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.

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.

Impact of 4 + 1 block scheduling on patient care continuity in resident clinic.

BACKGROUND: Leaders in medical education have called for redesign of internal medicine training to improve ambulatory care training. 4 + 1 block scheduling is one innovative approach to enhance ambulatory education. AIM: To determine the impact of 4 + 1 scheduling on resident clinic continuity. SETTING: Resident continuity clinic in traditional scheduling in which clinics are scheduled intermittently one-half day per week, compared to 4 + 1 in which residents alternate 1 week of clinic with 4 weeks of an inpatient rotation or elective. PARTICIPANTS: First-year internal medicine residents. PROGRAM DESCRIPTION: We measured patient-provider visit continuity, phone triage encounter continuity, and lab follow-up continuity. PROGRAM EVALUATION: In traditional scheduling as opposed to 4 + 1 scheduling, patients saw their primary resident provider a greater percentage; 71.7% vs. 63.0% (p = 0.008). In the 4 + 1 model, residents saw their own patients a greater percentage; 52.1% vs. 37.1% (p = 0.0001). Residents addressed their own labs more often in 4 + 1 model; 90.7% vs. 75.6% (p = 0.001). There was no significant difference in handling of triage encounters; 42.3% vs. 35.8% (p = 0.12). DISCUSSION: 4 + 1 schedule improves visit continuity from a resident perspective, and may compromise visit continuity from the patient perspective, but allows for improved laboratory follow-up, which we pose should be part of an emerging modern definition of continuity.

Resident Burnout, Wellness, Professional Development, and Engagement Before and After New Training Schedule Implementation.

Importance: Burnout is a work-related syndrome of depersonalization (DP), emotional exhaustion (EE), and low personal achievement (PA) that is prevalent among internal medicine resident trainees. Prior interventions have had modest effects on resident burnout. The association of a new 4 + 4 block schedule (4 inpatient weeks plus 4 outpatient weeks) with resident burnout has not previously been evaluated. Objective: To evaluate the association of a 4 + 4 block schedule, compared with a 4 + 1 schedule, with burnout, wellness, and self-reported professional engagement and clinical preparedness among resident physicians. Design, Setting, and Participants: This nonrandomized preintervention and postintervention survey study was conducted in a single academic-based internal medicine residency program from June 2019 to June 2021. The study included residents in the categorical, hospitalist, and primary care tracks in postgraduate years 1 and 2 (PGY1 and PGY2). Data analysis was conducted from October to December 2022. Intervention: In the 4 + 4 structure, resident schedules alternated between 4-week inpatient call-based rotations and 4-week ambulatory non-call-based rotations. Main Outcomes and Measures: The primary outcome was burnout, assessed using the Maslach Burnout Inventory subcategories of EE (range, 0-54), DP (range, 0-30), and PA (range, 0-48), adjusted for sex and PGY. Secondary outcomes included In-Training Examination (ITE) scores and a questionnaire on professional, educational, and health outcomes. Multivariable logistic regression was used to assess the primary outcome, 1-way analysis of variance was used to compare ITE percentiles, and a Bonferroni-adjusted Kruskal Wallis test was used for the remaining secondary outcomes. The findings were reexamined with several sensitivity analyses, and Cohen's D was used to estimate standardized mean differences (SMDs). Results: Of the 313 eligible residents, 216 completed the surveys. A total of 107 respondents (49.5%) were women and 109 (50.5%) were men; 119 (55.1%) were PGY1 residents. The survey response rates were 78.0% (85 of 109) in the preintervention cohort and 60.6% (63 of 104) and 68.0% (68 of 100) in the 2 postintervention cohorts. The PGY1 residents had higher response rates than the PGY2 residents (119 of 152 [78.2%] vs 97 of 161 [60.2%]; P < .001). Adjusted EE scores (mean difference [MD], -6.78 [95% CI, -9.24 to -4.32]) and adjusted DP scores (MD, -3.81 [95% CI, -5.29 to -2.34]) were lower in the combined postintervention cohort. The change in PA scores was not statistically significant (MD, 1.4 [95% CI, -0.49 to 3.29]). Of the 15 items exploring professional, educational, and health outcomes, a large positive association was observed for 11 items (SMDs >1.0). No statistically significant change in ITE percentile ranks was noted. Conclusions and Relevance: In this survey study of internal medicine resident physicians, a positive association was observed between a 4 + 4 block training schedule and internal medicine resident burnout scores and improved self-reported professional, educational, and health outcomes. These results suggest that specific 4 + 4 block combinations may better improve resident burnout than a 4 + 1 combination used previously.

