Intersection of Race, Rurality, and Income in Defining Access to Minimally Invasive Lung Surgery.

BACKGROUND: Race is a potent influencer of healthcare access. Geography and income may exert equal or greater influence on patient outcomes. We sought to define the intersection of race, rurality, and income and their influence on access to minimally invasive lung surgery in Medicare beneficiaries. METHODS: Medicare and Medicaid Services data were used to evaluate patients with lung cancer who underwent right upper lobectomy, via open, robotic-assisted (RATS), or video-assisted thoracic surgery (VATS) between 2018 and 2020. International Classification of Diseases 10th edition was used to define diagnoses and procedures. We excluded sub-lobar, segmental, wedge, bronchoplastic, or reoperative patients with non-malignant or metastatic disease or a history of neoadjuvant chemotherapy. Risk adjustment was performed using inverse probability of treatment weighting (IPTW) propensity scores with generalized linear models and Cox Proportional Hazards models. RESULTS: The cohort comprised 13,404 patients, 4,291 (32.1%) open, 4,317 (32.2%) RATS, and 4,796 (35.8%) VATS. Black/Urban patients had significantly higher RATS and VATS rates (p<0.001), higher long-term survival (p=0.007), fewer open resections (p<0.001), and lower overall mortality (p=0.007). Low-income Black/Urban patients had higher RATS (p=0.002), VATS (p<0.001), higher long-term survival (p=0.005), fewer open resections (p<0.001), and lower overall mortality compared to rural white patients. (p=0.005). CONCLUSIONS: Rural white populations living close to the federal poverty line may suffer a burden of disparity traditionally observed among poor Black people. This suggests a need for health policies that extend services to impoverished, rural areas to mitigate social determinants of health.

Lifestyle Factors and Other Influences on Medical Students Choosing a Career in Emergency Medicine.

OBJECTIVE: The purpose of this study was to determine which lifestyle factors influence medical students who choose a career in emergency medicine (EM). METHODS: Final-year medical students from 10 medical schools were surveyed after the National Residency Match Program match but prior to graduation regarding preferred medical specialty and lifestyle preferences. Responses from students pursuing EM regarding importance of lifestyle factors were compared to students interested in other specialties. RESULTS: A total of 453 of 1,575 invited medical students completed an electronic survey. EM was the third most preferred specialty. Students selecting EM were less likely to endorse "having control of work schedule" as being important (p < 0.005), but more likely to endorse "having time off work" as important (p < 0.05). When students were asked what specific factors were important in choosing a specialty, EM students differed from other students in the importance of flexible work schedule, time outside of work, and balance between work and personal life (p < 0.001). Fewer EM students endorsed that having a "low-stress work day" was an important consideration in their specialty choice (p < 0.001). CONCLUSIONS: In this study representing 10 medical schools, graduating medical students who prefer EM as opposed to other specialties exhibit differences in lifestyle factors deemed important when choosing a specialty as a physician. Further investigation regarding any potential link to these factors and career longevity is warranted.

Where Do International Medical Graduates Matriculate for Internal Medicine Training? A National Longitudinal Study.

INTRODUCTION: In 2020, roughly 25% of applicants who matched into internal medicine (IM) residencies were international medical graduates (IMGs). We examine 12-year trends in distribution of IMGs among IM training programs and explore differences in program perceptions towards IMG recruitment. METHODS: Since 2007, Association of Program Directors in Internal Medicine Annual Surveys have collected data about trainees by medical school graduate type. Sixteen additional questions regarding perceptions of IMGs were included in the 2017 spring survey. RESULTS: The 2017 survey response rate was 63.3% (236/373) and ranged from 61.9 to 70.2% for the 2007-2019 Annual Surveys. During that 12-year period, 55-70% of community programs' and 22-30% of university programs' PGY1 positions were filled by IMGs. In 2017, 45% of community programs' and 15% of university programs' interview and ranking positions were allocated to IMGs. Departmental pressure (university 45.6% [95% CI 43.7-47.5]; community 28.2% [95% CI 26.6-29.7]; p = 0.007), institutional priority (university 64.0% [95% CI 62.1-66.0]; community 41% [95% CI 36.9-44.6]; p = 0.001), and reputational concerns (university 52.8% [95% CI 50.0-55.6]; community 38.5% [95% CI 36.0-40.9]; p = 0.045) were cited as factors influencing recruitment of IMGs. CONCLUSION: Our study was limited to exploring program factors in residency recruitment and did not assess applicant preferences. There is a large, longstanding difference in the recruitment of IMGs to US community-based and university residencies, beginning during the interview and ranking process. Further research in disparities in IMG recruitment is needed, including exploring pressures, preferences, and potential biases associated with the recruitment of IMGs.

