The Association of Subspecialty and Sex with Industry Payments to Internal Medicine Physicians Who Recently Completed Training.

BACKGROUND: Financial relationships with drug and medical device companies may impact quality of care and academic research. However, little is known when and how these financial relationships develop among newly independent physicians who recently completed from residency or fellowship programs in internal medicine (IM). OBJECTIVE: To compare patterns of industry payments among IM graduates. DESIGN: Retrospective, observational cohort study. SUBJECTS: IM graduates from residency or fellowship programs between January 2015 and December 2019. MAIN MEASURES: We analyzed Open Payments reports made between July 2015 and June 2021 to recent graduates of U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs in IM. The primary outcome was general payments accepted by these physicians, stratified by procedural (i.e., critical care medicine/pulmonary medicine, cardiac/cardiovascular disease, and gastroenterology) and non-procedural (i.e., infectious disease, general internal medicine, and other specialties) subspecialties. The secondary outcomes included general payments stratified by sex and age at residency or fellowship training completion. KEY RESULTS: There were 41,669 IM physicians with a median age of 33.0 years. In the first 3 years after completion, the proportion of physicians accepting any general payments was 72.6%, 91.9%, and 86.8% in Critical Care Medicine/Pulmonary Medicine, Cardiac/Cardiovascular Disease, and Gastroenterology, compared to 56.1%, 52.6%, and 52.3% in Infectious Disease, General Internal Medicine, and Other Specialties (p<0.0001). After adjusting for confounding variables, the procedural group showed an increased hazard ratio (HR) for accepting any general payments and at least $5000 of general payments compared to the non-procedural group. The HRs of accepting any general payments in the procedural subspecialty were 2.26 (95% CI, 2.11-2.42) and 2.83 (95% CI, 2.70-2.97) in female and male physicians, respectively (p-value < 0.0001). CONCLUSION: Industry financial relationships among newly independent physicians in IM exist immediately after completion of training and are influenced by subspecialty, sex, and age.

Factors Influencing Primary Care Career Choice: A Multi-Institutional Cross-sectional Survey of Internal Medicine Primary Care Residency Graduates.

BACKGROUND: Although primary care is associated with population health benefits, the supply of primary care physicians continues to decline. Internal medicine (IM) primary care residency programs have produced graduates that pursue primary care; however, it is uncertain what characteristics and training factors most affect primary care career choice. OBJECTIVE: To assess factors that influenced IM primary care residents to pursue a career in primary care versus a non-primary care career. DESIGN: Multi-institutional cross-sectional study. PARTICIPANTS: IM primary care residency graduates from seven residency programs from 2014 to 2019. MAIN MEASURES: Descriptive analyses of respondent characteristics, residency training experiences, and graduate outcomes were performed. Bivariate logistic regression analyses were used to assess associations between primary care career choice with both graduate characteristics and training experiences. KEY RESULTS: There were 256/314 (82%) residents completing the survey. Sixty-six percent of respondents (n = 169) practiced primary care or primary care with a specialized focus such as geriatrics, HIV primary care, or women's health. Respondents who pursued a primary care career were more likely to report the following as positive influences on their career choice: resident continuity clinic experience, nature of the PCP-patient relationship, ability to care for a broad spectrum of patient pathology, breadth of knowledge and skills, relationship with primary care mentors during residency training, relationship with fellow primary care residents during training, and lifestyle/work hours (all p < 0.05). Respondents who did not pursue a primary care career were more likely to agree that the following factors detracted them from a primary care career: excessive administrative burden, demanding clinical work, and concern about burnout in a primary care career (all p < 0.05). CONCLUSIONS: Efforts to optimize the outpatient continuity clinic experience for residents, cultivate a supportive learning community of primary care mentors and residents, and decrease administrative burden in primary care may promote primary care career choice.

The selection of chief residents across residency programs at a large academic medical center.