Removing Barriers: A Confidential Opt-Out Mental Health Pilot Program for Internal Medicine Interns.

PROBLEM: There are significant barriers for resident physicians seeking mental health care, including lack of time, cost, and concerns about confidentiality. The authors sought to improve access to mental health resources by addressing these barriers through the development of a confidential opt-out mental health pilot program for interns and to assess the feasibility, acceptability, and resident satisfaction with the program. APPROACH: All internal medicine and internal medicine-pediatrics interns in the 2017-2018 residency class at the University of Colorado were enrolled in the confidential opt-out mental health program. Each intern was provided with an additional half-day off during their continuity clinic week, during which a mental health screening appointment at the campus health center with an in-network mental health provider was scheduled. All costs were covered by the residency program. An anonymous follow-up survey was sent to all interns to assess participation in the program and its perceived impact on their wellness. OUTCOMES: Appointments were made for 80 interns: 23 (29%) attended the appointment, 45 (56%) opted out in advance, and 12 (15%) were no-shows. The total cost of the program was $940 or $11.75 per intern. Of the 41 interns who responded to the survey, 35 (85%) agreed the program should continue next year. The majority of interns felt the program positively affected their wellness regardless of whether they attended the appointment. Of the 16 interns who attended the appointment and completed the survey, 4 (25%) reported receiving additional mental health referrals or follow-up appointments. NEXT STEPS: This confidential opt-out mental health pilot program for interns was feasible, relatively low cost and simple to implement, and had positive impacts on self-reported wellness. Further study of interventions that remove barriers to accessing mental health care for residents is urgently needed.

Training internal medicine residents in outpatient HIV care: a survey of program Directors.

BACKGROUND: The care of patients with HIV is increasingly focused on outpatient chronic disease management. It is not known to what extent internal medicine residents in the US are currently being trained in or encouraged to provide primary care for this population of patients. OBJECTIVE: To survey internal medicine residency program directors about their attitudes regarding training in outpatient HIV care and current program practices. DESIGN: Program directors were surveyed first by email. Non-responding programs were mailed up to two copies of the survey. SUBJECTS: All internal medicine residency program directors in the US. MAIN MEASURES: Program director attitudes and residency descriptions. KEY RESULTS: Of the 372 program directors surveyed, 230 responded (61.8 %). Forty-two percent of program directors agreed that it is important to train residents to be primary care providers for patients with HIV. Teaching outpatient-based HIV curricula was a priority for 45.1%, and 56.5% reported that exposing residents to outpatient HIV clinical care was a high priority. Only 46.5% of programs offer a dedicated rotation in outpatient HIV care, and 50.5% of programs have curricula in place to teach about outpatient HIV care. Only 18.8% of program directors believed their graduates had the skills to be primary providers for patients with HIV, and 70.6% reported that residents interested in providing care for patients with HIV pursued ID fellowships. The strongest reasons cited for limited HIV training during residency were beliefs that patients with HIV prefer to be seen and receive better care in ID clinics compared to general medicine clinics. CONCLUSIONS: With a looming HIV workforce shortage, we believe that internal medicine programs should create educational experiences that will provide their residents with the skills and knowledge necessary to meet the healthcare needs of this population.

The dilemma of disclosure: patient perspectives on gay and lesbian providers.

