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.

Moving Beyond the Dichotomous Assessment of Professionalism in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors.

PURPOSE: This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students. METHOD: The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics. RESULTS: Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students. CONCLUSIONS: Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.

Bias Reporting in the Clinical Learning Environment: A National Survey of Internal Medicine Clerkship Directors.

PURPOSE: Bias exists in the internal medicine (IM) clinical learning environment; however, it is unclear how often bias is identified by clerkship directors (CDs), how bias is addressed, and whether best practices exist for identifying or mitigating bias. This study investigated how IM CDs receive and respond to bias reports in the clinical learning environment. METHOD: In May 2021, the Clerkship Directors in Internal Medicine (CDIM) created an 18-question survey assessing the frequency of bias reports, macroaggressions and microaggressions, and report outcomes. Of the 152 U.S. medical schools that met study accreditation criteria, the final survey population included 137 CDs (90%) whose medical schools held valid CDIM membership. RESULTS: Of the 137 surveys sent, 100 were returned (survey response rate, 73%). Respondents reported a median of 3 bias events (interquartile range, 1-4; range, 0-50) on the IM clerkship in the past year. Among 76 respondents who reported 1 or more event, microaggressions represented 43 of the 75 total events (57%). No mechanism emerged as the most commonly used method for reporting bias. Race/ethnicity (48 of 75 [64%]) and gender (41 of 75 [55%]) were cited most as the basis for bias reports, whereas the most common sources of bias were student interactions with attending physicians (51 of 73 [70%]) and residents (40 of 73 [55%]). Of the 75 respondents, 53 (71%) described the frequency of bias event reports as having increased or remained unchanged during the past year. Only 48 CDs (49%) responded that they were "always" aware of the outcome of bias reports. CONCLUSIONS: Bias reports remain heterogeneous, are likely underreported, and lack best practice responses. There is a need to systematically capture bias events to work toward a just culture that fosters accountability and to identify bias events through more robust reporting.

Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors.

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

Reviewing Internal Medicine Clerkship Grading Through a Proequity Lens: Results of a National Survey.

PURPOSE: Equity in assessment and grading has become imperative across medical education. Although strategies to promote equity exist, there may be variable penetrance across institutions. The objectives of this study were to identify strategies internal medicine (IM) clerkship directors (CDs) use to reduce inequities in assessment and grading and explore IM CDs' perceptions of factors that impede or facilitate the implementation of these strategies. METHOD: From October to December 2021, the Clerkship Directors in Internal Medicine of the Alliance for Academic Internal Medicine conducted its annual survey of IM core CDs at 137 U.S. and U.S. territory-based medical schools. This study is based on 23 questions from the survey about equity in IM clerkship assessment and grading. RESULTS: The survey response rate was 73.0% (100 of 137 medical school CDs). Use of recommended evidence-based strategies to promote equity in clerkship assessment and grading varied among IM clerkships. Only 30 respondents (30.0%) reported that their clerkships had incorporated faculty development on implicit bias for clinical supervisors of students; 31 (31.0%) provided education to faculty on how to write narrative assessments that minimize bias. Forty respondents (40.0%) provided guidance to clerkship graders on how to minimize bias when writing final IM clerkship summaries, and 41 (41.0%) used grading committees to determine IM clerkship grades. Twenty-three CDs (23.0%) received formal education by their institution on how to generate clerkship grades and summaries in a way that minimized bias. CONCLUSIONS: This national survey found variability among medical schools in the application of evidence-based strategies to promote equity in assessment and grading within their IM clerkships. Opportunities exist to adopt and optimize proequity grading strategies, including development of programs that address bias in clerkship assessment and grading, reevaluation of the weight of standardized knowledge exam scores on grades, and implementation of grading committees.

Medical student advising during virtual residency recruitment: results of a national survey of internal medicine clerkship and sub-internship directors.