BACKGROUND: Chief residents have a unique role in graduate medical education (GME). They not only connect residents with program and hospital leadership, but also advocate for the wellbeing and educational priorities of trainees. Previous studies have focused on describing the characteristics of chief residents (CRs), however little is known about how CRs are selected across GME programs. METHODS: One-on-one semi-structured interviews with all (n = 21) GME program directors at the Johns Hopkins University School of Medicine were conducted from January to March 2022. Investigators independently coded the transcripts using an inductive approach to categorize meaningful segments of text; this culminated in the identification of explanatory themes. RESULTS: From discussions with 21 program directors, four themes were identified: (1) identifying candidates: timing, recruitment, nominations, as well as desirable attributes and data considered; (2) applications: expression of intent and participation in interviews; (3) selections: voting, discussions leading to consensus, and program director intimately involved in the choice(s); and (4) confidence in processes and outcomes. CONCLUSIONS: Our results provide a deeper understanding of the nuances associated with the selection of CRs. It is hoped that the descriptions of the similarities and differences across GME programs will prompt reflection about what is done at one institution such that all programs can consider what are the best practices to serve their individual goals and needs.

Multimodal Intervention Assessing the Appropriateness of Acid Suppression Therapy is Associated With Reduced Prescriptions at the Time of Discharge for Hospitalized Inpatients.

Background: Acid suppression therapy (AST), including proton pump inhibitors and histamine 2 receptor antagonists, are an overused class of medications. When used inappropriately, AST leads to polypharmacy, increased healthcare costs, and possible negative health consequences. Objective: To assess whether an intervention including prescriber education combined with a pharmacist-driven protocol was effective in reducing the percentage of patients who were discharged with inappropriate AST. Methods: This was a prospective pre-post study of adult patients who were prescribed AST before or during their admission to an internal medicine teaching service. All internal medicine resident physicians received education on appropriate AST prescribing. During the 4-week intervention period, dedicated pharmacists assessed the appropriateness of AST and made recommendations regarding deprescribing if no appropriate indication was identified. Results: During the study period, there were 14 166 admissions during which patients were prescribed AST. Out of the 1143 admissions during the intervention period, appropriateness of AST was assessed by a pharmacist for 163 patients. AST was determined to be inappropriate for 52.8% (n = 86) of patients and discontinuation or de-escalate of therapy occurred in 79.1% (n = 68) of these cases. The percentage of patients discharged on AST decreased from 42.5% before the intervention to 39.9% after the intervention (P = .007). Conclusion: This study suggests that a multimodal deprescribing intervention reduced prescriptions for AST without an appropriate indication at the time of discharge. To increase the efficiency of the pharmacist assessment several workflow improvements were identified. Further study is necessary to understand the long-term outcomes of this intervention.

Self-Directed Learning among Internal Medicine Residents in the Information Age.

OBJECTIVES: The revolution in information technology and a rapidly expanding evidence base are changing residency training. Understanding the habits and preferences of trainees' self-directed learning (SDL) has never been more important. Our goal was to provide a contemporary description of residents' SDL practices. METHODS: Internal medicine residents at four university-affiliated programs were surveyed in Spring 2017. Residents estimated the number of hours in their typical week spent in SDL on service and after hours when on inpatient and noninpatient rotations, how often they used specific educational resources for SDL, and the percentage of time that they used four different modes to access resources. RESULTS: Of 384 residents, a total of 254 (66%) responded. Residents spent more total hours in SDL on noninpatient services (median 11, interquartile range 8-17) than on inpatient services (median 7, interquartile range 4-10) and the same median number of hours in SDL on clinical duty as off hours for both inpatient (median 3 hours) and noninpatient (median 5 hours) rotations. Nearly all of the respondents (99%) reported using online point-of-care resources for SDL at least once per week. Most (77%) never used printed textbooks. Desktop/laptop was the most commonly used (47% of the time) medium to access resources. CONCLUSIONS: Although the resident learning environment and resource use are changing, residents engage in as much or more time in SDL as in previous studies, with a large proportion occurring during clinical service. Understanding residents' current SDL habits will better prepare educators to support and guide our trainees.

A National Survey of Internal Medicine Primary Care Residency Program Directors.