BACKGROUND: Discrimination toward gay and lesbian patients by health care providers has been documented. No study has determined if patient behavior would change when seeing a gay/lesbian provider. OBJECTIVE: The objective of the study was to examine whether a provider's sexual orientation would affect the choice of provider, practice, or preference for a chaperone during genital exams. DESIGN: The design of the study was an anonymous, cross-sectional survey. PARTICIPANTS: The participants were a random national sample of persons 18 years or older residing in the USA able to read English. MEASUREMENTS: The measurements were self-reported perceptions and chaperone preference based on provider gender and sexual orientation. RESULTS: The response rate was 32% (n = 502). Many respondents indicated they would change providers upon finding out their provider was gay/lesbian (30.4%) or change practices if gay/lesbian providers were employed there (35.4%). Female respondents preferred chaperones most with heterosexual male providers (adjusted odds ratio [OR] 1.50, 95% confidence interval [CI] = 1.15 to 1.95) followed by homosexual male (OR 1.17, 95% CI = 0.93 to 1.47), lesbian (reference), and heterosexual female providers (OR 0.63, 95% CI = 0.51 to 0.77). Male respondents showed an increased preference for chaperones with gay/lesbian providers of either gender (OR 1.52, 95%, CI = 1.22 to 1.90, for gay male provider, [reference] for lesbian provider) than with either heterosexual male (OR 0.36, 95% CI = 0.26 to 0.52) or heterosexual female providers (OR 0.39, 95% CI = 0.29 to 0.54). CONCLUSIONS: Patients may change providers, practices, or desire for chaperone based on a provider's gender and sexual orientation. Although the low response rate may limit generalizability, these findings have the potential to impact aspects of practice structure including chaperone use and provider-patient relationships.

Heart rate recovery predicts mortality and cardiovascular events in patients with type 2 diabetes.

PURPOSE: Heart rate recovery (HRR) immediately after peak exercise has utility as a predictor of all-cause mortality. However, a prognostic role for HRR has not been specifically evaluated in patients with type 2 diabetes mellitus (T2DM), nor has an association between HRR and cardiovascular (CV) events been documented. This study investigated whether HRR is predictive of all-cause mortality, CV mortality, and CV events in asymptomatic patients with T2DM. METHODS: HRR in subjects with T2DM was obtained via chart review of peak exercise treadmill tests (N = 890) performed at entry into the Appropriate Blood Pressure Control in Diabetes trial. Survival analysis was used to test the association of 1- and 2-min HRR with all-cause mortality, CV mortality, and CV events during the follow-up period. RESULTS: Subjects were followed for a median of 5.0 yr. All-cause mortality and CV events were significantly greater among the lowest quintile (< 12 bpm) of 1-min HRR compared with the fourth (23-28 bpm) quintile. Similarly all-cause mortality and CV events were significantly greater among the lowest quintile (< 28 bpm) of 2-min HRR compared with the third quintile (37-42 bpm) quintile. After adjustment for traditional cardiac risk factors, attenuated 1- and 2-min HRR remained significantly associated with increased risk of CV events as compared with those without attenuation. CONCLUSIONS: HRR provides information beyond traditional CV risk factors that could aid in the clinical risk stratification of patients with T2DM. The results suggest that HRR results should be incorporated into standard diagnostic treadmill testing reports and target those patients with T2DM and attenuated HRR who can benefit from directed therapies.

Postinterview Communications: Two Surveys of Internal Medicine Residency Program Directors Before and After Guideline Implementation.

