[Messages from the estates general on French internal medicine]. / Que retenir des états généraux de la médecine interne française ?

Internal medicine is a medical specialty that is often poorly understood by the general public and sometimes misidentified. In an era of increasing subspecialization and high technicality, it is characterized by a comprehensive approach centered on clinical evaluation. Unlike what is observed in most developed countries, where systemic autoimmune diseases are managed by organ specialists based on their mode of presentation, French internists are at the forefront for diagnosing and managing these diseases. Their multidisciplinary training gives them legitimacy to justify this role. Internists also play a crucial role in the management of patients requiring unplanned hospitalizations downstream from emergency departments and in connection with primary care. Internists primarily practice in a hospital setting, with a specific position in the French healthcare system aligned with the training frameworks of all medical specialties. To better define internal medicine, its role in care activities, as well as in education and research, internists organized a General Assembly of internal medicine that took place on September 28, 2023, in Paris. Structured around think tanks focusing on care, education, and research activities, the general assembly aimed to improve visibility on internal medicine and internists. This article recounts the discussions that animated this meeting and highlights the main ideas that emerged. These general assemblies constitute a foundational step and will be followed by a Consultation Conference in order to better identify and promote internal medicine and internists, regardless of their types and places of practice.

USMLE step 1 and step 2 CK as indicators of resident performance.

BACKGROUND: The purpose of this systematic review was to (1) determine the scope of literature measuring USMLE Step 1 and Step 2 CK as predictors or indicators of quality resident performance across all medical specialties and (2) summarize the ability of Step 1 and Step 2 CK to predict quality resident performance, stratified by ACGME specialties, based on available literature. METHODS: This systematic review was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [16]. The original search strategy surveyed MEDLINE and was adapted to survey Cochrane Library and Embase. A study was deemed eligible if it provided all three of the following relevant information: (a) Step 1 or Step 2 CK as indicators for (b) resident outcomes in (c) any ACGME accredited specialty training program. RESULTS: A total of 1803 articles were screened from three separate databases. The 92 included studies were stratified by specialty, with Surgery (21.7% [20/92]), Emergency Medicine (13.0% [12/92]), Internal Medicine (10.9% [10/92]), and Orthopedic Surgery (8.7% [8/92]) being the most common. Common resident performance measures included ITE scores, board certification, ACGME milestone ratings, and program director evaluations. CONCLUSIONS: Further studies are imperative to discern the utility of Step 1 and Step 2 CK as predictors of resident performance and as tools for resident recruitment and selection. The results of this systematic review suggest that a scored Step 1 dated prior to January 2022 can be useful as a tool in a holistic review of future resident performance, and that Step 2 CK score performance may be an effective tool in the holistic review process. Given its inherent complexity, multiple tools across many assessment modalities are necessary to assess resident performance comprehensively and effectively.

Using Natural Language Processing and Machine Learning to Identify Internal Medicine-Pediatrics Residency Values in Applications.

PROBLEM: Although holistic review has been used successfully in some residency programs to decrease bias, such review is time-consuming and unsustainable for many programs without initial prescreening. The unstructured qualitative data in residency applications, including notable experiences, letters of recommendation, personal statement, and medical student performance evaluations, require extensive time, resources, and metrics to evaluate; therefore, previous applicant screening relied heavily on quantitative metrics, which can be socioeconomically and racially biased. APPROACH: Using residency applications to the University of Utah internal medicine-pediatrics program from 2015 to 2019, the authors extracted relevant snippets of text from the narrative sections of applications. Expert reviewers annotated these snippets into specific values (academic strength; intellectual curiosity; compassion; communication; work ethic; teamwork; leadership; self-awareness; diversity, equity, and inclusion; professionalism; and adaptability) previously identified as associated with resident success. The authors prospectively applied a machine learning model (MLM) to snippets from applications from 2023, and output was compared with a manual holistic review performed without knowledge of MLM results. OUTCOMES: Overall, the MLM had a sensitivity of 0.64, specificity of 0.97, positive predictive value of 0.62, negative predictive value of 0.97, and F1 score of 0.63. The mean (SD) total number of annotations per application was significantly correlated with invited for interview status (invited: 208.6 [59.1]; not invited: 145.2 [57.2]; P < .001). In addition, 8 of the 10 individual values were significantly predictive of an applicant's invited for interview status. NEXT STEPS: The authors created an MLM that can identify several values important for resident success in internal medicine-pediatrics programs with moderate sensitivity and high specificity. The authors will continue to refine the MLM by increasing the number of annotations, exploring parameter tuning and feature engineering options, and identifying which application sections have the highest correlation with invited for interview status.

