The State of Morning Report in the Current Healthcare Landscape: a National Survey of Internal Medicine Program Directors.

BACKGROUND: Case-based Morning Report (MR) has long been the predominant educational conference in Internal Medicine (IM) residency programs. The last comprehensive survey of IM MR was in 1986. Much has changed in the healthcare landscape since 1986 that may impact MR. OBJECTIVE: We sought to determine the current state of MR across all US IM programs. DESIGN: In 2018, US IM program directors (PDs) were surveyed about the dynamics of MR at their institutions, perceived pressures, and realized changes. KEY RESULTS: The response rate was 70.2% (275/392). MR remains highly prevalent (97.5% of programs), although held less frequently (mean 3.9 days/week, SD 1.2), for less time (mean 49.4 min, SD 12.3), and often later in the day compared to 1986. MR attendees have changed, with more diversity of learners but less presence of educational leaders. PD presence at MR is associated with increased resident attendance (high attendance: 78% vs 61%, p=0.0062) and punctuality (strongly agree/agree: 59% vs 43%, p=0.0161). The most cited goal for MR is utilizing cases to practice clinical reasoning. Nearly 40% of PDs feel pressure to move or cancel MR; of those, 61.2% have done so, most commonly changing the timing (48.5%), reducing the length (18.4%), and reducing the number of sessions per week (11.7%). Compared to community-based and to community-based, university-affiliated programs, university-based programs have 2.9 times greater odds (95% CI: 1.3, 6.9; p = 0.0081) and 2.5 times greater odds (95% CI 1.5, 4.4; p =0.0007), respectively, of holding MR after 9 AM, and 1.8 times greater odds (95% CI: 0.8, 4.2; p = 0.1367) and 2.0 times greater odds (95% CI: 1.2, 3.5; p = 0.0117), respectively, of reporting pressure to cancel or move MR compared to their counterparts. CONCLUSIONS: While MR ubiquity reflects its continued perceived value, PDs have modified MR to accommodate changes in the healthcare environment. This includes reduced frequency, shorter length, and moving conferences later in the day. Additional studies are needed to understand how these changes impact learning.

Comparison of analogue and electronic stethoscopes for pulmonary auscultation by internal medicine residents.

BACKGROUND: Electronic stethoscopes are becoming more common in clinical practice. They may improve the accuracy and efficiency of pulmonary auscultation, but the data to support their benefit are limited. OBJECTIVE: To determine how auscultation with an electronic stethoscope may affect clinical decision making. METHODS: An online module consisting of six fictional ambulatory cases was developed. Each case included a brief history and lung sounds recorded with an analogue and electronic stethoscope. Internal medicine resident participants were randomly selected to hear either the analogue or electronic lung sounds. Numbers of correct answers, time spent on each case and numbers of times the recordings were played were compared between the groups who heard each mode of auscultation, with a p value of less than 0.05 indicating statistical significance. RESULTS: 61 internal medicine residents completed at least one case, and 41 residents completed all six cases. There were no significant differences in overall scores between participants who heard analogue and electronic lung sounds (3.14±0.10 out of 6 correct for analogue, 3.20±0.10 out of 6 for electronic, p=0.74). There were no significant differences in performance for any of the six cases (p=0.78), time spent on the cases (p=0.67) or numbers of times the recordings were played (p=0.85). CONCLUSION: When lung sounds were amplified with an electronic stethoscope, we did not detect an effect on performance, time spent on the cases or numbers of times participants listened to the recordings.

Resident duty hours: a survey of internal medicine program directors.

INTRODUCTION: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new Common Program Requirements to regulate duty hours of resident physicians, with three goals: improved patient safety, quality of resident education and quality of life for trainees. We sought to assess Internal Medicine program director (IMPD) perceptions of the 2011 Common Program Requirements in July 2012, one year following implementation of the new standards. METHODS: A cross-sectional study of all IMPDs at ACGME-accredited programs in the United States (N = 381) was performed using a 32-question, self-administered survey. Contact information was identified for 323 IMPDs. Three individualized emails were sent to each director over a 6-week period, requesting participation in the survey. Outcomes measured included approval of duty hours regulations, as well as perceptions of changes in graduate medical education and patient care resulting from the revised ACGME standards. RESULTS: A total of 237 surveys were returned (73% response rate). More than half of the IMPDs (52%) reported "overall" approval of the 2011 duty hour regulations, with greater than 70% approval of all individual regulations except senior resident daily duty periods (49% approval) and 16-hour intern shifts (17% approval). Although a majority feel resident quality of life has improved (55%), most IMPDs believe that resident education (60%) is worse. A minority report that quality (8%) or safety (11%) of patient care has improved. CONCLUSION: One year after implementation of new ACGME duty hour requirements, IMPDs report overall approval of the standards, but strong disapproval of 16-hour shift limits for interns. Few program directors perceive that the duty hour restrictions have resulted in better care for patients or education of residents. Although resident quality of life seems improved, most IMPDs report that their own workload has increased. Based on these results, the intended benefits of duty hour regulations may not yet have been realized.