INTRODUCTION: The residency application process is a critical time for medical students. The COVID-19 pandemic prompted changes to the residency recruitment procedures with the conversion of interviews to a virtual format. For medical school advisors guiding students on an all-virtual residency application process brought uncertainty to their advising practices. Thus, this study aimed to identify advising practices during the 2021 virtual application cycle. METHODS: We administered an IRB-exempt national survey through the Clerkship Directors in Internal Medicine to 186 internal medicine core/co-/associate/assistant clerkship directors and sub-internship directors representing 140 Liaison Committee on Medical Education-accredited U.S./U.S.-territory-based medical schools in spring 2021. The 23-question survey was designed and pilot-tested by faculty-educators and leaders with expertise in undergraduate medical education. Data analysis included paired t- and z-tests and thematic analysis of open-ended questions. RESULTS: The institutional response rate was 67% (93/140) and individual rate 55% (103/186). Half of the respondents felt prepared/very prepared (40% and 13% respectively) for their advising roles. Compared to pre-pandemic cycles, respondents advised a typical student in the middle-third of their class at their institution to apply to more residency programs (mean 24 programs vs 20, p < 0.001) and accept more interviews (mean 14 interviews vs 12, p < 0.001). Sixty-three percent (64/101) of respondents spent more time on student advising; 51% (51/101) reported more students asked them for informal advice. Fifty-nine percent (60/101) of respondents reported their advisees were able to assess a residency program 'somewhat well;' 31% (31/101) expressed that residency recruitment should remain entirely virtual in the future. CONCLUSION: The transition to virtual residency recruitment due to COVID-19 prompted advising practices that may have contributed to application inflation and increased advising workload. Future studies should explore longitudinal outcomes of virtual interviews on student success to guide best practices in how to advise students during residency recruitment.

Residency Program Responses to Early COVID-19 Surges Highlight Tension as to Whether Residents Are Learners or Essential Workers.

PURPOSE: To quantify the extent to which internal medicine (IM) residents provided care for patients with COVID-19 and examine characteristics of residency programs with or without plans (at some point) to exclude residents from COVID-19 care during the first 6 months of the pandemic. METHOD: The authors used data from a nationally representative, annually recurring survey of U.S. IM program directors (PDs) to quantify early (March-August 2020) resident participation in COVID-19 care. The survey was fielded from August to December 2020. PDs reported whether they had planned to exclude residents from COVID-19 care (i.e., PTE status). PTE status was tested for association with program and COVID-19 temporal characteristics, resident schedule accommodations, and resident COVID-19 cases. RESULTS: The response rate was 61.5% (264/429). Nearly half of PDs (45.4%, 118/260) reported their program had planned at some point to exclude residents from COVID-19 care. Northeastern U.S. programs represented a smaller percentage of PTE than non-PTE programs (26.3% vs 36.6%; P = .050). PTE programs represented a higher percentage of programs with later surges than non-PTE programs (33.0% vs 13.6%, P = .048). Median percentage of residents involved in COVID-19 care was 75.0 (interquartile range [IQR]: 22.5-100.0) for PTE programs, compared with 95.0 (IQR: 60.0-100.0) for non-PTE programs ( P < .001). Residents participated most in intensive care units (87.6%, 227/259) and inpatient wards (80.8%, 210/260). Accommodations did not differ by PTE status. PTE programs reported fewer resident COVID-19 cases than non-PTE programs (median percentage = 2.7 [IQR: 0.0-8.6] vs 5.1 [IQR: 1.6-10.7]; P = .011). CONCLUSIONS: IM programs varied widely in their reported plans to exclude residents from COVID-19 care during the early pandemic. A high percentage of residents provided COVID-19 care, even in PTE programs. Thus, the pandemic highlighted the tension as to whether residents are learners or employees.

Innovation and Missed Opportunities in Internal Medicine Undergraduate Education During COVID-19: Results from a National Survey.

