Factors Influencing Selection of Infectious Diseases Training for Military Internal Medicine Residents.

Background: Applications to infectious diseases fellowships have declined nationally; however, the military has not experienced this trend. In the past 6 years, 3 US military programs had 58 applicants for 52 positions. This study examines military resident perceptions to identify potential differences in factors influencing career choice, compared with published data from a nationwide cohort. Methods: An existing survey tool was adapted to include questions unique to the training and practice of military medicine. Program directors from 11 military internal medicine residencies were asked to distribute survey links to their graduating residents from December 2016 to January 2017. Data were categorized by ID interest. Result: The response rate was 51% (n = 68). Of respondents, 7% were ID applicants, 40% considered ID but reconsidered, and 53% were uninterested. Of those who considered ID, 73% changed their mind in their second and third postgraduate years and cited salary (22%), lack of procedures (18%), and training length (18%) as primary deterrents to choosing ID. Active learning styles were used more frequently by ID applicants to learn ID concepts than by those who considered or were uninterested in ID (P = .02). Conclusions: Despite differences in the context of training and practice among military trainees compared with civilian colleagues, residents cited similar factors affecting career choice. Interest in global health was higher in this cohort. Salary continues to be identified as a deterrent to choosing ID. Differences between military and civilian residents' desire to pursue ID fellowship are likely explained by additional unmeasured factors deserving further study.

Diagnosis and management of Q fever--United States, 2013: recommendations from CDC and the Q Fever Working Group.

Q fever, a zoonotic disease caused by the bacterium Coxiella burnetii, can cause acute or chronic illness in humans. Transmission occurs primarily through inhalation of aerosols from contaminated soil or animal waste. No licensed vaccine is available in the United States. Because many human infections result in nonspecific or benign constitutional symptoms, establishing a diagnosis of Q fever often is challenging for clinicians. This report provides the first national recommendations issued by CDC for Q fever recognition, clinical and laboratory diagnosis, treatment, management, and reporting for health-care personnel and public health professionals. The guidelines address treatment of acute and chronic phases of Q fever illness in children, adults, and pregnant women, as well as management of occupational exposures. These recommendations will be reviewed approximately every 5 years and updated to include new published evidence.

Curriculum mapping to audit and grow longitudinal graduate medical education leadership training.

BACKGROUND: Residents need and want practical leadership training, yet leadership curricula are lacking in graduate medical education (GME). We describe our process of curriculum mapping, a method for auditing a curriculum, and its role in iterative leadership curriculum development. AIMS: To show how to create a curriculum map for auditing a curriculum using examples from our leadership curriculum and to demonstrate its value through case examples of leadership education integration into existing resident experiences. METHODS: We selected our recent systematic review on current leadership curricula to prioritise leadership content given it was the basis for our initial curriculum. We identified existing resident experiences where training can occur. We use the selected content and training environments, layered with a modified Miller's pyramid, to construct a curriculum map. RESULTS: Our curriculum map provides an example of curriculum auditing that reveals opportunities for leadership training that could be integrated into current residency experiences. We provide case examples of application. DISCUSSION: Effective leadership training should address critical topics and capitalise on experiential learning opportunities that exist within residency training programmes. The training must be seamlessly integrated into the demanding obligations of GME trainees, a process that can be achieved using curriculum mapping. Curriculum mapping can provide insight into a residency programme's leadership curriculum and create a direction for future leadership curriculum development.

A Common Trajectory Toward a Professional Identity as a Faculty Developer.

BACKGROUND AND OBJECTIVES: Professional identity formation is a complex construct that continually evolves in relation to an individual's experiences. The literature on educators identifying as faculty developers is limited and incompletely addresses how that identify affects other identities, careers, and influences on teaching. Twenty-six health professionals were trained to serve as faculty developers within our educational system. We sought to examine the factors that influence the professional identity of these faculty developers and to determine whether a common trajectory existed. METHODS: We employed a constructivist thematic analysis methodology using an inductive approach to understand the experiences of faculty developers. We conducted semistructured recorded interviews. Coding and thematic analysis were completed iteratively. RESULTS: We identified eight primary themes: (1) initial invitation, (2) discovery of faculty development as a professional activity, (3) discovery of educational theory, skills, and need for more education, (4) process of time and experience, (5) fostering relationships and community, (6) transfer of skills to professional and personal roles, (7) experiences that lead to credibility, and (8) sense of greater impact. CONCLUSIONS: An individual's journey to a faculty developer identity is variable, with several shared pivotal experiences that help foster the emergence of this identity. Consideration of specific programmatic elements to support the themes identified might allow for a strategic approach to faculty development efforts in health professions education.

