How Are We Teaching Advocacy? A National Survey of Internal Medicine Residency Program Directors.

BACKGROUND: Although internal medicine (IM) physicians accept public advocacy as a professional responsibility, there is little evidence that IM training programs teach advocacy skills. The prevalence and characteristics of public advocacy curricula in US IM residency programs are unknown. OBJECTIVES: To describe the prevalence and characteristics of curricula in US IM residencies addressing public advocacy for communities and populations; to describe barriers to the provision of such curricula. DESIGN: Nationally representative, web-based, cross-sectional survey of IM residency program directors with membership in an academic professional association. PARTICIPANTS: A total of 276 IM residency program directors (61%) responded between August and December 2022. MAIN MEASUREMENTS: Percentage of US IM residency programs that teach advocacy curricula; characteristics of advocacy curricula; perceptions of barriers to teaching advocacy. KEY RESULTS: More than half of respondents reported that their programs offer no advocacy curricula (148/276, 53.6%). Ninety-five programs (95/276, 34.4%) reported required advocacy curricula; 33 programs (33/276, 12%) provided curricula as elective only. The content, structure, and teaching methods of advocacy curricula in IM programs were heterogeneous; experiential learning in required curricula was low (23/95, 24.2%) compared to that in elective curricula (51/65, 78.5%). The most highly reported barriers to implementing or improving upon advocacy curricula (multiple responses allowed) were lack of faculty expertise in advocacy (200/276, 72%), inadequate faculty time (190/276, 69%), and limited curricular flexibility (148/276, 54%). CONCLUSION: Over half of US IM residency programs offer no formal training in public advocacy skills and many reported lack of faculty expertise in public advocacy as a barrier. These findings suggest many IM residents are not taught how to advocate for communities and populations. Further, less than one-quarter of required curricula in public advocacy involves experiential learning.

Implementation, Reach, and Effectiveness of the Direct Observation of Residents in Clinic Program.

BACKGROUND: Direct observation is important, yet medical residents are rarely observed. We implemented and evaluated a direct observation program in resident clinics to increase the frequency of observation and feedback and improve perceptions about direct observation. METHODS: We assigned faculty as observers in our resident clinics between June 2019 and February 2020. We surveyed residents and faculty before and after the program. Faculty completed a form for each observation performed. We analyzed surveys to examine changes in barriers, frequency and type of observations and feedback, and attitudes toward observation. The analytical sample included 38 and 37 pre- and postresident surveys, respectively, and 20 and 25 pre- and postfaculty surveys, respectively. RESULTS: Resident survey response rates were 32.3% (40/124) pre- and 30.7% (39/127) postintervention. Most residents (76% [pre], 86% [post], P = 0.258) reported being observed in at least one of the four areas: history, examination, counseling, or wrap-up. We received observation tracking forms on 68% of eligible residents. Observed history taking increased from 30% to 79% after the program (P = 0.0010). Survey response rates for faculty were 64.7% (22/34) pre- and 67.5% (25/37) postintervention. Fewer faculty reported time (80% [pre], 52% [post], P = 0.051) and competing demands (65% [pre], 52% [post], P = 0.380) as barriers postintervention. Fewer faculty postintervention viewed observation as a valuable teaching tool (100% [pre], 79% [post], P = 0.0534). All faculty who did not view observation as valuable were the least experienced. DISCUSSION: Assigning faculty as observers can increase observation, especially in history taking, though data suggest an increase in negative perceptions of observation by faculty.

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

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

Why Aren't More Primary Care Residents Going into Primary Care? A Qualitative Study.

BACKGROUND: Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. OBJECTIVE: We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. DESIGN: This was a qualitative study based on semi-structured, in-person interviews. PARTICIPANTS: Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. APPROACH: We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. KEY RESULTS: We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. CONCLUSIONS: Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

Hazard pay for internal medicine resident physicians during the COVID-19 pandemic: A national survey of program directors.

