Association of Gender and Race/Ethnicity with Internal Medicine In-Training Examination Performance in Graduate Medical Education.

BACKGROUND: Disparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern. OBJECTIVE: Examine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity. DESIGN: Longitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014-2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square. PARTICIPANTS: A total of 689 IM residents, including 330 women and URiM residents (48%). MAIN MEASURES: ITE score KEY RESULTS: There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F(2, 1321) 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p<0.001). Women and URiM residents had greater odds of being at potential risk for not passing the ABIM-CE (OR 1.75, 95% CI 1.10 to 2.78) with greatest odds in PGY3 (OR 3.13, 95% CI 1.54 to 6.37). CONCLUSION: Differences in ITE over training were associated with resident gender and race/ethnicity. Women and URiM residents had smaller ITE score gains across PGY translating into greater odds of potentially being seen as at-risk for not passing the ABIM-CE. Differences in ITE over training may reflect differences in experiences of women and URiM residents during training and may lead to further disparities.

What Women Need: a Study of Institutional Factors and Women Faculty's Intent to Remain in Academic Medicine.

BACKGROUND: A longstanding gender gap exists in the retention of women in academic medicine. Several strategies have been suggested to promote the retention of women, but there are limited data on impacts of interventions. OBJECTIVE: To identify what institutional factors, if any, impact women faculty's intent to remain in academic medicine, either at their institutions or elsewhere. DESIGN: A survey was designed to evaluate institutional retention-linked factors, programs and interventions, their impact, and women's intent to remain at their institutions and within academic medicine. Survey data were analyzed using non-parametric statistics and regression analyses. PARTICIPANTS: Women with faculty appointments within departments of medicine recruited from national organizations and specific social media groups. MAIN MEASURES: Institutional factors that may be associated with women's decision to remain at their current institutions or within academic medicine. KEY RESULTS: Of 410 surveys of women at institutions across the USA, fair and transparent family leave policies and opportunities for work-life integration showed strong associations with intent to remain at one's institution (leave policies: OR 2.22, 95% CI 1.20-4.18, p = 0.01; work-life: OR 4.82, 95% CI 2.50-9.64, p < 0.001) and within academic medicine (leave policies: OR 2.31, 95% CI 1.09-5.03, p = 0.03; work-life: OR 4.66, 95% CI 2.04-11.36, p < 0.001). Other institutional factors associated with intent to remain in academics include peer mentorship (OR 3.16, 95% CI 1.56-6.57, p < 0.01) and women role models (OR 2.21, 95% CI 1.04-4.68, p = 0.04). Institutions helping employees recognize bias, fair compensation and provision of resources, satisfaction with mentorship, peer mentorship, and women role models within the institutions were associated with intent to remain at an institution. CONCLUSIONS: Our findings suggest that institutional factors such as support for work-life integration, fair and transparent policies, and meaningful mentorship opportunities appear impactful in the retention of women in academic medicine.

Training Residents in Virtual Advance Care Planning: A New Twist in Telehealth.

CONTEXT: Advance care planning (ACP) conversations represent an important physician skill, a need further highlighted by the COVID-19 pandemic. Most resident ACP training occurs in inpatient, settings, often featuring goals of care (GOC) conversations during a crisis. Outpatient clinics are valuable but underutilized settings to provide skills training for residents, yet little research has been done in these spaces. OBJECTIVE: We sought to 1) create an ACP curriculum harnessing the principles of a community of practice in a virtual format, and 2) obtain residents' perspectives regarding their skills and confidence in having early GOC conversations in the outpatient setting. METHODS: We interviewed 48 internal medicine residents using questionnaires, reflective narratives, and transcripts of debriefing conversations. We created a virtual curriculum during the ambulatory week which included didactics, virtual role plays, ACP phone conversations with five patients, and group debriefings. Quantitative data were analyzed for changes in resident confidence. Qualitative data were coded using thematic analysis, guided by instructor field notes. RESULTS: Residents reported decreased confidence in navigating advance directive conversations following training [Z=2.24, P=0.03, r = 0.33]. Resident reflections indicated that they felt more practiced at inpatient late GOC conversation skills, and that these skills were not fully transferable to the outpatient early GOC setting. Residents also endorsed the ambulatory environment as the best space for ACP conversations. CONCLUSION: This study illustrates the feasibility of a virtual format for ACP curriculum. The virtual community of practice created space for a metacognitive unmasking of prior resident unconscious incompetence. Also, inpatient, crisis-oriented late GOC conversation skills may translate poorly to the outpatient setting requiring early and ongoing GOC skills. Residents need more training to navigate ACP conversations in ambulatory environments.

Regional variation in human papillomavirus vaccination uptake and completion among adolescents 13-17 in the state of Texas.

BACKGROUND: HPV vaccination rates remain low in the United States despite efforts to increase them, although rates vary geographically both at the state and regional level within the United States. This study examines differences in teen HPV vaccination rates and associated sociodemographic factors among six regions in Texas to understand potential variation insmaller regions. These differences may inform planning of local public health interventions aimed at increasing vaccination uptake in teens. METHODS: We analyzed sociodemographic and vaccination data for a total of 2256 teens 13-17 years old from six regions in Texas using the 2017 National Immunization Survey--Teen (NIS-Teen). We used survey-weighted chi-squared tests to compare demographic characteristics and HPV vaccination initiation and series completion across regions and multivariable robust Poisson regression models to examine the association between region of residence and HPV vaccination outcomes. RESULTS: Rates of initiation and completion of the HPV vaccine series varied significantly between six regions in Texas and were both highest in El Paso County and lowest in Dallas County (initiation 82.8% vs52.5%, P < 0.001; completion 51.3% vs 30.2%, P < 0.001). Adjusted multivariable log binomial regression models demonstrated that teens in Dallas county were significantly less likely to initiate the HPV vaccine series than teens in Travis county (RR = 0.79, 95% CI: (0.65, 0.95), P = 0.01). DISCUSSION: HPV vaccination uptake varied significantly between six regions in Texas, highlighting the importance of closely examining local regions in public health planning efforts. Intervention efforts should consider the variation in sociodemographic characteristics as well as policy at the regional level to best improve vaccination rates in communities across the nation.