Challenges in the transition from resident to attending physician in general internal medicine: a multicenter qualitative study.

BACKGROUND: The attending physician in general internal medicine (GIM) guarantees comprehensive care for persons with complex and/or multiple diseases. Attendings from other medical specialties often report that transitioning from resident to attending is burdensome and stressful. We set out to identify the specific challenges of newly appointed attendings in GIM and identify measures that help residents better prepare to meet these challenges. METHODS: We explored the perceptions of 35 residents, attendings, and department heads in GIM through focus group discussions and semi-structured interviews. We took a thematic approach to qualitatively analyze this data. RESULTS: Our analysis revealed four key challenges: 1) Embracing a holistic, patient centered perspective in a multidisciplinary environment; 2) Decision making under conditions of uncertainty; 3) Balancing the need for patient safety with the need to foster a learning environment for residents; and 4) Taking on a leader's role and orchestrating an interprofessional team of health care professionals. Newly appointed attendings required extensive practical experience to adapt to their new roles. Most attendings did not receive regular, structured, professional coaching during their transition, but those who did found it very helpful. CONCLUSIONS: Newly appointed attending physician in GIM face a number of critical challenges that are in part specific to the field of GIM. Further studies should investigate whether the availability of a mentor as well as conscious assignment of a series of increasingly complex tasks during residency by clinical supervisors will facilitate the transition from resident to attending.

Spirituality and religion in residents and inter-relationships with clinical practice and residency training: a scoping review.

OBJECTIVES: With the increased emphasis on personalised, patient-centred care, there is now greater acceptance and expectation for the physician to address issues related to spirituality and religion (SR) during clinical consultations with patients. In light of the clinical need to improve SR-related training in residency, this review sought to examine the extant literature on the attitudes of residents regarding SR during residency training, impact on clinical care and psychological well-being of residents and SR-related curriculum implemented within various residency programmes. DESIGN: A scoping review was conducted on studies examining the topic of SR within residency training up until July 2020 on PubMed/Medline and Web of Science databases. Keywords for the literature search included: (Spirituality OR Religion) AND (Residen* OR "Postgraduate Medicine" OR "Post-graduate Medicine" OR "Graduate Medical Education"). RESULTS: Overall, 44 studies were included. The majority were conducted in North America (95.5%) predominantly within family medicine (29.5%), psychiatry (29.5%) and internal medicine (25%) residency programmes. While residents held positive attitudes about the role of SR and impact on patient care (such as better therapeutic relationship, treatment adherence and coping with illness), they often lacked the knowledge and skills to address these issues. Better spiritual well-being of residents was associated with greater sense of work accomplishment, overall self-rated health, decreased burnout and depressive symptoms. SR-related curricula varied from standalone workshops to continuous modules across the training years. CONCLUSIONS: These findings suggest a need to better integrate appropriate SR-related education within residency training. Better engagement of the residents through different pedagogical strategies with supervision, feedback, reflective practice and ongoing faculty and peer support can enhance learning about SR in clinical care. Future studies should identify barriers to SR-related training and evaluate the outcomes of these SR-related curriculum including how they impact the well-being of patients and residents over time.

Mission-Based Filters in the Electronic Residency Application Service: Saving Time and Promoting Diversity.