PURPOSE: Guidelines surrounding postinterview communication (PIC) after residency interviews were issued by the National Resident Matching Program and Association of Program Directors in Internal Medicine. How they have influenced PIC and program directors' (PDs') reasons for PIC is unknown. METHOD: Annual surveys of 365 U.S. internal medicine residency PDs in 2013 and 368 in 2015 were used. Questions about frequency, intent, and usefulness of PIC and knowledge of guidelines before and after new PIC guidelines were included. Chi-square tests were used to compare data sets, and multivariate logistic regression was performed for 2015 data to identify factors predicting engagement in PIC, using program characteristics, PD characteristics, and beliefs about the benefits of PIC as independent variables. RESULTS: There were 265 (73%) respondents in 2013 and 227 (62%) in 2015. While the number of programs with a PIC policy increased 43%, the level of contact increased 7%. Few PDs indicated PIC was helpful to them; however, PDs who felt PIC helps target applicants were more likely to engage in PIC (OR 4.21, SE 1.88, P = .001). The main reason for continuing PIC (50% of PDs) was that PIC, part of their program's culture, was considered "good manners." CONCLUSIONS: New guidelines increased the number of programs with a PIC policy, but the overall rate of applicant contact did not change despite few PDs feeling PIC was helpful to recruitment. The culture surrounding PIC may be difficult to overcome via guidelines alone, and more definitive rules are necessary to implement change.

US Internal Medicine Program Director Perceptions of Alignment of Graduate Medical Education and Institutional Resources for Engaging Residents in Quality and Safety.

Alignment between institutions and graduate medical education (GME) regarding quality and safety initiatives (QI) has not been measured. The objective was to determine US internal medicine residency program directors' (IM PDs) perceived resourcing for QI and alignment between GME and their institutions. A national survey of IM PDs was conducted in the Fall of 2013. Multivariable linear regression was used to test association between a novel Integration Score (IS) measuring alignment between GME and the institution via PD perceptions. The response rate was 72.6% (265/365). According to PDs, residents were highly engaged in QI (82%), but adequate funding (14%) and support personnel (37% to 61%) were lower. Higher IS correlated to reports of funding for QI (76.3% vs 54.5%, P = .012), QI personnel (67.3% vs 41.1%, P < .001), research experts (70.5% vs 50.0%, P < .001), and computer experts (69.0% vs 45.8%, P < .001) for QI assistance. Apparent mismatch between GME and institutional resources exists, and the IS may be useful in measuring GME-institutional leadership alignment in QI.

Laboratory screening at preventive health exams: trend of testing, 1978-2004.

BACKGROUND: Routine laboratory screening at preventive health exams continues to be a common practice despite expert opinion dating back to 1979 that supports only a few screening tests for apparently healthy adults. This report describes trends in such testing over a 27-year period. METHODS: Primary care physicians were surveyed five times between 1978 and 2004 at a yearly educational meeting in Colorado. Based on case vignettes describing two apparently healthy adults, physicians indicated which laboratory tests they would routinely order. RESULTS: Of a total of 2364 surveys collected during years 1978, 1983, 1988, 1999, and 2004, the corresponding percentage of physicians respondents who state they would order the following tests for a healthy man aged 35 years were: complete blood count (CBC) (87, 75, 73, 49, 46); urinalysis (UA) (93, 86, 79, 52, 44); chemistry panel (CHEM) (57, 48, 36, 43, 55); and electrocardiogram (ECG) (37, 27, 24, 9, 6). For a healthy woman aged 55 years, the corresponding percentages for each test were: CBC (89, 89, 86, 64, 67); UA (96, 93, 88, 62, 55); CHEM (70, 70, 66, 57, 76); ECG (63, 51, 51, 33, 29); and thyroid stimulating hormone (14, 20, 28, 42, 57). CONCLUSIONS: Although currently practicing physicians continue to report that they order screening tests for apparently healthy people, this practice appears to have decreased over the past 27 years. This trend may reflect expert guidelines and emphasis on medical cost containment.

Resident and Preceptor Perceptions of Preceptor Integration Into Resident Clinic Scheduling Templates.