BACKGROUND: Hazard pay for resident physicians has been controversial in the COVID-19 pandemic. Program director (PD) beliefs about hazard pay and the extent of provision to internal medicine (IM) residents are unknown. OBJECTIVE: To evaluate hazard pay provision to residents early in the COVID-19 pandemic and pandemic and residency program characteristics associated with hazard pay. DESIGN, SETTING, AND PARTICIPANTS: A nationally representative survey was conducted of 429 US/US territory-based IM PDs from August to December 2020. MAIN OUTCOME AND MEASURES: Hazard pay provision and PD beliefs about hazard pay were tested for association with factors related to the pandemic surge and program characteristics. RESULTS: Response rate was 61.5% (264/429); 19.5% of PDs reported hazard pay provision. PD belief about hazard pay was equivocal: 33.2% agreed, 43.1% disagreed, and 23.7% were uncertain. Hazard pay occurred more commonly in the Middle-Atlantic Census Division (including New York City) and with earlier surges and greater resident participation in COVID-19 patient care. Hazard pay occurred more commonly where PDs supported hazard pay (74.5% vs. 22.1%, p = .018). Reasons most frequently given in support of hazard pay were essential worker status, equity, and schedule disruption. Those opposed cited professional obligation and equity. CONCLUSION: Hazard pay for IM residents early in the COVID-19 pandemic was nominal but more commonly associated with heavily impacted institutions. Although PD beliefs were mixed, positive belief was associated with provision. The unique role of residents as both essential workers and trainees might explain our varied results. Further investigation may inform future policy, especially in times of crisis.

An Evaluation of Contraceptive Methods After Implementation of a Novel LARC Program in a Residency Primary Care Clinic.

BACKGROUND AND OBJECTIVE: Internal medicine (IM) residency programs have inadequate education and training around contraception, creating and perpetuating a potential barrier for patients. Contraceptive access is a critical part of primary care, yet few IM residency programs offer long-acting reversible contraception (LARC) in their clinic. To address the LARC needs of our patients and education needs of our residents, one attending (MS) created a procedure clinic and provided LARC in our residency clinic in 2015. In this initial study, we sought to determine the use of contraceptive methods among reproductive age women at our residency clinic two years after offering LARC. This data will shape future care provision and resident education. STUDY DESIGN AND METHODS: Data were extracted from 1,182 female patients ages 20-39 years attributed to the Rhode Island Hospital Center for Primary Care (CPC) between February 2017 to August 2018. Of the total, 260 patients were excluded because they had not been seen in the clinic within the preceding 12 months or had left the practice. Descriptive and bivariate methods were used to calculate the proportion of women using any contraception and long-acting reversible contraception (LARC) and to test for associations with demographic characteristics. PRIMARY RESULTS: Fifty-five percent used any contraception and 19% used LARC. LARC use was higher among women ages 20-29 when compared to women 30-39. Demographic characteristics other than age were not associated with contraceptive use. PRINCIPAL CONCLUSIONS: In this clinic, LARC usage exceeds the national average (19.0% v 10.3%). Residency training is ideal for learning skills around this aspect of medical care, providing the ability to ensure appropriate oversight and supervision. This initial study suggests almost one fifth (18%) of patients who utilize LARC find access at an IM residency primary care clinic acceptable. Internal medicine primary care clinics can address the nonsurgical contraceptive needs of their patients by providing access to LARC. To achieve this goal, internal medicine residents should receive training in and exposure to LARC provision.

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

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

Patient-provider communication about sexual health among unmarried middle-aged and older women.

BACKGROUND: Although past studies have highlighted the importance of patient-provider communication about sexual health and intimate relationships (SHIR), much of the research has focused on young women's or married women's experiences when discussing SHIR with their providers. OBJECTIVE: To describe experiences of unmarried, middle-aged and older women in communicating about SHIR with their health care providers. DESIGN AND PARTICIPANTS: Qualitative interviews were conducted with 40 unmarried women aged 40-75 years. We compared the responses of 19 sexual minority (lesbian and bisexual) women and 21 heterosexual women. RESULTS: Women varied in their definitions of intimate relationships. Not all women thought providers should ask about SHIR unless questions were directly related to a health problem, and most were not satisfied with questions about SHIR on medical intake forms. However, the themes women considered to be important in communication about SHIR were remarkably consistent across subgroups (e.g. previously married or never married; sexual minority or heterosexual). Sexual minority women were more hesitant to share information about SHIR because they had had prior negative experiences when disclosing their sexual orientation or perceived that clinicians were not informed about relevant issues. CONCLUSIONS: Some women felt that providers should ask about SHIR only if questions relate to an associated health problem (e.g. sexually transmitted infection). When providers do ask questions about SHIR, they should do so in ways that can be answered by all women regardless of partnering status, and follow questions with non-judgmental discussions.

Mindfulness in Residency: A Survey of Residents' Perceptions on the Utility and Efficacy of Mindfulness Meditation as a Stress-Reduction Tool.