How to Build It So They'll Come: Faculty Opinion on Faculty Development.

BACKGROUND: Residents report low satisfaction with faculty evaluation and feedback. To improve skills, successful faculty development interventions must be accessible and acceptable. METHODS: A faculty development survey was admin- istered to 145 specialty and non-specialty Internal Medicine faculty at the Warren Alpert Medical School of Brown University, Providence, RI. Analyses assessed demographics, opinion regarding evaluation and feedback and interest in faculty development. RESULTS: Only 70% of faculty were satisfied with their evaluation ability and only 59% were satisfied with their feedback skills. Despite this, 32% had limited interest in faculty development. Non-specialty faculty were more interested than subspecialty faculty, p-value=0.02. Faculty preferred short electronic audio slideshows and 38% reported participation barriers. CONCLUSIONS: Although faculty report evaluation and feedback are important skills, not all were satisfied with their abilities. Subspecialty faculty were less interested than non-specialty in faculty development. Our findings suggest that more effective ways to engage faculty in the process of faculty development are needed.

Perioperative care of the patient with hip fracture.

Primary care physicians can intervene to reduce perioperative complications due to comorbid medical illness in patients hospitalized with hip fracture. We review the role of the primary care physician in the treatment and prevention of perioperative morbidity and mortality.

Diagnosing and managing post menopausal osteoporosis: opportunities for fracture prevention.

Osteoporosis is an asymptomatic disease until a fracture occurs. Management includes primary prevention, early detection through targeted screening, and implementation of appropriate treatment and monitoring strategies. This article explores these issues in depth.

Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation.

INTRODUCTION: High-fidelity medical simulation of sudden cardiac arrest (SCA) presents an opportunity for systematic probing of in-hospital resuscitation systems. Investigators developed and implemented the SimCode program to evaluate simulation's ability to generate meaningful data for system safety analysis and determine concordance of observed results with institutional quality data. METHODS: Resuscitation response performance data were collected during in situ SCA simulations on hospital medical floors. SimCode dataset was compared with chart review-based dataset of actual (live) in-hospital resuscitation system performance for SCA events of similar acuity and complexity. RESULTS: 135 hospital personnel participated in nine SimCode resuscitations between 2006 and 2008. Resuscitation teams arrived at 2.5+/-1.3 min (mean+/-SD) after resuscitation initiation, started bag-valve-mask ventilation by 2.8+/-0.5 min, and completed endotracheal intubations at 11.3+/-4.0 min. CPR was performed within 3.1+/-2.3 min; arrhythmia recognition occurred by 4.9+/-2.1 min, defibrillation at 6.8+/-2.4 min. Chart review data for 168 live in-hospital SCA events during a contemporaneous period were extracted from institutional database. CPR and defibrillation occurred later during SimCodes than reported by chart review, i.e., live: 0.9+/-2.3 min (p<0.01) and 2.1+/-4.1 min (p<0.01), respectively. Chart review noted fewer problems with CPR performance (simulated: 43% proper CPR vs. live: 98%, p<0.01). Potential causes of discrepancies between resuscitation response datasets included sample size and data limitations, simulation fidelity, unmatched SCA scenario pools, and dissimilar determination of SCA response performance by complementary reviewing methodologies. CONCLUSION: On-site simulations successfully generated SCA response measurements for comparison with live resuscitation chart review data. Continued research may refine simulation's role in quality initiatives, clarify methodologic discrepancies and improve SCA response.

Diagnostic evaluation of mononucleosis-like illnesses.

Clinicians face a diagnostic challenge when a patient with the classic fever, pharyngitis, and lymphadenopathy triad of infectious mononucleosis has a negative "spot" heterophile antibody test. This screening test, although commonly considered sensitive for the presence of Epstein-Barr virus (EBV) infection, may be negative early after infection. A growing number of pathogens have been reported to cause heterophile-negative mononucleosis-like illnesses, including cytomegalovirus (CMV), human herpesvirus 6 (HHV-6), human immunodeficiency virus (HIV), adenovirus, herpes simplex virus (HSV), Streptococcus pyogenes, and Toxoplasma gondii. Other infectious and noninfectious disorders also may present in ways that mimic mononucleosis, but fail to generate EBV's archetypal triad of clinical findings. A systematic approach to the diagnosis of mononucleosis-like illnesses ensures that conditions warranting specific therapy are distinguished from others requiring only supportive care.

Early scurvy complicating anorexia nervosa.

Scurvy is an extremely rare complication of anorexia nervosa. Despite the poor intake of nutrients, anorexia nervosa is not commonly associated with vitamin deficiencies. We report a case of early scurvy complicating long-standing anorexia nervosa. Anorexia nervosa appears to be increasing in incidence. Although scurvy is unusual, this case shows the importance of its recognition as a nutritional consequence of anorexia nervosa.