BACKGROUND: Some internal medicine residency programs on X+Y schedules have modified clinic preceptor schedules to mimic those of the resident cohort (resident matched). This is in contrast to a traditional model, in which preceptors supervise on the same half-day each week. OBJECTIVE: We assessed preceptor and resident perceptions of the 2 precepting models. METHODS: We surveyed 44 preceptors and 97 residents at 3 clinic sites in 2 academic medical centers. Two clinics used the resident-matched model, and 1 used a traditional model. Surveys were completed at 6 months and 1 year. We assessed resident and preceptor perceptions in 5 domains: relationships between residents and preceptors; preceptor familiarity with complex patients; preceptor ability to assess milestone achievements; ability to follow up on results; and quality of care. RESULTS: There was no difference in perceptions of interpersonal relationships or satisfaction with patient care. Preceptors in the resident-matched schedule reported they were more familiar with complex patients at both 6 months and 1 year, and felt more comfortable evaluating residents' milestone achievements at 6 months, but not at 1 year. At 1 year, residents in the resident-matched model perceived preceptors were more familiar with complex patients than residents in the traditional model. The ability to discuss patient results between clinic weeks was low in both models. CONCLUSIONS: The resident-matched model increased resident and preceptor perceptions of familiarity with complex patients and early preceptor perceptions of comfort in assessment of milestone achievements.

Patient and physician perceptions of timely access to care.

BACKGROUND: Timeliness of care is 1 of 6 dimensions of quality identified in Crossing the Quality Chasm. We compared patient and physician perceptions of appropriate timing of visits for common medical problems. METHODS: This study was conducted at 2 internal medicine clinics at the University of Colorado Health Sciences Center. Adult patients and companions, and outpatient General Internists were surveyed. The survey contained 11 clinical scenarios of varying urgency. Respondents indicated how soon the patient in each scenario should be seen. Responses ranged from that day to 1 to 3 months. Responses were analyzed using the Mann-Whitney U test. RESULTS: Two hundred and sixty-two patients and 46 of 61 physicians responded. For 8 of the 11 scenarios patients felt they should be seen significantly earlier than physicians. Scenarios involving chronic knee and stomach pain, routine diabetes care, and hyperlipidemia generated the greatest differences. Patients and physicians agreed on the urgency of scenarios concerning wheezing in an asthmatic, an ankle injury, and acute pharyngitis. CONCLUSIONS: Patients expected to be seen sooner than physicians thought necessary for many common chronic medical conditions, but are in agreement about timeliness for some acute problems. Understanding patient expectations may help physicians respond to requests for urgent evaluation of chronic conditions.

Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors.

PURPOSE: To assess internal medicine (IM) and surgery program directors' views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations. METHOD: In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes. RESULTS: Of 381 IM program directors, 287 (75.3%) responded; of 225 surgery program directors, 118 (52.4%) responded. Significantly more surgeons than internists indicated that the new regulations would likely negatively impact learning climate, including faculty morale and residents' relationships (P < .001). Most leaders in both specialties (80.8% IM, 80.2% surgery) felt that the regulations would likely increase faculty workload (P = .73). Both IM (82.2%) and surgery (96.6%) leaders most often rated, of all education opportunities, first-year resident clinical experience to be adversely affected (P < .001). Respondents from both specialties indicated that they will hire more nonphysician/midlevel providers (59.5% IM, 89.0% surgery, P < .001) and use more nonteaching services (66.8% IM, 70.1% surgery, P = .81). Respondents expect patient safety (45.1% IM, 76.9% surgery, P < .001) and continuity of care (83.6% IM across all training levels, 97.5% surgery regarding first-year residents) to decrease. CONCLUSIONS: IM and surgery program directors agree that the 2011 duty hours regulations will likely negatively affect the quality of the learning environment, workload, education opportunities, program administration, and patient outcomes. Careful evaluation of actual impact is important.

The annual physical examination: important or time to abandon?

The annual physical examination remains a popular format with both patients and providers, despite the lack of evidence that either a comprehensive examination or laboratory screening tests are indicated for healthy adults. Patient desire for extensive testing and comprehensive examination combined with provider belief that the physical examination is both of proven value and can detect subclinical illness have led to the continued pervasive practice of annual physical examinations in our country. The authors review the current forces behind the ongoing popularity of the annual physical examination and the current recommendations for preventive services in healthy adults, and provide thoughts on what the busy practicing clinician can focus on in the realm of proven preventive health.