BACKGROUND: The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes. OBJECTIVE: We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers. DESIGN: Cross-sectional study PARTICIPANTS: Seventy out of 100 (70%) IM primary care program directors completed the survey. MAIN MEASURES: Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences. KEY RESULTS: Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs. CONCLUSIONS: IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.

National Survey of Primary Care Physicians' Knowledge, Practices, and Perceptions of Prediabetes.

BACKGROUND: Despite strong evidence and national policy supporting type 2 diabetes prevention, little is known about type 2 diabetes prevention in the primary care setting. OBJECTIVE: Our objective was to assess primary care physicians' knowledge and practice regarding perceived barriers and potential interventions to improving management of prediabetes. DESIGN: Cross-sectional mailed survey. PARTICIPANTS: Nationally representative random sample of US primary care physicians (PCPs) identified from the American Medical Association Physician Masterfile. MAIN MEASURES: We assessed PCP knowledge, practice behaviors, and perceptions related to prediabetes. We performed chi-square and Fisher's exact tests to evaluate the association between PCP characteristics and the main survey outcomes. KEY RESULTS: In total, 298 (33%) eligible participants returned the survey. PCPs had limited knowledge of risk factors for prediabetes screening, laboratory diagnostic criteria for prediabetes, and management recommendations for patients with prediabetes. Only 36% of PCPs refer patients to a diabetes prevention lifestyle change program as their initial management approach, while 43% discuss starting metformin for prediabetes. PCPs believed that barriers to type 2 diabetes prevention are both at the individual level (e.g., patients' lack of motivation) and at the system level (e.g., lack of weight loss resources). PCPs reported that increased access to and insurance coverage of type 2 diabetes prevention programs and coordination of referral of patients to these resources would facilitate type 2 diabetes preventive efforts. CONCLUSIONS: Addressing gaps in PCP knowledge may improve the identification and management of people with prediabetes, but system-level changes are necessary to support type 2 diabetes prevention in the primary care setting.

Survey of primary care providers' knowledge of screening for, diagnosing and managing prediabetes.

BACKGROUND: Prediabetes affects 86 million US adults, but primary care providers' (PCPs') knowledge, practices, attitudes and beliefs toward prediabetes are unclear. OBJECTIVE: Assess PCPs' (1) knowledge of risk factors that should prompt prediabetes screening, laboratory criteria for diagnosing prediabetes and guidelines for management of prediabetes; (2) management practices around prediabetes; (3) attitudes and beliefs about prediabetes. DESIGN: Self-administered written survey of PCPs. PARTICIPANTS: One hundred forty of 155 PCPs (90%) attending an annual provider retreat for academically affiliated multispecialty practices in the mid-Atlantic region. MAIN MEASURES: Descriptive analyses of survey questions on knowledge, management, and attitudes and beliefs related to prediabetes. Multivariate logistic regression was used to determine the association between provider characteristics (gender, race/ethnicity, years since training, specialty and provider type) and knowledge, management, and attitudes and beliefs about prediabetes. KEY RESULTS: Six percent of PCPs correctly identified all of the risk factors that should prompt prediabetes screening. Only 17% of PCPs correctly identified the laboratory parameters for diagnosing prediabetes based on both fasting glucose and hemoglobin A1c. Nearly 90% of PCPs reported close follow-up (within 6 months) of patients with prediabetes. Few PCPs (11%) selected referral to a behavioral weight loss program as the recommended initial management approach to prediabetes. PCPs agreed that patient-related factors are important barriers to lifestyle change and metformin use. Provider characteristics were generally not associated with knowledge, management, attitudes and beliefs about prediabetes in multivariate analyses. CONCLUSIONS: Addressing gaps in knowledge and the underutilization of behavioral weight loss programs in prediabetes are two essential areas where PCPs could take a lead in curbing the diabetes epidemic.

An obesity medicine curriculum increases the obesity care self-efficacy of internal medicine residents in the primary care setting.

