259) and inpatient wards (80.8%, 210/260). Accommodations did not differ by PTE status. PTE programs reported fewer resident COVID-19 cases than non-PTE programs (median percentage = 2.7 [IQR: 0.0-8.6] vs 5.1 [IQR: 1.6-10.7]; P = .011). CONCLUSIONS: IM programs varied widely in their reported plans to exclude residents from COVID-19 care during the early pandemic. A high percentage of residents provided COVID-19 care, even in PTE programs. Thus, the pandemic highlighted the tension as to whether residents are learners or employees.

Transcriptional Profiles Elucidate Differential Host Responses to Infection with Cryptococcus neoformans and Cryptococcus gattii.

Many aspects of the host response to invasive cryptococcal infections remain poorly understood. In order to explore the pathobiology of infection with common clinical strains, we infected BALB/cJ mice with Cryptococcus neoformans, Cryptococcus gattii, or sham control, and assayed host transcriptomic responses in peripheral blood. Infection with C. neoformans resulted in markedly greater fungal burden in the CNS than C. gattii, as well as slightly higher fungal burden in the lungs. A total of 389 genes were significantly differentially expressed in response to C. neoformans infection, which mainly clustered into pathways driving immune function, including complement activation and TH2-skewed immune responses. C. neoformans infection demonstrated dramatic up-regulation of complement-driven genes and greater up-regulation of alternatively activated macrophage activity than seen with C gattii. A 27-gene classifier was built, capable of distinguishing cryptococcal infection from animals with bacterial infection due to Staphylococcus aureus with 94% sensitivity and 89% specificity. Top genes from the murine classifiers were also differentially expressed in human PBMCs following infection, suggesting cross-species relevance of these findings. The host response, as manifested in transcriptional profiles, informs our understanding of the pathophysiology of cryptococcal infection and demonstrates promise for contributing to development of novel diagnostic approaches.

Internal Medicine Residency Program Director Support and Burnout During the COVID-19 Pandemic: Results of a National Survey.

Background: Burnout is common among physicians and physician leaders, including residency program directors (PDs). The effects of the COVID-19 pandemic and other stressors in 2020 on PDs is unknown. Objective: To measure the prevalence of burnout among internal medicine (IM) residency PDs 6 months into the COVID-19 pandemic. Methods: A total of 429 IM PDs, representing 83% of accredited residency programs, were surveyed from August to December 2020. Burnout, using a 2-item screening tool, and self-reported consideration of resigning in 2020, were compared to their annual prevalence since 2012 and tested for possible associations with pandemic stressors and program characteristics. Results: The survey response rate was 61.5% (264 of 429). One-third (33.6%, 87 of 259) of PD respondents met burnout criteria, and 45.1% (110 of 244) reported considering resigning in the past year, which were within the range of preceding years. PDs who reported feeling highly supported by institutional leadership were less likely to meet burnout criteria and to have considered resigning. There were no associations between burnout or consideration of resigning and the amount of clinical time PDs spent in their roles, duration of maximum stress on programs, budget cuts to programs, or geographic region. Conclusions: The prevalence of burnout among PDs in fall 2020 was similar to the prevalence of burnout in pre-pandemic years despite uniquely extreme stressors. PDs' perception of being highly supported by institutional leadership was associated with lower prevalence of burnout and consideration of resigning. Perceived leadership support may be a protective factor against burnout during periods of high stress.

Training in Safe Opioid Prescribing and Treatment of Opioid Use Disorder in Internal Medicine Residencies: a National Survey of Program Directors.