BACKGROUND: Holistic review promotes diversity, but widespread implementation remains limited. OBJECTIVE: We aimed to develop a practical approach to incorporate holistic review principles in screening applicants in the Electronic Residency Application Service (ERAS) and to assess the impact on diversity. METHODS: Three residency programs (internal medicine [IM], pediatrics, and surgery) at McGovern Medical School developed filters to identify applicants with experiences/attributes aligned with the institutional mission. These filters were retroactively applied to each program's 2019-2020 applicant pool using built-in ERAS capabilities to group applicants by user-defined features. We compared the demographics of applicants reviewed during the cycle with those identified retrospectively through experiences/attributes filters. RESULTS: The IM, pediatrics, and surgery programs received 3527, 1341, and 1313 applications, respectively, in 2019-2020. Retrospective use of experiences/attributes filters, without scores, narrowed the IM applicant pool for review to 1301 compared to 1323 applicants reviewed during actual recruitment, while the pediatrics filters identified 514 applicants compared to 384 at baseline. The surgery filters resulted in 582 applicants, but data were missing for baseline comparison. Compared to the baseline screening approach utilizing scores, mission-based filters increased the proportions of underrepresented in medicine applicants selected for review in IM (54.8% [95% CI 52.1-57.5] vs 22.7% [20.4-24.9], P < .0001) and pediatrics (63.2% [95% CI 59.1-67.4] vs 25.3% [20.9-29.6], P < .0001). CONCLUSIONS: Program directors can leverage existing ERAS features to conduct application screening in alignment with holistic review principles. Widespread implementation could have important repercussions for enhancing physician workforce diversity.

A Cautionary Tale: The 2019 Orphaning of Hahnemann's Graduate Medical Trainees.

Hahnemann University Hospital provided care for Philadelphians starting in 1848, but its recent history has been riddled with financial turmoil that culminated in its rapid closure in summer 2019. As the hospital shuttered its doors to patients, it also orphaned 583 medical trainees. This crisis exposed vulnerabilities in graduate medical education (GME). In a firsthand account of the situation that developed in Philadelphia and reached academic institutions across the country, the authors reflect on lessons learned that may help leaders at other institutions mitigate the inevitable difficulties that arise when academic hospitals close. These lessons pertain to handling panic and administrative burdens in the aftermath of closure, the importance of well-defined processes, a clear understanding of GME funding, and strategies for placement of trainees that minimize disruption of their education.

Assessing mentoring: A scoping review of mentoring assessment tools in internal medicine between 1990 and 2019.

BACKGROUND: Mentoring's success in enhancing a mentee's professional and personal development, and a host organisations' reputation has been called into question, amidst a lack of effective tools to evaluate mentoring relationships and guide oversight of mentoring programs. A scoping review is proposed to map available literature on mentoring assessment tools in Internal Medicine to guide design of new tools. OBJECTIVE: The review aims to explore how novice mentoring is assessed in Internal Medicine, including the domains assessed, and the strengths and limitations of the assessment methods. METHODS: Guided by Levac et al.'s framework for scoping reviews, 12 reviewers conducted independent literature reviews of assessment tools in novice mentoring in PubMed, Embase, Scopus, ERIC, Cochrane, GreyLit, Web of Science, Open Dissertations and British Education Index databases. A 'split approach' saw research members adopting either Braun and Clarke's approach to thematic analysis or directed content analysis to independently evaluate the data and improve validity and objectivity of the findings. RESULTS: 9662 abstracts were identified, 187 full-text articles reviewed, and 54 full-text articles included. There was consensus on the themes and categories identified through the use of the split approach, which were the domains assessed and methods of assessment. CONCLUSION: Most tools fail to contend with mentoring's evolving nature and provide mere snap shots of the mentoring process largely from the mentee's perspective. The lack of holistic, longitudinal and validated assessments propagate fears that ethical issues in mentoring are poorly recognized and addressed. To this end, we forward a framework for the design of 'fit for purpose' multi-dimensional tools. PRACTICE POINTS: Most tools focus on the mentee's perspective, do not consider mentoring's evolving nature and fail to consider mentoring holistically nor longitudinallyA new tool capable of addressing these gaps must also consider inputs from all stakeholders and take a longitudinal perspective of mentoring.

Internal Medicine Residency Program Directors' Screening Practices and Perceptions About Recruitment Challenges.