Year in review: tips for effective graduate medical education programme leadership and management.

Programme leaders in graduate medical education (GME) are responsible for the final stage of physician training, guiding the transition from supervised to independent practice. The influence of GME programme leaders extends beyond clinical practice, affecting trainees' relationship with and attitudes towards the healthcare system, future leadership behaviours, work-life prioritisations and professional identity among others. Given the potential magnitude of GME programme leaders' impact, both positive and negative, on GME trainees, we reflected on our shared leadership model that developed iteratively as a leadership team. We draw on our experiences to emphasise practical leadership behaviours and provide a summary of our observations, leading to nine recommendations for effective GME programme leadership and associated suggestions for implementation. We divide our recommendations into four leadership recommendations and five management recommendations. Throughout, we highlight the process of developing our shared leadership model, recognising that our process and observations will aid leadership teams in evaluating and, potentially, adapting our recommendations to meet their needs. We anticipate that leaders and leadership teams at every level will find value in our recommendations, even if our intended audience is GME leaders from chief residents to programme directors.

Read to Lead: Developing a Leadership Book Club Curriculum for Graduate Medical Education.

Background: The importance of effective leadership for improving patient care and physician well-being is gaining increased attention in medicine. Despite this, few residency programs have formalized education on leadership in medicine. The most effective ways to train graduate medical education (GME) trainees in leadership are unclear. Methods: Our large internal medicine residency program implemented a book club to develop leadership skills in residency. Through independent reading of the selected book and resident-led small group discussions, we facilitated dialogue on the challenges of leading effectively. Results: A survey-based curricular evaluation demonstrated that 61% of respondents felt that the book club influenced their thoughts about leadership and that 66% of participants would recommend the book club to other residency programs. Lack of time was the main barrier to participation while addition of complementary media or alternative book formats were identified as possible solutions to increase engagement. Conclusions: Leadership book clubs are a practical and effective way to teach leadership during residency. More research is needed to identify the best formats for book club discussion and to develop additional tools to foster future physician leaders.

Updating the Military Unique Curriculum for a Ready Medical Force.

INTRODUCTION: Previous conflicts have demonstrated the impact of physician readiness on early battlefield mortality rates. To prepare for the lethal nature of today's threat environment and the rapid speed with which conflict develops, our medical force needs to sustain a high level of readiness in order to be ready to "fight tonight." Previous approaches that have relied on on-the-job training, just-in-time predeployment training, or follow-on courses after residency are unlikely to satisfy these readiness requirements. Sustaining the successes in battlefield care achieved in Iraq and Afghanistan requires the introduction of effective combat casualty care earlier and more often in physician training. This needs assessment seeks to better understand the requirements, challenges, and opportunities to include the Military Unique Curriculum (MUC) during graduate medical education. MATERIALS AND METHODS: This needs assessment used a multifaceted methodology. First, a literature review was performed to assess how Military Unique Curricula have evolved since their initial conception in 1988. Next, to determine their current state, a needs-based assessment survey was designed for trainees and program directors (PDs), each consisting of 18 questions with a mixture of multiple choice, ranking, Likert scale, and free-text questions. Cognitive interviewing and expert review were employed to refine the survey before distribution. The Housestaff Survey was administered using an online format and deployed to Internal Medicine trainees at the Walter Reed National Military Medical Center (WRNMMC). The Program Director Survey was sent to all Army and Navy Internal Medicine Program Directors. This project was deemed to not meet the definition of research in accordance with 32 Code of Federal Regulation 219.102 and Department of Defense Instruction 3216.02 and was therefore registered with the WRNMMC Quality Management Division. RESULTS: Out of 64 Walter Reed Internal Medicine trainees who received the survey, 32 responses were received. Seven of nine PDs completed their survey. Only 12.5% of trainees felt significantly confident that they would be adequately prepared for a combat deployment upon graduation from residency with the current curriculum. Similarly, only 14.29% of PDs felt that no additional training was needed. A majority of trainees were not satisfied with the amount of training being received on any MUC topic. When incorporating additional training on MUC topics, respondents largely agreed that simulation and small group exercises were the most effective modalities to employ, with greater than 50% of both trainees and PDs rating these as most or second most preferred among seven options. Additionally, there was a consensus that training should be integrated into the existing curriculum/rotations as much as possible. CONCLUSIONS: Current Military Unique Curricula do not meet the expected requirements of future battlefields. Several solutions to incorporate more robust military unique training without creating any significant additional time burdens for trainees do exist. Despite the limitation of these results being limited to a single institution, this needs assessment provides a starting point for improvement to help ensure that we limit the impact of any "peacetime effect."