BACKGROUND: Training future clinicians in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD) is critical to address the opioid epidemic. The Accreditation Council on Graduate Medical Education requires all programs to provide instruction and experience in pain management and will mandate addiction medicine clinical experiences for internal medicine trainees. OBJECTIVE: Assess residents' training in SOP and treatment of OUD and identify training barriers. DESIGN: Cross-sectional nationally representative survey was emailed in 2019. PARTICIPANTS: Four hundred twenty-two Association of Program Directors in Internal Medicine members in US internal medicine residency programs. MAIN MEASURES: Program opportunities and challenges to developing or implementing training in SOP, treatment of OUD, and buprenorphine waiver training, and perceived curricular effectiveness. KEY RESULTS: The response rate was 69.4% (293/422). Most programs required didactics in SOP (94.2%) and treatment of OUD (71.7%). Few programs required clinical experiences including addiction medicine clinics (28/240, 11.7%), inpatient consult services (11/240, 4.6%), or offsite treatment rotations (8/240, 3.3%). Lack of trained faculty limited developing or implementing curricula (61.5%). Few respondents reported that their program was "very effective" in teaching SOP (80/285, 28.1%) or treatment of OUD (43/282, 15.3%). Some programs offered buprenorphine waiver training to residents (83/286, 29.0%) and faculty (94/286, 32.9%) with few mandating training (11.7% (28/240) and 5.4% (13/240) respectively). Only 60 of 19,466 (0.3%) residents completed buprenorphine waiver training. Primary care programs/tracks were more likely to offer waiver training to residents (odds ratio [OR], 3.07; 95% CI, 1.68-5.60; P < 0.001) and faculty (OR, 1.08; 95% CI, 1.01-3.22; P = 0.05). CONCLUSIONS: In this nationally representative survey, few internal medicine residency programs provided clinical training in SOP and treatment of OUD, and training was not viewed as very effective. Lack of effective training may have adverse implications for patients, clinicians, and society.

Focusing on Diversity: A Regional Internal Medicine Residency Viewpoint on Underrepresented Minority Support, Retention, and Mentoring.

BACKGROUND: While the overall percentage of residents who withdraw (2.7%) or take extended leave (1.0%) are low, subgroup analysis has found that minority physicians are approximately 30% more likely to withdraw from residency than their white counterparts and 8 times more likely to take extended leave of absence. With ongoing national efforts to support diversity in medical education through increased recruitment of underrepresented in medicine (UiM) students to residency programs, there is paucity of data identifying specific experiences challenging or contributing to their overall resiliency. Better understanding of the lived experience of UiM residents will allow residency programs to create successful curricular programing and support structures for residents to thrive. OBJECTIVE: We sought to understand UiM internal medicine residents' experiences during residency training. METHODS: We used a retrospective review of focus group transcripts of UiM internal medicine residents from 5 academic institutions in 2017 (4 in North Carolina and 1 in Georgia). RESULTS: Of 100 self-identified UiM residents from 5 institutions, 59 participated in the focus groups. Using a consensus-based review of transcripts, 25 distinct codes in 8 parent code categories were determined. Two primary themes emerged: resilience and isolation. Three secondary themes-social support, mentorship, and external expectations and/or biases-served as mediators for the primary themes. CONCLUSIONS: UiM residents who became or were already resilient commonly experienced isolation at some time in their medical career, specifically during residency. Moreover, they could be influenced and positively or negatively affected by social support, mentorship, and external expectations and biases.

Does Increased Schedule Flexibility Lead to Change? A National Survey of Program Directors on 2017 Work Hours Requirements.

BACKGROUND: The learning and working environment for resident physicians shifted dramatically over the past two decades, with increased focus on work hours, resident wellness, and patient safety. Following two multi-center randomized trials comparing 16-h work limits for PGY-1 trainees to more flexible rules, the ACGME implemented new flexible work hours standards in 2017. OBJECTIVE: We sought to determine program directors' (PDs) support for the work hour changes and programmatic response. DESIGN: In 2017, US Internal Medicine PDs were surveyed about their degree of support for extension of PGY-1 work hour limits, whether they adopted the new maximum continuous work hours permitted, and reasons for their decisions. KEY RESULTS: The response rate was 70% (266/379). Fifty-seven percent of PDs (n = 151) somewhat/strongly support the new work hour rules for PGY-1 residents, while only 25% of programs (N = 66) introduced work periods greater than 16-h on any rotation. Higher rates of adopting change were seen in PDs who strongly/somewhat supported the change (56/151 [37%], P < 0.001), had tenure of 6+ years (33/93 [35%], P = 0.005), were of non-general internal medicine subspecialty (30/80 [38%], P = 0.003), at university-based programs (35/101 [35%], P = 0.009), and with increasing number of approved positions (< 38, 10/63 [16%]; 38-58, 13/69 [19%]; 59-100, 15/64 [23%]; > 100, 28/68 [41%], P = 0.005). Areas with the greatest influence for PDs not extending work hours were the 16-h rule working well (56%) and risk to PGY1 well-being (47%). CONCLUSIONS: Although the majority of PDs support the ACGME 2017 work hours rules, only 25% of programs made immediate changes to extend hours. These data reveal that complex, often competing, forces influence PDs' decisions to change trainee schedules.