PURPOSE: Mindfulness meditation can help reduce burnout in medical students and attendings, yet has not demonstrated efficacy in residents. The authors surveyed internal medicine residents to determine their prior experience with and interest in mindfulness meditation. METHODS: An anonymous survey was given to 130 internal medicine residents at the Alpert Medical School at Brown University during the 2016-2017 academic year. The survey assessed prior experience, perceived efficacy, and interest in learning about mindfulness meditation. RESULTS: Of 104 completed surveys, 61% reported prior use of mindfulness and 25% reported current weekly or greater use. Eighty-seven percent of residents believed mindfulness meditation would help with stress reduction, and 87% were interested in receiving mindfulness training. CONCLUSIONS: Though a minority of residents currently practice mindfulness meditation, most believe it is an effective stress reduction tool and are interested in receiving further training. These results support the inclusion of mindfulness training within residency wellness initiatives.

Attitudes Toward Advocacy Do Not Match Actions: A Cross-sectional Survey of Residents and Fellows.

BACKGROUND/OBJECTIVE: We sought to determine baseline physician advocacy knowledge and attitudes of resident and fellow trainees at our institution to inform future graduate medical education (GME) activities. METHODS: A cross-sectional survey was developed and administered to all house staff in 2014 at Lifespan Hospitals, affiliated with The Warren Alpert Medical School of Brown University. RESULTS: The response rate was 24% (134/558). Eighty-eight percent reported voting in the 2012 presidential election, with lower participation in regional elections. Less than 25% felt comfortable explaining the Affordable Care Act, communicating with media, or influencing legislation on a health care issue. The majority (94%) agreed that "as a physician I have a duty to advocate." Few reported receiving adequate advocacy training in medical school (18%) or residency (12%). CONCLUSIONS: House staff agreed that physicians have a duty to advocate, but this did not translate into knowledge or action. GME should increase curricular efforts for trainees in the health care advocacy domain.

Patient-provider communication and cancer screening among unmarried women.

OBJECTIVES: Unmarried women are less likely than married women to receive recommended cancer screenings. Patient-provider communication is a consistent predictor of cancer screening among women. The purpose of this study was to investigate the relationship between patient and provider communication, barriers to cancer screening, and on-schedule breast and cervical cancer screening (BCCS) among unmarried women. METHODS: Data were from the Cancer Screening Project for Women, a 2003-2005 survey examining cancer screening practices. We computed polytomous logistic regression models to examine the relationship between communication (communication about tests, communication about sexual and intimate relationships), barriers to screening, and on-schedule BCCS among unmarried women. RESULTS: A total of 630 women were enrolled, and 605 women completed the baseline questionnaire. Overall, more than 60% reported on-schedule BCCS. More than half reported that their providers communicated about BCCS most or all of the time. Fewer than half communicated about sexual history and intimate relationships. Women who reported that their providers communicated about screening tests and their sexual and intimate relationships were more likely to be on-schedule for BCCS. CONCLUSION: Patient-provider communication about multiple topics may encourage women to remain on-schedule for their recommended cancer screenings. Longitudinal research should be conducted to examine whether communication predicts BCCS, and to examine how patient and provider characteristics may influence communication in order to promote adherence to screening guidelines for unmarried women. PRACTICE IMPLICATIONS: Comprehensive communication that goes beyond information about screening tests may impact adherence to cancer screening guidelines.

Caring for vulnerable populations: curricula in U.S. internal medicine residencies.

The Accreditation Council for Graduate Medical Education (ACGME) encourages internal medicine training programs to include specific curricula devoted to health care issues of vulnerable populations. Our aim was to determine the prevalence of curricula involving selected vulnerable populations among U.S. Internal Medicine residencies. We conducted a survey of Program Directors of all US Internal Medicine Residencies assessing whether the program had a curriculum for six vulnerable populations (racial and ethnic minorities, non-English speaking patients, lesbians, gay men, victims of domestic violence and patients with substance abuse problems). Most residencies address substance abuse and victims of domestic violence, while there remains a lack of dedicated teaching on other vulnerable populations, including lesbians, gay men, racial and ethnic minorities and non-English speaking patients.

Beyond Estrogen: Treatment Options for Hot Flashes.