Role of the battalion surgeon in the Iraq and Afghanistan War.

The battalion surgeon is an invaluable asset to a deploying unit. The primary role of a battalion surgeon is to provide basic primary care medicine and combat resuscitation. Other expectations include health care screening, vaccinations, supervision of medics, and being a medical advisor to the unit's commander. As many physicians who fill this role previously worked at medical treatment facilities or medical centers without prior deployment experience, the objective of this article is to highlight some of the challenges a battalion surgeon may encounter before, during, and following deployment.

Practice guidelines for the diagnosis and management of patients with Q fever by the Armed Forces Infectious Diseases Society.

This issue in the series Current Topics in Military Tropical Medicine focuses on Q Fever. Q fever is a zoonotic infection caused by the bacterium Coxiella burnetii. Over 150 confirmed cases have occurred among U.S. military personnel deployed to Iraq since 2007. Acute Q fever is underdiagnosed because of a myriad of possible clinical presentations but typically presents as a flu-like illness. The most common chronic manifestation is endocarditis. Most providers are not familiar with the diagnosis, treatment, or appropriate follow-up of this disease. In order to facilitate the care of patients infected with C. burnetii, the Armed Forces Infectious Diseases Society convened a panel of experts in the field to develop practical guidelines for those caring for infected patients. The recommendations and rationale are reviewed in this article.

Invasive fungal infections following combat-related injury.

Invasive mold infections are a rare complication of traumatic wounds. We examined the incidence and outcomes of these infections in combat wounds. A retrospective chart review from March 2002 through July 2008 of U.S. soldiers returning from Iraq and Afghanistan with traumatic wounds was performed. A confirmed fungal wound infection was defined as growth of a known pathogenic mold and visualization of fungal elements on histopathology. Six cases were identified for an incidence of 0.4 cases/1,000 admissions. The incidence of invasive mold infections increased over time (p = 0.008) with a peak of 5.2 cases/1,000 admissions in 2007. Isolated molds included Aspergillus (n = 4), Bipolaris (n = 2), and 1 each Mucor and Absidia. All patients were male with a mean age of 22. Blast (n = 5) and gunshot wound (n = 1) were the sources of injury. All patients had fever (mean 39.4 degrees C) and leukocytosis (mean white blood cell count 25 x 10(3)/microL). The average acute physiology and chronic health evaluation II score was 22. All patients received antifungal agents, surgical debridement, and 3 required amputation revision. Average length of stay was 97 days. There were no deaths. Invasive mold infections are a rare complication of combat wounds but are associated with significant morbidity and may be increasing in frequency.

Building Individual and Organizational Wellness Through Effective Followership.

Burnout is widespread across the healthcare industry. Physician burnout has been linked to significant decrements in personal wellness, patient satisfaction, patient outcomes, and organizational financial losses. Appropriately, burnout has been identified as an important issue for leaders in the field as it can lead to physician turnover and loss of talent. In this article, we address how burnout is related to followership. We assert that physicians can utilize effective followership to increase wellness not only for themselves, but also for their leaders and organizations.

Reflective Essays During Clerkship Following a Pre-clerkship Leadership Curriculum.

Introduction: Leadership curricula in medical student education require assessment - to determine if leadership skills can be taught to medical students and applied during clinical and medical team interactions to aid in medical student leadership development. Objectives: To examine whether medical students applied principles of their pre-clerkship leadership curriculum (character, competence, context, and communication elements across four levels: personal, interpersonal, team, and organizational) during an internal medicine clerkship. Methods: Using art as a prompt, Uniformed Services University (USU) internal medicine clerkship students completed a structured reflection on a critical incident. Medical student essays written during a 10-week internal medicine clerkship at USU in 2019 were collected. 158 medical student submissions were de-identified and analyzed. Results: Sixty-four submissions (40.5%) focused on leadership or leadership and professionalism. Students identified as male (n = 34, 53%), female (21, 33%), or not reported (9, 14%). Most, 48 (75%), did not describe PITO explicitly in their essay. They instead focused on personal and interpersonal aspects (17, 27%) of leadership, the attending physicians they worked with (33, 52%), and effective leadership strategies (46, 72%). The most common themes written about were responsibility (30, 47%), teamwork (18, 28%), competence (17, 27%), and character/integrity (15, 23%). Conclusion: Although the students' explicit use of the PITO model was limited, student essays centered on themes that reflected leadership concepts taught in pre-clerkship years, such as character, competence, and responsibility. This study demonstrates that an internal medicine clerkship rotation can feasibly implement a leadership reflection.