A transcriptional signature accurately identifies Aspergillus Infection across healthy and immunosuppressed states.

Invasive aspergillosis (IA) is a major cause of critical illness in immunocompromised (IC) patients. However, current fungal tests are limited. Disease-specific gene expression patterns in circulating host cells show promise as novel diagnostics, however it is unknown whether such a 'signature' exists for IA and the effect of iatrogenic immunosuppression on any such biomarkers. Male BALB/c mice were separated into 6 experimental groups based on Aspergillus fumigatus inhalational exposure and IC status (no immunosuppression, cyclophosphamide, and corticosteroids). Mice were sacrificed 4 days postinfection. Whole blood was assayed for transcriptomic responses in peripheral white blood cells via microarray. An elastic net regularized logistic regression was employed to develop classifiers of IA based on gene expression. Aspergillus infection triggers a powerful response in non-IC hosts with 2718 genes differentially expressed between IA and controls. We generated a 146-gene classifier able to discriminate between non-IC infected and uninfected mice with an AUC of 1. However, immunosuppressive medications exhibited a confounding effect on this transcriptomic classifier. After controlling for the genomic effects of immunosuppression, we were able to generate a 187-gene classifier with an AUC of 0.92 in the absence of immunosuppression, 1 with cyclophosphamide, and 0.9 with steroids. The host transcriptomic response to IA is robust and conserved. Pharmacologic perturbation of the host immune response has powerful effects on classifier performance and must be considered when developing such novel diagnostics. When appropriately designed, host-derived peripheral blood transcriptomic responses demonstrate the ability to accurately diagnose Aspergillus infection, even in the presence of immunosuppression.

The Nephrology Immersion Classroom for Internal Medicine Residents.

Background: In graduate medical education (GME), there are many barriers to achieving a personalized learning process with standardized learning outcomes. One way to support this is through mobile-friendly digital blackboard videos. We sought to measure the effect of a mobile-friendly video curriculum on resident satisfaction, knowledge, and clinical skills during a nephrology rotation. Methods: This was a prospective, controlled, nonrandomized trial. The control group consisted of internal medicine residents who completed our inpatient nephrology consult rotation as usual. The classroom group had the same clinical experience, but also had access to a library (Nephrology Immersion Classroom) of mobile-friendly, nephrology-themed, digital blackboard videos. In a postrotation assessment, we measured resident satisfaction, clinical knowledge using 15 multiple-choice questions, and nephrology-specific clinical skills. Results: Of the residents in the classroom group, 77% enrolled in the online classroom, and the majority reported using the classroom occasionally or frequently. A majority found it very easy to use (86%) and strongly recommended having similar videos for other rotations (77%). We observed improved report of rotation-specific clinical skills, but no difference in short-term knowledge between the two study groups. Conclusions: A mobile-friendly, digital video curriculum for internal medicine residents on an inpatient consult rotation was well utilized, highly rated, and associated with improved nephrology-specific clinical skills. Continued evaluation and incremental improvement of such resources could enhance implementation of GME core curricula.

Relationship Between Institutional Investment in High-Value Care (HVC) Performance Improvement and Internal Medicine Residents' Perceptions of HVC Training.

PURPOSE: To measure the association between institutional investment in high-value care (HVC) performance improvement and resident HVC experiences. METHOD: The authors analyzed data from two 2014 surveys assessing institutions' investments in HVC performance improvement as reported by program directors (PDs) and residents' perceptions of the frequency of HVC teaching, participation in HVC-focused quality improvement (QI), and views on HVC topics. The authors measured the association between institutional investment and resident-reported experiences using logistic regression, controlling for program and resident characteristics. RESULTS: The sample included 214 programs and 9,854 residents (59.3% of 361 programs, 55.2% of 17,851 residents surveyed). Most PDs (158/209; 75.6%) reported some support. Residents were more likely to report HVC discussions with faculty at least a few times weekly if they trained in programs that offered HVC-focused faculty development (odds ratio [OR] = 1.19; 95% confidence interval [CI] 1.04-1.37; P = .01), that supported such faculty development (OR = 1.21; 95% CI 1.04-1.41; P = .02), or that provided physician cost-of-care performance data (OR = 1.19; 95% CI 1.03-1.39; P = .02). Residents were more likely to report participation in HVC QI if they trained in programs with a formal HVC curriculum (OR = 1.83; 95% CI 1.48-2.27; P < .001) or with HVC-focused faculty development (OR = 1.46; 95% CI 1.15-1.85; P = .002). CONCLUSIONS: Institutional investment in HVC-related faculty development and physician feedback on costs of care may increase the frequency of HVC teaching and resident participation in HVC-related QI.