PURPOSE: To examine internal medicine residency program directors' (PDs') screening practices and perceptions about current recruitment challenges. METHOD: In March-May 2017, the Association of Program Directors in Internal Medicine Survey Committee sent a survey to 373 Alliance for Academic Internal Medicine member residency programs. PDs rated the importance of 23 inclusion and 11 exclusion criteria for interview invitation decision making, provided United States Medical Licensing Examination (USMLE) cutoff scores for U.S. medical school and international medical graduates, and indicated changes in recruitment practices due to application inflation, including their ability to conduct holistic review and interest in potential solutions to address application inflation. Exploratory factor analysis was used to identify and confirm factors that were most important to interview invitation decision making. RESULTS: The response rate for eligible programs was 64% (233/363). USMLE Step 2 Clinical Knowledge scores were the criteria most frequently reported to be "very important" (131/233, 57%). Among respondents who reported any criteria as "very important," 155/222 (70%) identified a single most important (SMI) criterion. Non-USMLE criteria were frequently reported as an SMI criterion (68%). Concerning exclusion criteria, 157/231 (68%) reported they "absolutely would not invite" applicants with hints of unprofessional behavior. Of the 214/232 (92%) who reported an increase in applications, 138 (64%) adjusted recruitment practices. Respondents were most interested in limiting the number of applications per applicant (163/231, 71%), allowing applicants to indicate high interest in a subset of programs (151/229, 66%), and creating a national database of qualities of matched applicants for each program (121/228, 53%). CONCLUSIONS: PDs rely heavily on USMLE scores when making interview invitation decisions. However, collectively, non-USMLE criteria were more frequently reported as an SMI criterion. Most programs adjusted recruitment practices to respond to application volume. Several potential solutions to address application inflation garnered wide support.

A systematic scoping review of ethical issues in mentoring in internal medicine, family medicine and academic medicine.

Mentoring's role in medical education is threatened by the potential abuse of mentoring relationships. Particularly affected are mentoring relationships between senior clinicians and junior doctors which lie at the heart of mentoring. To better understand and address these concerns, a systematic scoping review into prevailing accounts of ethical issues and professional lapses in mentoring is undertaken. Arksey and O'Malley's (Int J Soc Res Methodol 8(1):19-32, 2005. https://doi.org/10.1080/1364557032000119616) methodological framework for conducting scoping reviews was employed to explore the scope of ethical concerns in mentoring in general medicine. Databases searcheed included PubMed, ScienceDirect, ERIC, Embase, Scopus, Mednar and OpenGrey. 3391 abstracts were identified from the initialy search after removal of duplicates, 412 full-text articles were reviewed, 98 articles were included and thematically analysed. Unsatisfactory matching, misaligned expectations, inadequate mentor training, cursory codes of conduct, sketchy standards of practice, meagre oversight and unstructured processes have been identified as potential causes for ethical and professional breaches in mentoring practice. Changes in how professionalism is viewed suggest further studies of educational culture should also be carried out. The host organization plays a major role in establishing codes of conduct, expectations, and holistically, longitudinally oversight of the mentoring process and mentoring relationships.

Internal Medicine Residency Program Responses to the Increase of Residency Applications: Differences by Program Type and Characteristics.

BACKGROUND: Over the past decade, the number of residency applications has increased substantially, causing many residency programs to change their recruitment practices. OBJECTIVE: We determined how internal medicine (IM) residency programs have responded to increased applications by program type (community-based, community-based/university-affiliated, and university-based) and characteristics (percentage of international medical graduates, program size, and program director [PD] tenure). METHODS: The Association of Program Directors in Internal Medicine conducted a national survey of 363 IM PDs in 2017. Five questions assessed IM program responses to the increased number of residency applications in 3 areas: changes in recruitment strategies, impact on ability to perform holistic review, and interest in 5 potential solutions. We performed a subgroup analysis to measure differences by program type and characteristics. RESULTS: The response rate was 64% (233 of 363). There were no differences by program type or characteristics for experiencing an increase in the number of applicants, altering recruitment practices, or conducting holistic reviews. There were moderate differences in alterations of recruitment practices by program characteristics and moderate differences in interest in proposed solutions by program type. Community-based programs had the greatest interest in a program-specific statement (59%, P = .032) and the lowest percentage in a national database of matched applicants (44%, P = .034). CONCLUSIONS: IM residency programs are experiencing an increasing number of applications and are accommodating by adjusting recruitment practices in a variety of ways. A majority of IM PDs supported 4 of the 5 solutions, although the level of interest differed by program type.