Nonhormonal medications and complementary and alternative therapies are used by many women seeking relief from bothersome hot flashes. However, health care professionals may be less familiar with these treatment modalities. Although estrogen remains the most effective medication to reduce hot flashes, its potential harmful effects have led investigators to examine other treatments for hot flashes, and many women seek alternative forms of relief. Most of these trials are limited by a significant placebo effect, which frequently equals the effectiveness of the medication being evaluated. Despite this limitation, selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and gabapentin have robust evidence for hot flash reduction. Each of these may be chosen for additional treatmenteffects that may benefit some women. Complementary and alternative medication trials are fraught with additional limitations, namely, a large placebo effect, greater homogeneity of participants, lack of validated tools, and lack of robust reporting of adverse effects. The data appear most robust for isoflavone supplementation, with overall hot flash reduction similar to the SSRIs, SNRIs, and gabapentin. Mindfulness-based stress reduction therapy also has evidence of effectiveness and may be an ideal choice for some. Primrose oil, Chinese herbal medicine, acupuncture, and yoga have mixed results. The concerns related to hepatotoxicity preclude the use of black cohosh. Exercise, relaxation, and paced respiration have no proven benefit thus far in reducing hot flashes. Our goal with this commentary is to arm clinicians with information about the medications and complementary therapies available to provide symptom relief to women. Providing information about the possible benefits and harms of these therapies despite the limitations of the current evidence is helpful to patients and can help guide them to seek the treatment option most beneficial and appealing to them.

Use of Eflornithine (DFMO) in the Treatment of Early Alzheimer's Disease: A Compassionate Use, Single-Case Study.

Background: Recent genome-wide association screening (GWAS) studies have linked Alzheimer's disease (AD) neuropathology to gene networks that regulate immune function. Kan et al. recently reported that Arg1 (an anti-inflammatory gene that codes for arginase-1) is expressed in parts of the brain associated with amyloidosis prior to the onset of neuronal loss, suggesting that chronic brain arginine deprivation promotes AD-related neuropathology. They blocked arginine catabolism in their mouse AD model by administration of eflornithine (DFMO) to juvenile animals, effectively blocking the expression of AD-related amyloid pathology as the mice aged. We report results from a single-case study in which DFMO was administered, for the first time, in an attempt to slow progression of AD in a single woman with multi-domain, amnestic MCI who was unable to tolerate an acetylcholinesterase inhibitor. Methods: Patient C.S. is a 74-year old female with a 5-year history of cognitive decline who was placed on DFMO (500 mg b.i.d.) for 12 months, with amyloid PET scans (baseline and 12-months), APOE genotyping and neuropsychological exams at baseline, 3, 9, and 12 months. Results: C.S. suffered continued cognitive decline over 12 months, including progressive worsening of orientation, social functions and ability to engage in IADL's. She also showed progressive decline on measures of episodic memory and executive function. Florbetapir PET imaging yielded elevated total neocortical SUVr scores at both baseline (SUVr = 1.55) and at 12 months (SUVr = 1.69). Conclusions: We report a first attempt at using DFMO to slow AD progression. This 12-month single-case trial did not halt continued amyloidosis nor cognitive decline. Although this trial was predicated on data reported by Kan et al. (2015) showing that DFMO administered to juvenile AD-prone mice led to diminished amyloid aggregation, this attempt to treat an older mild AD patient may not be a fair test of Kan et al.'s model and results. A future trial might seek to block amyloidosis in young adults who are autosomal gene carriers for early onset AD, or perhaps in adults who are very clearly in the pre-clinical disease stage. Trial Registration: This trial was registered as a Compassionate Use IND #128888 with the United States Food and Drug Administration (FDA).

Internal Medicine Resident Perspectives on Virtual Recruitment.

This survey study describes the perceived implications of virtual-only recruitment and the preferred application process for residents and fellows.

Hormone therapy for the prevention of bone loss in menopausal women with osteopenia: is it a viable option?

Osteopenia is a state of low bone mass, the appropriate clinical management of which is not always clear. The use of hormone therapy for postmenopausal bone loss has become controversial given recent data regarding the risks of therapy. Fragility fractures are common, and result in substantial morbidity and mortality. Although the fracture rate is higher among osteoporotic women, the substantially larger population of osteopenic women accounts for a higher absolute number of fractures. Osteopenia is defined solely according to the statistical properties of the distribution of bone mineral density (BMD) values, which limits its usefulness in clinical care. BMD, although inversely related to fracture risk, should not be used as the sole criterion for fracture risk. Limited data suggest that benefits of treatment seen in women with documented osteoporosis may not extend to osteopenic women. Although estrogen prevents postmenopausal bone loss, preservation of BMD does not necessarily translate into reduced fracture risk. In making decisions about whether to treat a woman with osteopenia, it is critical to estimate how treatments will affect the individual's risk of fracture. Treatment decisions should be based on whether the net benefits of treatment outweigh the anticipated risks, which will depend on the age of the patient and her risk profile. In our opinion, there is insufficient evidence to support treatment for women with a BMD in the osteopenic range in the absence of fragility fracture. For osteopenic women with higher risk, the availability of other treatments with a more favourable risk-benefit profile eliminates the role of hormone therapy for fracture prevention.