Evaluation of an Individualized Learning Plan Template for the Transition to Residency.

Background Specialty-specific individualized learning plans (ILPs) have been promoted to improve the undergraduate to graduate medical education transition, yet few pilots have been described. Objective To create and report on the feasibility and acceptability of a pilot internal medicine (IM) ILP template. Methods The ILP was created by a group of diverse IM expert stakeholders and contained questions to stimulate self-reflection and collect self-reported readiness data from incoming interns. US IM residency programs were invited to pilot the ILP with interns in spring 2022. Data was used at the programs' discretion. The pilot was evaluated by a post-pilot survey of programs to elicit perceptions of the impact and value of the ILP and analyze anonymous ILP data from 3 institutions. Results Fifty-two IM residency programs agreed to participate with a survey response rate of 87% (45 of 52). Of responding programs, 89% (40 of 45) collected ILPs, thus we report on data from these 40 programs. A total of 995 interns enrolled with 782 completing ILPs (79%). One hundred eleven ILPs were analyzed (14%). Most programs found the ILP valuable to understand incoming interns' competencies (26 of 40, 65%) and areas for improvement (24 of 40, 60%) and thought it should continue (29 of 40, 73%). Programs estimated the ILP took interns 29.2±14.9 minutes and 21.6±10.3 minutes for faculty mentors to complete. The most common barrier was faculty mentor participation. Conclusions An ILP based on interns' self-reported data was feasible and valuable to IM residency programs in understanding interns' competencies and areas for improvement.

A New Formula for Estimating the True QT Interval in Left Bundle Branch Block.

INTRODUCTION: QT prolongation is an independent risk factor for cardiac mortality. Left bundle branch block (LBBB) is more common in patients as they age. Widening of the QRS in LBBB causes false QT prolongation and thus makes true QT assessment difficult. We aimed to develop a simple formula to achieve a good estimate of the QT interval in the presence of LBBB. METHODS AND RESULTS: To determine the effect of QRS duration on the QT interval, QRS and QT were measured in sinus rhythm and during right ventricular apical pacing in 62 patients (age 55 ± 11 years, 60% male) undergoing electrophysiology studies. A QT formula for LBBB (QT-LBBB) was derived based on the effect of increased QRSLBBB on QTLBBB . The predictive accuracy of the QT-LBBB formula was then tested in 22 patients (age 66 ± 13 years, 64% male) with intermittent LBBB with comparisons to prior QT formulae and JT index. On average, the net increase in QRSLBBB constituted 92% of the net increase in QTLBBB . A new formula, QT-LBBB = QTLBBB - (0.86 * QRSLBBB - 71), which takes the net increase in QRSLBBB into account, best predicted the QT interval with heart rate corrected QTc in the test set of LBBB ECGs when compared to the baseline value and prior formulae. CONCLUSION: The QT-LBBB formula developed in this study best estimates the true QT interval in the presence of LBBB. It is simple and therefore can be easily utilized in clinical practice.

Assessing Correlations of Physicians' Practice Intensity and Certainty During Residency Training.

BACKGROUND: Variation in physicians' practice patterns contributes to unnecessary health care spending, yet the influences of modifiable determinants on practice patterns are not known. Identifying these mutable factors could reduce unnecessary testing and decrease variation in clinical practice. OBJECTIVE: To assess the importance of the residency program relative to physician personality traits in explaining variations in practice intensity (PI), the likelihood of ordering tests and treatments, and in the certainty of their intention to order. METHODS: We surveyed 690 interns and residents from 7 internal medicine residency programs, ranging from small community-based programs to large university residency programs. The surveys consisted of clinical vignettes designed to gauge respondents' preferences for aggressive clinical care, and questions assessing respondents' personality traits. The primary outcome was the participant-level mean response to 23 vignettes as a measure of PI. The secondary outcome was a certainty score (CS) constructed as the proportion of vignettes for which a respondent selected "definitely" versus "probably." RESULTS: A total of 325 interns and residents responded to the survey (47% response rate). Measures of personality traits, subjective norms, demographics, and residency program indicators collectively explained 27.3% of PI variation. Residency program identity was the largest contributor. No personality traits were significantly independently associated with higher PI. The same collection of factors explained 17.1% of CS variation. Here, personality traits were responsible for 63.6% of the explained variation. CONCLUSIONS: Residency program affiliations explained more of the variation in PI than demographic characteristics, personality traits, or subjective norms.

Evaluating proteinuria and nephrotic syndrome in patients with venous thromboembolism.

INTRODUCTION: Venous thromboembolism (VTE) is a well-known complication of nephrotic syndrome (NS). Proteinuria, a marker of chronic kidney disease, discovered at the time of VTE, may be the first presentation in patients with occult chronic kidney disease and/or NS. METHODS: Electronic medical records at a community teaching hospital were retrospectively reviewed to measure the percentage of patients with acute VTE who had a urinalysis (UA) and/or an evaluation of 24-hour urine protein collection or urine protein to creatinine ratio. Thromboembolic events were defined as acute deep vein thrombosis and/or pulmonary embolism. NS was defined as ≥3.5 g proteinuria in 24 hours or by urine protein to creatinine ratio exceeding 3.5. RESULTS: UA was done in 198 patients (63%) on the same admission for VTE and in 83 patients (26%) at a later date. Proteinuria, on routine UA, was identified in 154 (54%) patients. However, only 29 of 154 patients (19%) with proteinuria on UA had a formal evaluation of urine protein excretion, either by 24-hour collection or by spot protein to creatinine ratio. Eight of these 29 patients (28%) had NS. CONCLUSIONS: Patients suffering from VTE may have proteinuria if not frank NS. The UA should be part of the routine evaluation of a patient with VTE given the unexpectedly high prevalence of proteinuria and even NS in this cohort.