Learning to Lead: 10 Leadership Lessons From Operation Bushmaster.

Medical students at the Uniformed Services University of the Health Sciences participate in a leadership curriculum designed to develop leadership skills. Operation Bushmaster is a 5-day field practicum designed to test these skills. In this article, we describe 10 leadership lessons learned during Operation Bushmaster applicable to all leaders.

Recognizing Gender Parity in Military Medicine: An Analysis of Plenary Speakers and Award Recipients at Military American College of Physicians Chapter Meetings.

INTRODUCTION: Despite the advances toward gender parity in medicine, a gap exists in the recognition of women physicians at academic and subspecialty medical conferences as plenary speakers and award winners. Conferences are cornerstones in the practice of medicine because they serve as platforms to showcase physicians' successes and disseminate work. The selection of who is honored at such events can impact an individual's career by creating networks that may lead to future opportunities. Additionally, the trend of who is honored may create expectations in the minds of trainees and early career physicians about what qualities help an individual achieve success. Our group sought to determine whether there was a gender gap in award recognition and speakership opportunities at the American College of Physicians (ACP) annual military chapter meetings. METHODS: This was a cross-sectional study with data extracted from publicly available conference programs for the Army-Air Force annual ACP meetings and the Navy annual ACP meetings. Five years of data erewere reviewed for invited plenary speakers. Ten years of data were reviewed for award recipients. For an award to be included, it had to have a preset description and criteria for recipient selection. Awards not given annually or awards given for less than 3 years were excluded. Individuals' gender was determined based on the first name and confirmed through internet searches of pronoun descriptors from professional websites. Comparisons were done using Fisher's exact test and chi-square tests when appropriate, with statistical significance set at a two-tailed P-value of <.05. RESULTS: Women comprised 26-30% of the chapter membership and there was no significant difference in gender distribution between the chapters. Fourteen of the 69 plenary speakers were women (20%), with significantly fewer women presenters in the Navy as compared to men. Thirty-six of the 134 award winners were women (27%), which was not significantly different from the overall chapter gender distributions. While women recipients of lifetime, teaching, research, and medical student awards were not significantly different from chapter gender distribution, women faculty were significantly more likely to receive an award for teaching than for research, with women receiving 13 of the 28 teaching awards (41%), and none of the 10 faculty research awards. CONCLUSIONS: The military chapter ACP meetings reviewed mirrored civilian data in many ways, although military plenary speaker and award recipient distributions were more representative of the gender distribution of the branches. Review of the nomination process, planning committee selection, and opportunities for diversity training could be optimized to ensure that future conferences have a gender-balanced representation of individuals being honored. Improving upon current practices is important for the growth and retention of women military physicians.

A Faculty Development Model for Academic Leadership Education Across A Health Care Organization.

Academic leadership in undergraduate and graduate medical education requires a specific set of leadership and managerial skills that are unique to academic leadership positions. While leadership development training programs exist for traditional leadership roles such as department chairs, executives, and deans, there are fewer models of leadership training specifically geared for academic leadership positions such as program and clerkship directors, and designated institutional officials. There are academic programs at the national level, but there is sparse literature on the specific decisions required to create such programs locally. With growing regulatory and accreditation requirements as well as the challenges of balancing the clinical and educational missions, effective leadership is needed across the spectrum of academic medicine. To meet this need for the military health care system in the United States, we used Kern's six-step framework for curriculum development to create a 1-week academic leadership course. This paper describes the process of development, implementation, outcomes, and lessons learned following the initial 3 years of courses. Specific discussions regarding who to train, which faculty to use, content, and other elements of course design are reviewed. The course and process outlined in the paper offer a model for other organizations desiring to establish an academic leadership course.

The Ripple Effect: A Train-the-Trainer Model to Exponentially Increase Organizational Faculty Development.