Bridging the Gap: Holistic Review to Increase Diversity in Graduate Medical Education.

PROBLEM: Racial and ethnic disparities in health outcomes remain pervasive in the U.S. health care system. Increasing the diversity of the physician workforce is recognized as an important component of addressing these disparities. Holistic review, which gives balanced consideration to applicants' academic metrics, experiences, and attributes, has gained popularity in undergraduate medical education and led to improvement in student diversity. Limited research has investigated how holistic review and other strategies can be implemented in graduate medical education to enhance diversity. APPROACH: The internal medicine (IM) residency program of the John P. and Kathrine G. McGovern Medical School implemented a pilot intervention in academic years (AY) 2016-2017 and 2017-2018 aimed at increasing the number of matriculating residents who are underrepresented in medicine (URM). The intervention included (1) using holistic review in the process of selecting applicants for interview, (2) standardizing the interview encounters, and (3) explicitly highlighting the program's commitment to diversity on interview days. OUTCOMES: From AY 2015-2016 (preintervention) to AY 2017-2018, the percentage of URM applications reviewed increased from 14.1% (180/1,276) to 20.4% (183/897), the proportion of URM applicants interviewed rose from 16.0% (60/374) to 24.5% (95/388), and the proportion of URM residents matriculating increased from 12.5% (5/40) to 31.7% (13/41). NEXT STEPS: Further efforts are needed to expand the pool of URM applicants at McGovern and elsewhere and to identify how holistic review can be widely employed in other IM residency programs and in other specialties.

Innovation in Residency Selection: The AAMC Standardized Video Interview.

PURPOSE: Innovative tools are needed to shift residency selection toward a more holistic process that balances academic achievement with other competencies important for success in residency. The authors evaluated the feasibility of the AAMC Standardized Video Interview (SVI) and evidence of the validity of SVI total scores. METHOD: The SVI, developed by the Association of American Medical Colleges, consists of six questions designed to assess applicants' interpersonal and communication skills and knowledge of professionalism. Study 1 was conducted in 2016 for research purposes. Study 2 was an operational pilot administration in 2017; SVI data were available for use in residency selection by emergency medicine programs for the 2018 application cycle. Descriptive statistics, correlations, and standardized mean differences were used to examine data. RESULTS: Study 1 included 855 applicants; Study 2 included 3,532 applicants. SVI total scores were relatively normally distributed. There were small correlations between SVI total scores and United States Medical Licensing Examination Step exam scores, Alpha Omega Alpha Honor Medical Society membership, and Gold Humanism Honor Society membership. There were no-to-small group differences in SVI total scores by gender and race/ethnicity, and small-to-medium differences by applicant type. CONCLUSIONS: Findings provide initial evidence of the validity of SVI total scores and suggest that these scores provide different information than academic metrics. Use of the SVI, as part of a holistic screening process, may help program directors widen the pool of applicants invited to in-person interviews and may signal that programs value interpersonal and communication skills and professionalism.

El trabajo en equipo y método clínico / Team work on clinical method

Uno de los propósitos de la Sociedad Cubana de Medicina Interna es juntar voluntades con fines investigativos entre varios internistas interesados en el tema de método clínico. Sobre este tema se escribe mucho a lo largo del país. En cada provincia existen líderes de opinión y la búsqueda en la web está orientada a artículos relacionados con el proceso de atención médica, proceso del diagnóstico, método clínico y toma de decisiones clínica. En relación con el valor que tiene abordar estos temas asociados a problemas que impactan el trabajo asistencial y la educación médica, este intento de aunar artículos que reflejen el quehacer teórico de internistas en el país es, sin duda, un paso positivo. Sobre estos aspectos existen otras compilaciones como los números de revistas, discos compactos, libros y destacados autores en el país, dentro...(AU)

Women's Health Curricula in Internal Medicine Residency Programs: A Scoping Review.