Does Increased Schedule Flexibility Lead to Change? A National Survey of Program Directors on 2017 Work Hours Requirements.

BACKGROUND: The learning and working environment for resident physicians shifted dramatically over the past two decades, with increased focus on work hours, resident wellness, and patient safety. Following two multi-center randomized trials comparing 16-h work limits for PGY-1 trainees to more flexible rules, the ACGME implemented new flexible work hours standards in 2017. OBJECTIVE: We sought to determine program directors' (PDs) support for the work hour changes and programmatic response. DESIGN: In 2017, US Internal Medicine PDs were surveyed about their degree of support for extension of PGY-1 work hour limits, whether they adopted the new maximum continuous work hours permitted, and reasons for their decisions. KEY RESULTS: The response rate was 70% (266/379). Fifty-seven percent of PDs (n = 151) somewhat/strongly support the new work hour rules for PGY-1 residents, while only 25% of programs (N = 66) introduced work periods greater than 16-h on any rotation. Higher rates of adopting change were seen in PDs who strongly/somewhat supported the change (56/151 [37%], P < 0.001), had tenure of 6+ years (33/93 [35%], P = 0.005), were of non-general internal medicine subspecialty (30/80 [38%], P = 0.003), at university-based programs (35/101 [35%], P = 0.009), and with increasing number of approved positions (< 38, 10/63 [16%]; 38-58, 13/69 [19%]; 59-100, 15/64 [23%]; > 100, 28/68 [41%], P = 0.005). Areas with the greatest influence for PDs not extending work hours were the 16-h rule working well (56%) and risk to PGY1 well-being (47%). CONCLUSIONS: Although the majority of PDs support the ACGME 2017 work hours rules, only 25% of programs made immediate changes to extend hours. These data reveal that complex, often competing, forces influence PDs' decisions to change trainee schedules.

Separate but Equal? The Sorting of USMDs and Non-USMDs in Internal Medicine Residency Programs.

BACKGROUND: The US internal medicine workforce relies on international and osteopathic medical graduates to fill gaps in residency. Little is known about the distribution and impact of IMGs, DOs, and USMDs concentrating in different types of IM programs. OBJECTIVE: Determining the extent to which USMDs, DOs, and IMGs concentrate in different types of IM programs and comparing Board pass rates by program concentration. DESIGN, SETTINGS, AND PARTICIPANTS: This survey study used data from the AMA's FREIDA database for 476 non-military IM programs in 2017-2018, and 2016-2018 ABIM exam pass rates for 388 accredited programs. MEASUREMENTS: Outcomes were (1) program concentration based on percentage of residents who were USMDs, IMGs, and DOs in 2017-2018 and (2) 2016-2018 program ABIM pass rates as proxies for program quality. Key independent variables were hospital type (community-based, community-based university-affiliated, or university-based) when program concentration was the outcome, and program concentration when Board pass rates were the outcome. RESULTS: Twenty-five percent of programs were "USMD-dominated," 17% were "DO-dominated," 42% were "IMG dominated," and 16% were "integrated." The chances that a university hospital was USMD-dominated were 32 percentage points higher than that for a community hospital (AME = 0.32, baseline probability = 0.11, 95% CI, 0.17-0.46, P < .001). USMD-dominated programs also had significantly higher pass rates by 4.0 percentage points (AME = 0.04, baseline proportion = 0.90, 95% CI, 0.02-0.06, P < .001) than integrated programs, while DO-dominated programs had significantly lower pass rates (AME = - 0.1, baseline proportion = 0.90, 95% CI, - 0.15 to - 0.04, P < .001). CONCLUSION: USMDs and non-USMDs systematically cluster in certain types of residency programs and their training may not be equal, as measured by board pass rates.