BACKGROUND: COVID-19 disrupted undergraduate clinical education when medical schools removed students from clinical rotations following AAMC recommendations. Clerkship directors (CDs) had to adapt rapidly and modify clerkship curricula. However, the scope and effects of these modifications are unknown. OBJECTIVE: To examine the effects of the initial phase of COVID-19 on the internal medicine (IM) undergraduate clinical education. DESIGN: A nationally representative web survey. PARTICIPANTS: IM CDs from 137 LCME-accredited US medical schools in 2020. MAIN MEASURES: Items (80) assessed clerkship structure and curriculum, assessment in clerkships, post-clerkship IM clinical experiences, and CD roles and support. The framework of Understanding Crisis Response (Royal Society for Encouragement of Arts, Manufactures, and Commerce) was used to determine whether curricular modifications were "amplified," "restarted," "let go," or "ended." KEY RESULTS: Response rate was 74%. In response to COVID-19, 32% (32/101) of clerkships suspended all clinical activities and 66% (67/101) only in-person. Prior to clinical disruption, students spent a median of 8.0 weeks (IQR: 2) on inpatient and 2.0 weeks (IQR: 4) on ambulatory rotations; during clinical re-entry, students were spending 5.0 (IQR: 3) and 1.0 (IQR: 2) weeks, respectively. Bedside teaching and physical exam instruction were "let go" during the early phase. Students were removed from direct patient care for a median of 85.5 days. The sub-internship curriculum remained largely unaffected. Before the pandemic, 11% of schools were using a pass/fail grading system; at clinical re-entry 47% and during the survey period 23% were using it. Due to the pandemic, 78.2% of CDs assumed new roles or had expanded responsibilities; 51% reported decreased scholarly productivity. CONCLUSIONS: Curricular adaptations occurred in IM clerkships across US medical schools as a result of COVID-19. More research is needed to explore the long-term implications of these changes on medical student education and clinical learning environments.

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.

Internal Medicine Residency Program Director Support and Burnout During the COVID-19 Pandemic: Results of a National Survey.

Background: Burnout is common among physicians and physician leaders, including residency program directors (PDs). The effects of the COVID-19 pandemic and other stressors in 2020 on PDs is unknown. Objective: To measure the prevalence of burnout among internal medicine (IM) residency PDs 6 months into the COVID-19 pandemic. Methods: A total of 429 IM PDs, representing 83% of accredited residency programs, were surveyed from August to December 2020. Burnout, using a 2-item screening tool, and self-reported consideration of resigning in 2020, were compared to their annual prevalence since 2012 and tested for possible associations with pandemic stressors and program characteristics. Results: The survey response rate was 61.5% (264 of 429). One-third (33.6%, 87 of 259) of PD respondents met burnout criteria, and 45.1% (110 of 244) reported considering resigning in the past year, which were within the range of preceding years. PDs who reported feeling highly supported by institutional leadership were less likely to meet burnout criteria and to have considered resigning. There were no associations between burnout or consideration of resigning and the amount of clinical time PDs spent in their roles, duration of maximum stress on programs, budget cuts to programs, or geographic region. Conclusions: The prevalence of burnout among PDs in fall 2020 was similar to the prevalence of burnout in pre-pandemic years despite uniquely extreme stressors. PDs' perception of being highly supported by institutional leadership was associated with lower prevalence of burnout and consideration of resigning. Perceived leadership support may be a protective factor against burnout during periods of high stress.

Parental Leave Policies in Residency: A National Survey of Internal Medicine Program Directors.

PURPOSE: To characterize the existence, accessibility, and content of parental leave policies, as well as barriers to program-level policy implementation among internal medicine (IM) program directors (PDs) and to assess the willingness of PDs to implement a national standardized policy. METHOD: In 2019, the Association of Program Directors in Internal Medicine conducted a survey of 422 IM PDs. Along with other content, 38 questions addressed 4 primary outcomes: parental leave policy existence, accessibility, content, and barriers. The authors compared programs with and without a program-level policy and applied qualitative content analysis to open-ended questions about barriers to policy implementation and openness to a national standard. RESULTS: The response rate was 69.4% (293/422). Of responding programs, 86% (250/290) reported a written parental leave policy with 43% (97/225) of these originating at the program level. Program-level policies, compared with policies at other levels, were more likely to address scheduling during pregnancy (38%, 36/95 vs 22%, 27/124; P = .018); peer coverage (24%, 21/89 vs 15%, 16/109; P = .037), how the duration of extended training is determined (81%, 72/89 vs 44%, 48/109; P < .001), and associated pay and benefits 61%, 54/89 vs 44%, 48/109; P = .009). PDs without program-level policy reported lacking guidance to develop policy, deferring upward to institutional policies, and wishing to retain flexibility. More than half of PDs (60%, 170/282) expressed agreement that a national standard for a residency program-level parental leave policy should exist. Those not in favor cited organization equity, lack of resources, implementation challenges, loss of flexibility, and potentially disadvantaging recruitment. CONCLUSIONS: While existing program-level policies included important content, most PDs reported not having them. A national standard to guide the development of program-level parental leave policies could be embraced if it provided flexibility for programs with limited resources.