Primary care physicians (PCPs) report insufficient knowledge and training gaps in obesity care. Internal Medicine (IM) residency offers an opportunity to address this educational gap for future PCPs. We designed an innovative, multicomponent curriculum on obesity medicine (OM) in the primary care setting for IM residents. We then conducted a prospective, 6-month, two-arm study within two residency programs in Maryland evaluating feasibility (use, appropriateness for IM training, and satisfaction) of the curriculum as well as changes in self-efficacy within seven obesity care domains, assessed on 4-point scales (1-not at all confident to 4-very confident). One residency program received the curriculum and the other served as the control group. We recruited 35 IM residents to participate (17 intervention, 18 control). Among intervention residents, 42% used all curricular components; appropriateness and satisfaction with the curriculum were high. Compared with controls, intervention residents had statistically significant increases in five obesity care self-efficacy domains: nutrition (intervention 0.8 vs. control 0.2, p = .02), behaviour change (1.2 vs. 0.4, p < .01), weight-gain-promoting medications (0.8 vs. 0.1, p = .01), anti-obesity medications (1.2 vs. 0.5, p = .03), and bariatric surgical counselling (0.9 vs. 0.4, p = .03). There were no significant changes in physical activity or post-bariatric surgical care domains. Our OM curriculum is feasible with IM residents and increases residents' obesity care self-efficacy beyond what is achieved with usual IM training.

What are Internal medicine residents' attitudes toward obesity as a disease, people living with obesity, and obesity treatment?

Objective: Despite the rising prevalence of people living with obesity, physicians are providing suboptimal care to these individuals, which may be a consequence of inadequate education in weight management and negative attitudes toward people living with obesity. Internal Medicine (IM) residency is an ideal setting to address physicians' attitudes toward people living with obesity. However, there is a paucity of recent literature on this topic. This study sought to assess the current attitudes of IM residents toward obesity as a disease, people living with obesity, and obesity treatment. Methods: A cross-sectional survey was conducted in 2020 across two IM programs assessing residents' attitudes toward obesity as a disease, people living with obesity, and obesity treatment. RESULTS: Among 42 residents who participated in the survey, 64% were women; 31 percent were Post Graduate Year 1, 31% PGY-2, and 38% PGY-3. Mean attitude scores were high on statements regarding obesity as a chronic disease [4.7 (SD 0.4)] and its association with serious medical conditions [4.9 (SD 0.3)]. Residents had overall positive attitudes toward people living with obesity. In contrast, residents felt negatively regarding their level of success in helping patients lose weight [2.0 (SD 0.7)]. CONCLUSIONS: While residents recognized obesity as a chronic disease and had positive attitudes toward people living with obesity, their low ratings regarding weight management success suggest that targeted educational efforts are needed to increase obesity treatment self-efficacy.

Money Talks: Pilot Financial Wellness Programs to Promote Positive Financial Planning Behaviors Among Residents.

PROBLEM: Graduate medical education programs and national organizations are becoming more involved in promoting trainee financial wellness. Current literature reports residents have poor financial knowledge, high debt levels, low concern about their finances, and deficits in financial preparedness, but there has been little published on best practices for implementing financial wellness programs for residents or measuring meaningful outcomes of such programs. APPROACH: From June 2017 to 2019, the authors invited 277 internal medicine residents from the Stony Brook University Hospital, Montefiore Medical Center, and Johns Hopkins Bayview Medical Center residency programs to participate in financial wellness programs. Each institution held at least one 90-minute financial planning session; Stony Brook also had biannual financial wellness check-ins. Participants were invited to complete a presession, an immediate postsession, and a year-end survey to assess changes in financial planning behaviors. OUTCOMES: Survey response rates were 49% (135/277) for the presession survey, 47% (130/277) for the immediate postsession survey, and 22% (61/277) for the year-end survey. Ninety-six percent (125/130) found the sessions helpful and 98% (120/123) recommended continuing the program in the future. At year-end, the most frequent completed financial planning actions prompted by the session included saving emergency funds, creating a monthly budget, consolidating loans via the Public Service Loan Forgiveness program, contributing to retirement savings, and participating in an employer's retirement plan. Residents liked that some sessions were during intern orientation before the selection of retirement plans. Postgraduate year (PGY) 1 residents were more likely to complete positive financial planning actions and to agree or strongly agree that the session prompted them to take financial planning actions than PGY-2 and PGY-3 residents. NEXT STEPS: While financial wellness programs are well received by internal medicine residents, more robust evidence is needed on curricular delivery methods and program features that promote positive financial planning behaviors.