Pain control using liposomal bupivacaine versus bupivacaine for robotic assisted thoracic surgery.

Background Despite a trend towards minimally invasive thoracic surgeries over thoracotomies, patients can still experience significant post-operative pain. Literature on the use of liposomal bupivacaine in patients undergoing robotic surgeries is lacking. Objective To compare pain control via intercostal nerve block with liposomal bupivacaine to bupivacaine for patients undergoing robotic assisted thoracic surgery. Setting A 455 bed community hospital. Methods This was a prospective observational study with a historical control group of 96 patients who underwent robotic lung resection. Patients in the control group received bupivacaine, while the intervention group received liposomal bupivacaine. Main outcome measure Average pain scores 24, 48, and 72 h after surgery. Results There were no significant differences in average pain scores between groups. The frequency of ketorolac use on the first post-operative day was lower for those who received liposomal bupivacaine. There were no significant differences in opioid requirements, length of stay, or rate of complications. Conclusions There was no significant difference in post-operative pain control between patients receiving liposomal bupivacaine and bupivacaine for robotic assisted surgery.

Specialty and Lifestyle Preference Changes during Medical School.

PURPOSE: Medical student specialty choices have significant downstream effects on the availability of physicians and, ultimately, the effectiveness of health systems. This study investigated how medical student specialty preferences change over time in relation to their demographics and lifestyle preferences. METHOD: Students from ten medical schools were surveyed at matriculation (2012) and graduation (2016). The two surveys included questions about specialty and lifestyle preferences, demographics, educational background, and indebtedness. Student data from 2012 to 2016 were paired together and grouped into those whose specialty preferences remained constant or switched. RESULTS: Response rates in 2012 and 2016 were 65% (997/1530) and 50% (788/1575), respectively. Fourth-year students ranked "enjoying the type of work I am doing" as less important to a good physician lifestyle than did first-year students (from 59.6 to 39.7%). The lifestyle factors "having control of work schedule" and "having enough time off work" were ranked as more important to fourth-year students than first-year students (from 15.6 to 18.2% and 14.8 to 31.9%, respectively). The paired dataset included 19% of eligible students (237/1226). Demographic and lifestyle factors were not significantly associated with specialty preference switching. Additionally, no significant association existed between changing lifestyle preferences and switching specialty preference (p = 0.85). CONCLUSIONS: During the course of medical school, lifestyle preferences became more focused on day-to-day factors and less on deeper motivational factors. Neither demographics nor lifestyle preferences appear to relate to a student's decision to switch specialty preference during medical school. These findings represent an important step in uncovering causes of specialty preference trends.

Preliminary Validity Evidence for a Milestones-Based Rating Scale for Chart-Stimulated Recall.

BACKGROUND: Minimally anchored Standard Rating Scales (SRSs), which are widely used in medical education, are hampered by suboptimal interrater reliability. Expert-derived frameworks, such as the Accreditation Council for Graduate Medical Education (ACGME) Milestones, may be helpful in defining level-specific anchors to use on rating scales. OBJECTIVE: We examined validity evidence for a Milestones-Based Rating Scale (MBRS) for scoring chart-stimulated recall (CSR). METHODS: Two 11-item scoring forms with either an MBRS or SRS were developed. Items and anchors for the MBRS were adapted from the ACGME Internal Medicine Milestones. Six CSR standardized videos were developed. Clinical faculty scored videos using either the MBRS or SRS and following a randomized crossover design. Reliability of the MBRS versus the SRS was compared using intraclass correlation. RESULTS: Twenty-two faculty were recruited for instrument testing. Some participants did not complete scoring, leaving a response rate of 15 faculty (7 in the MBRS group and 8 in the SRS group). A total of 529 ratings (number of items × number of scores) using SRSs and 540 using MBRSs were available. Percent agreement was higher for MBRSs for only 2 of 11 items-use of consultants (92 versus 75, P = .019) and unique characteristics of patients (96 versus 79, P = .011)-and the overall score (89 versus 82, P < .001). Interrater agreement was 0.61 for MBRSs and 0.51 for SRSs. CONCLUSIONS: Adding milestones to our rating form resulted in significant, but not substantial, improvement in intraclass correlation coefficient. Improvement was inconsistent across items.