A Novel, Web-Based Quality Improvement Platform to Address ACGME CLER Requirements.

BACKGROUND: In 2014, the Accreditation Council for Graduate Medical Education (ACGME) formally mandated trainee (resident and fellow) participation in health care quality improvement (QI) projects as one of the Clinical Learning Environment Review (CLER) Pathways to Excellence. Subsequent national reviews showed large variations in how QI education is conducted, as well as a significant mismatch between educational and organizational goals. OBJECTIVE: We developed a web-based platform to engage trainees in QI that better aligned with best practice methodology and matched identified institutional priorities. METHODS: A needs assessment survey was distributed to trainees to understand the obstacles to compliance with ACGME QI requirements. Based on the results, a web-based clearinghouse, called the QI Platform, was developed and launched in July 2016, and utilization was analyzed in February 2019. RESULTS: A total of 196 of 440 needs assessment surveys (45%) were completed. Themes extracted from surveys to identify barriers in QI participation included difficulties designing projects, lack of mentorship or expert support, and difficulty engaging an interprofessional team. Over 2.5 years, 151 projects were registered on the platform. Of these, 17 (11%) were collaborative entries. At the time of analysis, 166 of 437 trainees (38%) were listed as participants in active QI projects. A total of 22 projects were archived as complete, and 68 incomplete projects were reassigned to the "Ideas" section as works in progress after lead trainee graduation. CONCLUSIONS: An institutional QI Platform clearinghouse for GME QI projects was feasible to develop and maintain, and it appeared acceptable to most GME programs and trainees for recording and tracking QI projects, and linking these to hospital QI priorities.

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.

A Joint Quality Improvement and High-Value Care Curriculum in a Limited-Resource Setting.

INTRODUCTION: Since the release of the Institute of Medicine's To Err Is Human, there has been an increased focus on quality improvement (QI). QI training is now a requirement monitored via ACGME's clinical learning environment review committees. Given the significant cost of health care waste, teaching physicians to incorporate costs and value into medical decision making is crucial. Increasing information is available on methods to teach high-value care (HVC), but there is little information on combining HVC with QI. As these topics are intimately linked in efforts to provide effective, efficient care, a joint curriculum is a feasible solution. METHODS: We adapted material from two online resources-(1) Institute of Healthcare Improvement Open School and (2) American College of Physicians High Value Cost-Conscious Care Curriculum-to create a combined curriculum for use in a limited-resource setting. Our curriculum is divided into 10 seminars, each including both QI techniques and HVC theories, which are reinforced using a series of patient scenarios. Residents apply their knowledge in self-directed projects presented in the final seminar. Evaluation includes a pre-/postexposure QI knowledge application test, survey of self-assessed knowledge, and anonymous course feedback. RESULTS: For the 46 residents who completed the series, a statistically significant improvement in both tests was measured, and feedback was positive overall. Tailoring our in-seminar patient scenarios allowed residents to demonstrate their HVC knowledge acquisition. DISCUSSION: This seminar-based curriculum can be adapted to the time availability in any residency program and transfer to other disciplines with modification of the patient scenarios.

A 29-year-old man with an unusual cause of an abscess.

A 29-year-old man with no medical history presented with a left scalp abscess and left temporal oedema. He was initially started on treatment for community acquired Methicillin-resistant Staphylococcus aureus with sulfamethoxazole and trimethoprim. Over the next 2 weeks, his swelling improved; however, he continued to have localised swelling and drainage from the area. Eventually, larvae of a botfly were removed from his scalp, and his symptoms resolved.

Treatment preferences among problem drinkers in primary care.

OBJECTIVE: Alcohol misuse is common among primary care patients, yet many do not receive treatment because doctors believe problem drinkers are "in denial," or are unwilling to change their drinking habits. The real problem, however, may be that patients are being offered treatment modalities that do not meet their needs. This study was designed to measure the acceptability of various treatment options among drinkers who were currently not receiving treatment. METHOD: Patients in a primary care clinic were given a self-report questionnaire that included: (1) the Alcohol Use Disorders Questionnaire, (2) a measure of readiness to change drinking behavior, and (3) a list of treatment modalities to be rated based on level of interest. RESULTS: Within a random sample of 402 patients, 40.2% reported high risk drinking and 16.3% reported problem drinking. Among the latter group, 89.3% were either considering change, or had begun to take steps to make changes in their drinking behaviors. When asked about treatment preferences, the modalities most frequently recommended by physicians-group therapy and Alcoholics Anonymous-were among the least acceptable. The most popular options were getting help from a primary care doctor and taking a medication that would make it easier to avoid drinking without making them sick if they drank. CONCLUSIONS: The belief that problem drinkers are unwilling to change was not supported by this study. Treatment for problem drinking should involve a collaborative evaluation of options with an emphasis on patient preference and treatment within the primary care setting.