COVID-19: A systematic evaluation of personal protective equipment (PPE) performance during restraint.

BACKGROUND: Restraint is widely practised within inpatient mental health services and is considered a higher-risk procedure for patients and staff. There is a sparsity of evidence in respect of the efficacy of personal protective equipment (PPE) used during restraint for reducing risk of infection. METHODS: A series of choreographed restraint episodes were used to simulate contact contamination in research participants playing the roles of staff members and a patient. For comparison, one episode of simulated recording of physical observations was taken. Ultraviolet (UV) fluorescent material was used to track the simulated contact contamination, with analysis undertaken using established image registration techniques of UV photographs. This was repeated for three separate sets of PPE. RESULTS: All three PPE sets showed similar performance in protecting against contamination transfer. For teams not utilising coveralls, this was dependent upon effective cleansing as part of doffing. There were similar patterns of contamination for restraint team members assigned to specific roles, with hands and upper torso appearing to be higher-risk areas. The restraint-related contamination was 23 times higher than that observed for physical observations. DISCUSSION: A second layer of clothing that can be removed showed efficacy in reducing contact contamination. PPE fit to individual is important. Post-restraint cleansing procedures are currently inadequate, with new procedures for face and neck cleansing required. These findings leave scope for staff to potentially improve their appearance when donning PPE and engaging with distressed patients.

Predictors of Satisfying and Impactful Clinical Shadowing Experiences for Underrepresented Minority High School Students Interested in Healthcare Careers.

INTRODUCTION: Diversity among healthcare professionals lags behind the increasing racial and ethnic diversity of the United States' population. Increasing diversity of the health professional workforce may be one strategy to influence healthcare disparities. This study sought to understand factors associated with highly satisfying and impactful clinical shadowing experiences among underrepresented minority (URM) students in a health professional development program for urban high school students. METHODS: We analyzed data from students' summer clinical shadowing experiences in 2016 and 2017. We sought to determine if preceptor factors (e.g. racial and gender concordance with students), or patient related variables (e.g. racial concordance with students, the volume of patients per session) were associated with overall satisfaction with shadowing, the desire to pursue a similar career as their preceptor, and viewing their preceptor as a role model. After each shadowing experience, students completed evaluation forms. Chi-square tests were used for data analysis. RESULTS: Over two summers, 65 high school juniors participated in an average of 14 half-day clinical shadowing sessions; 59 of these students identify as URMs. Among URM students, racial/ethnic concordance between preceptor and student was significantly associated with viewing the preceptor as a role model (p = 0.028). Witnessing a greater number of patient-provider encounters (≥five patients per session) was associated with higher satisfaction with the experience (p = 0.0002), and viewing the preceptor as a role model (p = 0.04). CONCLUSION: To increase diversity of the healthcare workforce, URM students need high volume patient-provider encounters. Racial and/or ethnic concordance of URM students and preceptors may provide for preferable role models.

The genealogy of teaching clinical reasoning and diagnostic skill: the GEL Study.

The genealogy of graduate medical education in America begins at the bedside. However, today's graduate medical trainees work in a training environment that is vastly different from medical training a century ago. The goal of the Graduate Medical Education Laboratory (GEL) Study, supported by the American Medical Association's (AMA) "Reimagining Residency" initiative, is to determine the factors in the training environment that most contribute to resident well-being and developing diagnostic skills. We believe that increasing time at the bedside will improve clinical skill, increase professional fulfillment, and reduce workplace burnout. Our graduate medical education laboratory will test these ideas to understand which interventions can be shared among all training programs. Through the GEL Study, we aim to ensure resident readiness for practice as we understand, then optimize, the learning environment for trainees and staff.