Role Models' Influence on Specialty Choice for Residency Training: A National Longitudinal Study.

BACKGROUND: Role models in medical school may influence students' residency specialty choice. OBJECTIVE: We examined whether medical students who reported clinical exposure to a role model during medical school would have an increased likelihood of selecting the role model's specialty for their residencies. METHODS: We conducted a 5-year prospective, national longitudinal study (2011-2016) of medical students from 24 US allopathic medical schools, starting from the middle of their third year. The primary outcome measure was type of residency specialty choice 4 years after graduation. Main predictors were the clinical specialty of a student's most admired physician and the relative importance of 7 potentially influential factors for specialty choice in the fourth year of medical school. RESULTS: From 919 eligible participants, 564 (61%) responded to the first survey; 474 of the respondents (84%) completed the follow-up survey. We excluded 29 participants who were not in their fourth year by the time of the follow-up survey. Of the follow-up respondents, 427 (96%) had specialty data 4 years after graduation. In our multivariate models, exposure to an admired generalist physician prior to medical school (odds ratio [OR] = 2.21, 95% confidence interval [CI] 1.03-4.73) and during medical school (OR = 2.62, 95% CI 1.69-4.05) had the strongest odds with respect to training in a generalist residency 4 years after graduation. Role model exposure also predicted specialty choice among those training in surgical and radiology, ophthalmology, anesthesiology, and dermatology (ROAD) specialties. CONCLUSIONS: Personal exposure to role models in medical school is an important predictor of residency training in that role model's specialty.

Awareness of Bullying in Residency: Results of a National Survey of Internal Medicine Program Directors.

BACKGROUND: Bullying of medical trainees is believed to occur more frequently in medical education than once thought. OBJECTIVE: We conducted a survey to understand internal medicine program director (PD) perspectives and awareness about bullying in their residency programs. METHODS: The 2015 Association of Program Directors in Internal Medicine (APDIM) annual survey was e-mailed to 368 of 396 PDs with APDIM membership, representing 93% of internal medicine residency programs. Questions about bullying were embedded within the survey. Bivariate analyses were performed on PD and program characteristics. RESULTS: Of a total of 368 PD APDIM members, 227 PDs (62%) responded to the survey. Less than one-third of respondents (71 of 227, 31%) reported being aware of bullying in their residency programs during the previous year. There were no significant differences in program or PD characteristics between respondents who reported bullying in their programs and those who did not (gender, tenure as PD, geographic location, or specialty, all P > .05). Those who acknowledged bullying in their program were more likely to agree it was a problem in graduate medical education (P < .0001), and it had a significant negative impact on the learning environment (P < .0001). The majority of reported events entailed verbal disparagements, directed toward interns and women, and involved attending physicians, other residents, and nurses. CONCLUSIONS: This national survey of internal medicine PDs reveals that a minority of PDs acknowledged recent bullying in their training programs, and reportedly saw it as a problem in the learning environment.

Postinterview Communications: Two Surveys of Internal Medicine Residency Program Directors Before and After Guideline Implementation.

PURPOSE: Guidelines surrounding postinterview communication (PIC) after residency interviews were issued by the National Resident Matching Program and Association of Program Directors in Internal Medicine. How they have influenced PIC and program directors' (PDs') reasons for PIC is unknown. METHOD: Annual surveys of 365 U.S. internal medicine residency PDs in 2013 and 368 in 2015 were used. Questions about frequency, intent, and usefulness of PIC and knowledge of guidelines before and after new PIC guidelines were included. Chi-square tests were used to compare data sets, and multivariate logistic regression was performed for 2015 data to identify factors predicting engagement in PIC, using program characteristics, PD characteristics, and beliefs about the benefits of PIC as independent variables. RESULTS: There were 265 (73%) respondents in 2013 and 227 (62%) in 2015. While the number of programs with a PIC policy increased 43%, the level of contact increased 7%. Few PDs indicated PIC was helpful to them; however, PDs who felt PIC helps target applicants were more likely to engage in PIC (OR 4.21, SE 1.88, P = .001). The main reason for continuing PIC (50% of PDs) was that PIC, part of their program's culture, was considered "good manners." CONCLUSIONS: New guidelines increased the number of programs with a PIC policy, but the overall rate of applicant contact did not change despite few PDs feeling PIC was helpful to recruitment. The culture surrounding PIC may be difficult to overcome via guidelines alone, and more definitive rules are necessary to implement change.

