Performance of Cardiovascular Physical Exam Skills by Internal Medicine Residents.

BACKGROUND: Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients. METHODS: First year internal medicine interns from 2 large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on 5 clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs. RESULTS: One hundred nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r = 0.42, P < .001). Both technique (r = 0.34, P = .003) and identifying findings (r = 0.42, P < .001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse. CONCLUSIONS: Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.

Learner feedback and educational outcomes with an internet-based ambulatory curriculum: a qualitative and quantitative analysis.

BACKGROUND: Online medical education curricula offer new tools to teach and evaluate learners. The effect on educational outcomes of using learner feedback to guide curricular revision for online learning is unknown. METHODS: In this study, qualitative analysis of learner feedback gathered from an online curriculum was used to identify themes of learner feedback, and changes to the online curriculum in response to this feedback were tracked. Learner satisfaction and knowledge gains were then compared from before and after implementation of learner feedback. RESULTS: 37,755 learners from 122 internal medicine residency training programs were studied, including 9437 postgraduate year (PGY)1 residents (24.4 % of learners), 9864 PGY2 residents (25.5 %), 9653 PGY3 residents (25.0 %), and 6605 attending physicians (17.0 %). Qualitative analysis of learner feedback on how to improve the curriculum showed that learners commented most on the overall quality of the educational content, followed by specific comments on the content. When learner feedback was incorporated into curricular revision, learner satisfaction with the instructive value of the curriculum (1 = not instructive; 5 = highly instructive) increased from 3.8 to 4.1 (p < 0.001), and knowledge gains (i.e., post test scores minus pretest scores) increased from 17.0 % to 20.2 % (p < 0.001). CONCLUSIONS: Learners give more feedback on the factual content of a curriculum than on other areas such as interactivity or website design. Incorporating learner feedback into curricular revision was associated with improved educational outcomes. Online curricula should be designed to include a mechanism for learner feedback and that feedback should be used for future curricular revision.

Use of a Real-Time Locating System to Assess Internal Medicine Resident Location and Movement in the Hospital.

Importance: The patient-physician clinical encounter is the cornerstone of medical training, yet residents spend as little as 12% of their time in direct patient contact. Objectives: To use a real-time locating system (RTLS) to characterize intern work experiences in the hospital, understand factors associated with time spent at patients' bedsides, and inform future interventions to increase time spent with patients. Design, Setting, and Participants: This cross-sectional study was conducted from July 1, 2018, to June 30, 2019 (ie, the academic year 2018-2019). Internal medicine residents from postgraduate year 1 (interns) at an academic medical center wore an infrared badge that recorded location and duration (eg, patient room, ward hall, physician workroom). Data were analyzed from September 1, 2020, to August 30, 2021. Main Outcomes and Measures: Main outcome was time (in minutes) at the bedside; the unit of analysis was a 24-hour intern day or interval of time within the day (eg, rounding period). Descriptive statistics are reported overall, by intern, and for 5 clinical service categories. Multilevel modeling assessed the association of intern, service, and calendar time with time spent at the bedside. Results: Data from 43 of 52 interns (82.7%) encompassing 95 275 hours of observations were included for analyses. Twenty-six interns (60.5%) were women. Interns were detected for a mean (SD) of 722.8 (194.4) minutes per 24-hour period; 13.4% of this time was spent in patient rooms (mean [SD] time, 96.8 [57.2] minutes) and 33.3% in physician workrooms (mean [SD] time, 240.9 [228.8] minutes). Mean percentage of time at the bedside during a 24-hour period varied among interns from 8.8% to 18.3%. Mean (SD) percentage of time at the bedside varied by service for the 24-hour period from 11.7% (6.6%) for nononcology subspecialties to 15.4% (6.0%) for oncology, and during rounds from 8.0% (12.4%) for nononcology subspecialties to 26.5% (12.1%) for oncology. In multilevel modeling, the individual intern accounted for 8.1% of overall variance in time spent at the bedside during a 24-hour period, and service accounted for 18.0% of variance during rounds. Conclusions and Relevance: The findings of this cross-sectional study support previous evidence suggesting that interns spend only a small proportion of time with hospitalized patients. The differences in time spent in patients' rooms among interns and during rounds constitute an opportunity to design interventions that bring trainees back to the bedside.

Use of a Real-Time Location System to Understand Resident Location in an Academic Medical Center.

BACKGROUND: There is great interest in understanding how residents spend their time in the hospital, but traditional time and motion studies are resource intensive and limited in scale. OBJECTIVE: We determined whether a real-time location system (RTLS) that uses infrared emitting badges can be used to track resident time and location. METHODS: Residents rotating on an internal medicine service in January 2018 were given the option to wear an RTLS badge. RTLS data were compared to the call schedule for each participating resident in a deidentified manner. Rules were created to identify work periods to be manually reviewed for data integrity. Reviewed work periods where there were extended periods of time without RTLS badge movement (eg, greater than 300 minutes) were excluded from analysis. RESULTS: Data were collected from 18 residents and included 236 work periods (2922 hours). Based on prespecified rules, 146 work periods were included, representing 83% of total eligible residents (n = 15) and 82% of total hours recorded (2397 hours). Residents spent the highest percentage of their time in physician workrooms (44%, SD 15%), followed by ward hallways (25%, SD 7%) and patient rooms (17%, SD 7%). Several work periods were excluded because residents left their RTLS badge in physician workrooms after the work period ended. CONCLUSIONS: This study demonstrates the potential utility of RTLS to measure resident time and location in the hospital.

Health and wellness among incoming resident physicians: A multi-domain survey.

INTRODUCTION: Burnout and depression are well-described in medical students and physicians and can lead to adverse personal and patient outcomes; however, their time course and risk factors remain understudied. Here, we measured multiple domains of mental and physical health and wellness and assessed gender differences among incoming physician trainees beginning residency at an academic medical center. METHODS: Using a cross-sectional study design, all incoming trainees (i.e. housestaff) at Johns Hopkins Hospital received a questionnaire assessing depression, burnout, sleep, exercise, and alcohol consumption, among other domains. Standardized instruments were utilized for questionnaire development. Tests of significance were two-tailed. RESULTS: 196 of 229 incoming housestaff (86%) completed the survey, and 49% were female. A history of depression was reported in 8%, and 5.4% met criteria for at least moderate depression by Patient Health Questionnaire (PHQ-9). Females were more likely to report a history of depression than males (13% vs. 3%, p=0.02) but had similar PHQ-9 scores. Four percent of participants reported feeling they were in the wrong profession. Goal and mean sleep were 7 and 6.7 hours/night, respectively. Forty-seven percent reported exercising once/week or not at all. While mean reported weekly alcohol consumption was three drinks, participants reported consuming ≥5 drinks in one sitting on average 1.6 times in the prior 6 months, and 4% used alcohol to sleep. CONCLUSIONS: Incoming housestaff reported generally favorable mental and physical health at the beginning of residency training. However, exercise rates were low, and ill-suited alcohol consumption was noted, though infrequent. The few areas of possible improvement were largely similar between males and females. Wellness interventions might capitalize on the relatively high morale and health at the completion of medical school by helping to promote healthy habits, including regular exercise and avoidance of excess alcohol consumption, throughout future training and practice.