Infusing High Value Care Education Directly into Patient Care on the Medicine Wards.

This article was migrated. The article was marked as recommended. Background: Multiple national initiatives have been implemented to promote cost-conscious care. Yet, there remains a deficiency of formal high value care (HVC) curricula among internal medicine residency programs.We aimedto develop a curriculum that teaches HVC material that can be utilized at the point of care and to assess the curriculum's impact on the participants' attitudes, knowledge, and practice patterns pertaining to HVC. Methods: We conducted our study on the inpatient internal medicine service over two-week rotations at Johns Hopkins Bayview Medical Center. Internal medicine residentsparticipated in two collaborative educational sessions that incorporated an introduction of important concepts in HVC, Bayesian thinking, clinical cases, and a review of a hospital bill of one of the patients under the team's care. Participants were also encouraged to reflect on their practice patterns and incorporate the HVC principles taught into their daily clinical work. We administered pre- and post-curriculum surveys to assess change in reported HVC-related practice behaviors, knowledge, and attitudes. Results: Forty-seven residents participated in the study. We included the twenty participants who completed both a pre- and post-curriculum survey in the data analysis. After participation in the curriculum, there was a significant increase in the use of pre-test probabilities in clinical decision making ( p=0.005). There was also a trend toward improvement in HVC knowledge and practice patterns after the rotation. Conclusion: We implemented a curriculum that may have improved high-value practice patterns through point-of-care education on the inpatient medicine wards.

Searching for prohibited items in mental-health hospitals: A randomised controlled trial of two metal-detecting technologies.

Weapons and other items with potential to cause harm are usually prohibited in mental-health hospitals and other psychiatric facilities. Detecting such prohibited items (PIs) can be problematic, particularly if concealed, and metal detectors are commonly used to search for such items. Our study compared two types of metal detection: continuous wave detection (CWD) by hand-held metal detector (HHMD) and magnetic anomaly detection (MAD) by a static pole device. In the study, real and dummy PIs were hidden on test subjects and in a simulated body cavity. The results showed MAD to be significantly superior to CWD in detecting small concealed PIs containing ferrous metal. The MAD pole found 100% of the real PIs on the test subjects and in the simulated body cavity. The CWD HHMD found only 5.2% of the real PIs, and these were limited to those on the test subjects, as it detected none in the simulated body cavity. In addition, the time taken to search by MAD pole was shorter than time taken to search by CWD HHMD.

The value of autofluorescence as a diagnostic feature of acute promyelocytic leukemia.

Autofluorescence is an immunophenotypic characteristic of leukemic blasts in acute promyelocytic leukemia (APL). We examined the fluorescent intensity of isotype controls in 25 cases of APML and 25 controls with acute myeloid leukemia. The fluorescence of the FITC- and PE-conjugated controls was consistently higher in APML. Autofluorescence may therefore represent a helpful diagnostic marker in APML.

CD38 expression level and pattern of expression remains a reliable and robust marker of progressive disease in chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) follows a variable clinical course which is difficult to predict at diagnosis. We assessed somatic mutation (SHM) status, CD38 and ZAP-70 expression in 87 patients (49 male, 38 female) with stage A CLL and known cytogenetic profile to compare their role in predicting disease progression, which was assessed by the treatment free interval (TFI) from diagnosis. Sixty (69%) patients were SHM+, 24 (28%) were CD38+ and ten (12%) were ZAP-70+. The median TFI for: (i) SHM + versus SHM- patients was 124 versus 26 months; hazard ratio (HR) = 3.6 [95% confidence interval (CI) = 1.8 - 7.3; P = 0.001]: (ii) CD38- versus CD38+ patients was 120 versus 34 months; HR = 2.4 (95% CI = 1.4 - 5.3; P = 0.02); and (iii) ZAP70- versus ZAP70+ was 120 versus 16 months; HR = 3.4 (95% CI = 1.4 - 8.7; P = 0.01). SHM status and CD38 retained prognostic significance on multivariate analysis whereas ZAP-70 did not. We conclude that ZAP-70 analysis does not provide additional prognostic information in this group of patients.