Perceptions of X+Y Scheduling Among Combined Internal Medicine-Pediatrics Residency Trainees: A Qualitative Program Evaluation.

OBJECTIVE: The study aims to elicit perceived benefits and downsides of X+Y scheduling for combined Internal Medicine-Pediatrics (Med-Peds) residents via focus groups. METHODS: Five focus groups were conducted with Med-Peds residents in participating programs which utilized X+Y scheduling. Onefocus group was held per participating institution. Each focus group was facilitated by a chief resident from a different participating institution. Questions were developed by the study team after a review of the literature and local experience with X+Y scheduling and included open-ended questions. Focus groups were recorded and transcribed. Transcripts were reviewed by study team members, and representative themes and quotes were presented. The main outcome was to evaluate the perceived benefits and downsides of X+Y scheduling for Med-Peds. RESULTS: Results from four of the five focus groups were fully reviewed. Themes regarding the benefits of X+Y scheduling included (1) improved inpatient and outpatient experience, (2) predictability in schedule which improved wellness, and (3) longitudinal time for career exploration. Downsides of X+Y scheduling were highlighted as well including (1) condensing too many experiences into Y time and (2) challenges that exist when categorical medicine and pediatrics programs use different block schedules. CONCLUSIONS: X+Y schedules create potential solutions for longstanding barriers to medical education and notably conflict with inpatient and outpatient responsibilities. Our data shows similar benefits to X+Y scheduling for combined residents as for their categorical colleagues and sheds light on some unique considerations for combined programs and trainees. Additional studies should continue to assess the effect of X+Y scheduling on our combined trainees.

Safety and predictors of the success of lumbar punctures performed by a medicine procedure service.

BACKGROUND: Medicine procedure services (MPS) increasingly perform bedside procedures, including lumbar punctures (LPs). Success rates and factors associated with LP success performed by MPS have not been well described. OBJECTIVE: We identified patients undergoing LP by an MPS September 2015 to December 2020. We identified demographic and clinical factors, including patient position, body mass index (BMI), use of ultrasound, and trainee participation. We performed multivariable analysis to identify factors associated with LP success and complications. MAIN OUTCOME AND MEASURES: We identified 1065 LPs among 844 patients. Trainees participated in 82.2%; ultrasound guidance was used in 76.7% of LPs. The overall success rate was 81.3% with 7.8% minor and 0.1% major complications. A minority of LPs were referred to radiology (15.2%) or were traumatic (11.1%). In multivariable analysis, BMI > 30 kg/m2 (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.21-0.48), prior spinal surgery (OR 0.50, 95% CI 0.26-0.87), and Black race (OR 0.62, 95% CI 0.41-0.95) were associated with decreased odds of successful LP; trainee participation (OR 2.49, 95% CI 1.51-4.12) was associated with increased odds. Ultrasound guidance (OR 0.53, 95% CI 0.31-0.89) was associated with lower odds of traumatic LP. RESULTS: In a large cohort of patients undergoing LP by an MPS, we identified high success and low complication rates. Trainee participation was associated with increased odds of success, while obesity, prior spinal surgery, and Black race were associated with decreased odds of success. Ultrasound guidance was associated with lower odds of a traumatic LP. Our data may help proceduralists in planning and assist in shared decision-making.

The Implementation of X + Y Scheduling in Combined Internal Medicine-Pediatrics Residency Programs: Practical Considerations for Program Leadership.

The X + Y scheduling approach, or block scheduling, is common among internal medicine residency programs. With the beginning of a pilot program through the American College of Graduate Medical Education in 2018, pediatrics and internal medicine-pediatrics (Med-Peds) residency programs have been able to adopt X + Y scheduling as well. The X + Y scheduling approach presents unique challenges and opportunities for combined Med-Peds residencies. This paper describes an early experience with X + Y scheduling in Med-Peds residencies and describes practical considerations for Med-Peds programs considering or planning a transition to the X + Y schedule. These considerations include strategies for gaining stakeholder support; selecting the appropriate block structure; opportunities for designing the ambulatory curriculum; and maximizing the clinical benefit in the residency continuity clinic.

Focusing on Diversity: A Regional Internal Medicine Residency Viewpoint on Underrepresented Minority Support, Retention, and Mentoring.

BACKGROUND: While the overall percentage of residents who withdraw (2.7%) or take extended leave (1.0%) are low, subgroup analysis has found that minority physicians are approximately 30% more likely to withdraw from residency than their white counterparts and 8 times more likely to take extended leave of absence. With ongoing national efforts to support diversity in medical education through increased recruitment of underrepresented in medicine (UiM) students to residency programs, there is paucity of data identifying specific experiences challenging or contributing to their overall resiliency. Better understanding of the lived experience of UiM residents will allow residency programs to create successful curricular programing and support structures for residents to thrive. OBJECTIVE: We sought to understand UiM internal medicine residents' experiences during residency training. METHODS: We used a retrospective review of focus group transcripts of UiM internal medicine residents from 5 academic institutions in 2017 (4 in North Carolina and 1 in Georgia). RESULTS: Of 100 self-identified UiM residents from 5 institutions, 59 participated in the focus groups. Using a consensus-based review of transcripts, 25 distinct codes in 8 parent code categories were determined. Two primary themes emerged: resilience and isolation. Three secondary themes-social support, mentorship, and external expectations and/or biases-served as mediators for the primary themes. CONCLUSIONS: UiM residents who became or were already resilient commonly experienced isolation at some time in their medical career, specifically during residency. Moreover, they could be influenced and positively or negatively affected by social support, mentorship, and external expectations and biases.

Skeletal muscle metastasis from signet ring cell esophageal adenocarcinoma.

Symptomatic skeletal muscle metastasis from esophageal adenocarcinoma is rare. Here we report the case of a 49-year-old man who presented with right thigh pain, and was found to have symptomatic psoas muscle metastasis as the presentation of esophageal adenocarcinoma. The primary tumor was notable for signet ring cells (SRC), a poor prognostic indicator as well as a predictor of biologic aggressiveness. The patient passed away within 1 month of diagnosis due to disease progression, supporting the aggressiveness of such SRC esophageal lesions. Lastly, a literature review reveals a differential pattern of metastatic spread between esophageal adenocarcinomas and squamous cell carcinomas as regards muscle metastases. Skeletal muscle metastases are more likely to be due to esophageal adenocarcinoma, whereas myocardial metastases are almost exclusively due to esophageal squamous cell carcinoma (ESCC). These differences may represent an example of the 'seed and soil' hypothesis of metastasis.