Background: Despite national efforts to expand women's health education, internal medicine (IM) residents remain unprepared to provide comprehensive care to women. The objectives of this scoping review are to provide an overview of published women's health curricula in IM residency programs and to identify potential areas for improvement. Materials and Methods: Studies were identified using PubMed, Embase, Cochrane Library, Scopus, Education Resources Information Center (ERIC), Web of Science, and MedEdPORTAL. Inclusion criteria included the following: (1) women's health as defined by the authors (2) description of a curriculum (3) designed for IM residents (4) based in North America, and (5) published between 1998 and 2018. Data abstracted included content, educational and assessment methods, and quality. Descriptive analysis was used to compare data. Results: Sixteen articles met the inclusion criteria. The most common women's health topics were intimate partner violence (31%) and menopause (31%). Twelve curricula (75%) were implemented in the outpatient setting. Of the teaching methods, didactics (69%) and in-clinic teaching (44%) were most commonly used. All studies that assessed attitudes, knowledge, and/or behavior showed an improvement post-intervention. No studies evaluated patient outcomes. Conclusion: To our knowledge, this is the first review summarizing published women's health curricula in IM residency. There were a limited number of published articles describing women's health curricula. Although content varied, the curricula were effective in improving attitudes, knowledge, and/or behavior with regard to women's health topics. We encourage IM residency programs to develop and disseminate women's health curricula to inform future improvements and advancements in women's health education.

X + Y = Time for QI: Meaningful Engagement of Residents in Quality Improvement During the Ambulatory Block.

BACKGROUND: Meaningful resident engagement in quality improvement (QI) remains challenging. Barriers include a lack of time and of faculty with QI expertise. We leveraged our internal medicine (IM) residency program's adoption of an "X" (inpatient rotations) plus "Y" (ambulatory block) schedule to implement a QI curriculum for all residents during their ambulatory block. OBJECTIVE: We sought to engage residents in interprofessional QI, improve residents' QI confidence and knowledge and application to practice, and create opportunities for QI scholarship. METHODS: In July 2015, the program provided dedicated time for QI in the ambulatory block. All categorical IM residents and 11 voluntary faculty mentors were divided into 10 teams based on clinic site and "Y" block schedule. Teams participated in resident-led, interprofessional ambulatory QI projects. Resident QI knowledge and confidence were assessed before the curriculum and 11 months after using the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and surveys. QI project implementation and scholarship were tracked. RESULTS: All categorical residents (N = 81) participated. Residents reported increased confidence in all QI skills, and they demonstrated increased knowledge, with mean QIKAT-R paired scores improving from 15.8 ± 4.6 to 19.1 ± 5.9 (n = 45 pairs, P < .001). A total of 9 of 10 teams implemented process changes, and 6 team project improvements have been sustained. CONCLUSIONS: This ongoing curriculum engaged IM and IM-psychiatry residents in QI during their ambulatory block using volunteer clinic faculty mentors. Residents demonstrated improved QI confidence and knowledge. The majority of resident projects were sustained and generated scholarship.

A Qualitative Analysis of Stress and Relaxation Themes Contributing to Burnout in First-Year Psychiatry and Medicine Residents.

OBJECTIVE: Qualitative research on trainee well-being can add nuance to the understanding of propagators of burnout, and the role for interventions aimed at supporting well-being. This qualitative study was conducted to identify (i) situations and environments that cause stress for trainees, (ii) stress-reducing activities that trainees utilize, and (iii) whether trainees who report distress (high burnout and depression scores) describe different stressors and relaxation factors than those who do not. METHODS: The study was conducted with a convenience sample of first-year medicine and psychiatry residents at a large urban teaching hospital. Participants were asked to complete electronic stress and relaxation diaries daily for 1 week. Diary entries were coded for recurrent themes. Participants were screened for burnout and depression. Codes were compared by subgroup based on baseline burnout and depression status to elucidate if specific themes emerged in these subgroups. RESULTS: Study sample included 51 interns. Sixteen (16/50, 32%) screened positive for burnout and three (3/50, 14%) had a positive depression screen. The most common stressors related to aspects of the learning environment, compounded by feeling under-equipped, overwhelmed, or out of time. The majority of relaxation activities involved social connection, food, other comforts, and occurred outside of the hospital environment. CONCLUSIONS: This study reveals that interns (regardless of burnout or depression screen) identify stressors that derive primarily from organizational, interpersonal, and cultural experiences of the learning environment; whereas relaxation themes are diversely represented across realms (home, leisure, social, health), though emphasize activities that occur outside of the work place.