This article was migrated. The article was marked as recommended. INTRODUCTION: Faculty development is a key component of undergraduate and graduate medical education and is required for accreditation. Many institutions face the challenges of training large numbers of faculty at multiple locations on a recurring basis. In order to meet the faculty development demands of our organization, we implemented a train-the trainer model of faculty development. METHODS: A train-the-trainer program was created using deliberate practice as the theoretical framework. The primary goals of the program were to enhance content knowledge and develop facilitation skills of the participants (called faculty trainers). Two separate cohorts received 40 hours of in-person training consisting of attending the faculty development workshops as a learner, providing feedback to course faculty, facilitating and participating in journal club sessions on relevant content, and practicing facilitation and receiving feedback on the workshops. Cohorts 1 and 2 were trained on how to deliver 6 and 7 workshops, respectively. An additional 16 hours of training and further feedback occurred when faculty trainers delivered the workshops at outside institutions. RESULTS: Twenty-nine faculty trainers from 15 specialties and subspecialties were trained, including 18 in the first cohort (January 2018) and 14 in the second cohort (February 2019) with 3 who participated in both cohorts. From January 2018 to January 2020, faculty trainers delivered 298 workshops to 3742 attendees at 25 locations. For the faculty trainers, 1477 evaluations were completed with 1031 (88.1%) rated as excellent, 141 (9.5%) rated as good, and 8 (0.5%) as average. There were no fair or poor ratings. DISCUSSION: Our train-the-trainer program effectively developed a community of national faculty developers. Faculty trainer output was substantial and early evaluations of performance were positive. The model outlined in this paper serves as a potential sustainable model for other institutions desiring to train a cadre of faculty developers for their organization.

Leadership Training in Graduate Medical Education: Time for a Requirement?

INTRODUCTION: The need for all physicians to function as leaders in their various roles is becoming more widely recognized. There are increasing opportunities for physicians at all levels including Graduate Medical Education (GME) to gain leadership skills, but most of these opportunities are only for those interested. Although not an Accreditation Council for Graduate Medical Education (ACGME) requirement, some US graduate medical education programs have incorporated leadership training into their curricula. Interestingly, the Royal College of Physicians and Surgeons of Canada adopted the Leader role in its 2015 CanMEDS physician training model and requires leadership training. We sought to understand the value of a leadership training program in residency in our institution. MATERIALS AND METHODS: Our 2017 pilot leadership training program for senior military internal medicine residents consisted of four one-hour sessions of mini-lectures, self-assessments, case discussions, and small group activities. The themes were: Introduction to Leadership, Emotional Intelligence, Teambuilding, and Conflict Management. Participants were given an 18-question survey (14 Likert scale multiple-choice questions and 4 open-ended response questions) to provide feedback about the course. The Brooke Army Medical Center Institutional Review Board approved this project as a Quality Improvement effort. RESULTS: The survey response rate was 48.1% (26 of 54). The majority of respondents (84.6%) agreed the leadership training sessions were helpful and relevant. Following the sessions, 80.8% saw a greater role for physicians to function as leaders. Most (88.4%) agreed that these sessions helped them understand the importance of their roles as leaders, with 80.8% feeling more empowered to be leaders in their areas, 76.9% gaining a better understanding of their own strengths and weaknesses as leaders, and 80.8% feeling better prepared to meet challenges in the future. After exposure to leadership training, 73.1% indicated a plan to pursue additional leadership development opportunities. All respondents agreed that internists should be able to lead and manage a clinical team, and every respondent agreed that leadership principles should be taught in residency. CONCLUSIONS: This pilot project supports the premise that leadership training should be integrated into GME. Initial results suggest training can improve leadership skills and inspire trainees to seek additional leadership education. Moreover, much like the published literature, residents believe they should learn about leadership during residency. While more effort is needed to determine the best approach to deliver and evaluate this content, it appears even small interventions can make a difference. Next steps for this program include developing assessment tools for observation of leadership behaviors during routine GME activities, which would allow for reinforcement of the principles being taught. Additionally, our experience has led our institution to make leadership training a requirement in all of our GME programs, and we look forward to reporting future progress. Finally, an ACGME requirement to incorporate leadership training into GME programs nationwide would prove useful, as doing so would reinforce its importance, accelerate implementation, and expand knowledge of best approaches on a national level.

Nephrotoxicity associated with intravenous colistin (colistimethate sodium) treatment at a tertiary care medical center.

The incidence of acute renal failure, defined by the risk, injury, or failure criteria of the RIFLE criteria (risk, injury, failure, loss, and end-stage kidney disease), in 66 patients who received colistimethate sodium was 45%, and 21% of patients stopped therapy because of nephrotoxicity. The RIFLE criteria should be used in the future to allow for comparison of nephrotoxicity among studies.