Training in Safe Opioid Prescribing and Treatment of Opioid Use Disorder in Internal Medicine Residencies: a National Survey of Program Directors.

BACKGROUND: Training future clinicians in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD) is critical to address the opioid epidemic. The Accreditation Council on Graduate Medical Education requires all programs to provide instruction and experience in pain management and will mandate addiction medicine clinical experiences for internal medicine trainees. OBJECTIVE: Assess residents' training in SOP and treatment of OUD and identify training barriers. DESIGN: Cross-sectional nationally representative survey was emailed in 2019. PARTICIPANTS: Four hundred twenty-two Association of Program Directors in Internal Medicine members in US internal medicine residency programs. MAIN MEASURES: Program opportunities and challenges to developing or implementing training in SOP, treatment of OUD, and buprenorphine waiver training, and perceived curricular effectiveness. KEY RESULTS: The response rate was 69.4% (293/422). Most programs required didactics in SOP (94.2%) and treatment of OUD (71.7%). Few programs required clinical experiences including addiction medicine clinics (28/240, 11.7%), inpatient consult services (11/240, 4.6%), or offsite treatment rotations (8/240, 3.3%). Lack of trained faculty limited developing or implementing curricula (61.5%). Few respondents reported that their program was "very effective" in teaching SOP (80/285, 28.1%) or treatment of OUD (43/282, 15.3%). Some programs offered buprenorphine waiver training to residents (83/286, 29.0%) and faculty (94/286, 32.9%) with few mandating training (11.7% (28/240) and 5.4% (13/240) respectively). Only 60 of 19,466 (0.3%) residents completed buprenorphine waiver training. Primary care programs/tracks were more likely to offer waiver training to residents (odds ratio [OR], 3.07; 95% CI, 1.68-5.60; P < 0.001) and faculty (OR, 1.08; 95% CI, 1.01-3.22; P = 0.05). CONCLUSIONS: In this nationally representative survey, few internal medicine residency programs provided clinical training in SOP and treatment of OUD, and training was not viewed as very effective. Lack of effective training may have adverse implications for patients, clinicians, and society.

Roles and Responsibilities of Medicine Subinternship Directors : Medicine Subinternship Director Roles.

BACKGROUND: The internal medicine (IM) subinternship (also referred to as acting internship) plays a crucial part in preparing medical students for residency. The roles, responsibilities, and support provided to subinternship directors have not been described. OBJECTIVE: We sought to describe the current role of IM subinternship directors with respect to their responsibilities, salary support, and reporting structure. DESIGN: Nationally representative, annually recurring thematic survey of IM core clerkship directors with membership in an academic professional association as of September 2017. PARTICIPANTS: A total of 129 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited U.S./U.S.-territory-based medical schools. MAIN MEASURES: Responsibilities, salary support, and reporting structure of subinternship directors. KEY RESULTS: The survey response rate was 83.0% (107/129 medical schools). Fifty-one percent (54/107) of respondents reported overseeing both core clerkship inpatient experiences and/or one or more subinternships. For oversight, 49.1% (28/53) of subinternship directors also reported that they were the clerkship director, 26.4% (14/53) that another faculty member directed all medicine subinternships, and 18.9% (10/53) that each subinternship had its own director. The most frequently reported responsibilities for the subinternship directors were administration, including scheduling, and logistics of student schedules (83.0%, 44/53), course evaluation (81.1%, 43/53), and setting grades 79.2% (42/53). The modal response for estimated FTE per course was 10-20% FTE, with 33.3% (16/48) reporting this level of support and 29.2% (14/54) reporting no FTE support. CONCLUSIONS: The role of the IM subinternship director has become increasingly complex. Since the IM subinternship is critical to preparing students for residency, IM subinternship directors require standard expectations and adequate support. Future studies are needed to determine the appropriate level of support for subinternship directors and to define essential roles and responsibilities.