Improving Timely Resident Follow-Up and Communication of Results in Ambulatory Clinics Utilizing a Web-Based Audit and Feedback Module.

BACKGROUND: Failure to follow up and communicate test results to patients in outpatient settings may lead to diagnostic and therapeutic delays. Residents are less likely than attending physicians to report results to patients, and may face additional barriers to reporting, given competing clinical responsibilities. OBJECTIVE: This study aimed to improve the rates of communicating test results to patients in resident ambulatory clinics. METHODS: We performed an internal medicine, residency-wide, pre- and postintervention, quality improvement project using audit and feedback. Residents performed audits of ambulatory patients requiring laboratory or radiologic testing by means of a shared online interface. The intervention consisted of an educational module viewed with initial audits, development of a personalized improvement plan after Phase 1, and repeated real-time feedback of individual relative performance compared at clinic and program levels. Outcomes included results communicated within 14 days and prespecified "significant" results communicated within 72 hours. RESULTS: A total of 76 of 86 eligible residents (88%) reviewed 1713 individual ambulatory patients' charts in Phase 1, and 73 residents (85%) reviewed 1509 charts in Phase 2. Follow-up rates were higher in Phase 2 than Phase 1 for communicating results within 14 days and significant results within 72 hours (85% versus 78%, P < .001; and 82% versus 70%, P = .002, respectively). Communication of "significant" results was more likely to occur via telephone, compared with communication of nonsignificant results. CONCLUSIONS: Participation in a shared audit and feedback quality improvement project can improve rates of resident follow-up and communication of results, although communication gaps remained.

The Burden of Burnout.

This study sought to determine burnout prevalence and factors associated with burnout in internal medicine residents after introduction of the 2011 ACGME duty hour rules. Burnout was evaluated using an anonymized, abbreviated version of the Maslach Burnout Inventory. Surveys were collected biweekly for 48 weeks during the 2013-2014 academic year. Burnout severity was compared across subgroups and time. A score of 3 or higher signified burnout. Overall, 944 of 3936 (24%) surveys were completed. The mean burnout score across all surveys was 2.8. Categorical residents had higher burnout severity than noncategorical residents (2.9 vs 2.7, P = .005). Postgraduate year 2 residents had the highest burnout severity by year (3.1, P < .001). Residents on inpatient rotations had higher burnout severity than residents on outpatient or consultation rotations (3.1 vs 2.2 vs 2.2, P < .001). Night float rotations had the highest severity (3.8). Burnout remains a significant problem even with recent duty hour modifications.

Diabetes Quality of Care Before and After Implementation of a Resident Clinic Practice Partnership System.

Deficiencies in resident diabetes care quality may relate to continuity clinic design. This retrospective analysis compared diabetes care processes and outcomes within a traditional resident continuity clinic structure (2005) and after the implementation of a practice partnership system (PPS; 2009). Under PPS, patients were more likely to receive annual foot examinations (odds ratio [OR] = 11.6; 95% confidence interval [CI] = 7.2, 18.5), microalbumin screening (OR = 2.4; 95% CI = 1.6, 3.4), and aspirin use counseling (OR = 3.8; 95% CI = 2.5, 6.0) and were less likely to receive eye examinations (OR = 0.54; 95% CI = 0.36, 0.82). Hemoglobin A1c and lipid testing were similar between periods, and there was no difference in achievement of diabetes and blood pressure goals. Patients were less likely to achieve cholesterol goals under PPS (OR = 0.62; 95% CI = 0.39, 0.98). Resident practice partnerships may improve processes of diabetes care but may not affect intermediate outcomes.