Geriatrics Curriculum Needs Assessment for Dermatology Residency Programs.

BACKGROUND: Geriatric patients account for a growing proportion of dermatology clinic visits. Although their biopsychosocial needs differ from those of younger adults, there are no geriatrics training requirements for dermatology residency programs. OBJECTIVE: This study explored the state of geriatrics education in dermatology programs in 2016. METHODS: This constructivist study employed cross-sectional, mixed-methods analysis with triangulation of semistructured interviews, surveys, and commonly used curricular materials. We used purposive sampling of 5 US academic allopathic dermatology programs of different sizes, geographic locations, and institutional resources. Participants were interviewed about informal curricula, barriers, and suggestions for improving geriatrics education, and they also completed a survey about the geriatrics topics that should be taught. The constant comparative method with grounded theory was used for qualitative analysis. We identified formal geriatrics curricular content by electronically searching and counting relevant key texts. RESULTS: Fourteen of 17 participants (82%) agreed to be interviewed, and 10 of 14 (71%) responded to the survey. Themes of what should be taught included diagnosing and managing skin diseases common in older adults, holistic treatment, cosmetic dermatology, benign skin aging, and the basic science of aging. Topics currently covered that could be expanded included communication, systems-based challenges, ethical issues, safe prescribing, quality improvement, and elder abuse. Cosmetic dermatology was the most commonly taught formal geriatrics curricular topic. CONCLUSIONS: There were discrepancies among topics participants felt were important to teach about geriatric dermatology and curricular coverage of these areas. We identified challenges for expanding geriatrics curricula and potential solutions.

Standardized residency training in China: the new internal medicine curriculum.

China formally established a system of national standardized medical residency training in 2014, which affects the health of its 1.4 billion people. Accompanying this system were new guidelines and standards for internal medicine residency training. However, the majority of the standards focused on process measurements, such as minimum case requirements of diseases and procedural skills, rather than describing broader physician competencies in the domains of professionalism, patient care, communication, teamwork, quality improvement, and scholarship. While China has taken a large step forward with standardization of certain aspects of internal medicine residency training, the next step should focus on outcome measures and creating a system that is competency-based.

How do clinical competency committees use different sources of data to assess residents' performance on the internal medicine milestones?A mixed methods pilot study.

PURPOSE: This study examines how Clinical Competency Committees (CCCs) synthesize assessment data to make judgments about residents' clinical performances. METHODS: Between 2014 and 2015, after four six-month reporting periods to the Accreditation Council for Graduate Medical Education (ACGME), 7 of 16 CCC faculty at Rush University Medical Center completed questionnaires focused on their perspectives about rating residents on their achievement of the milestones and participated in a focus group. Qualitative data were analyzed using grounded theory. Milestones ratings for two six-month ACGME reporting cycles (n = 100 categorical residents) were also analyzed. RESULTS: CCC members weighted resident rotation ratings highest (weight = 37%), followed by faculty rotation comments (weight = 27%) and personal experience with residents (weight = 14%) for making judgments about learner's milestone levels. Three assessment issues were identified from qualitative analyses: (1) "design issues" (e.g. problems with available data or lack thereof); (2) "synthesis issues" (e.g. factors influencing ratings and decision-making processes) and (3) "impact issues" (e.g. how CCC generated milestones ratings are used). CONCLUSIONS: Identifying factors that affect assessment at all stages of the CCC process can contribute to improving assessment systems, including support for faculty development for CCCs. Recognizing challenges in synthesizing first and second-hand assessment data is an important step in understanding the CCC decision-making process.

Surveys of Health Professions Trainees: Prevalence, Response Rates, and Predictive Factors to Guide Researchers.

PURPOSE: To establish a baseline overall response rate for surveys of health professions trainees, determine strategies associated with improved response rates, and evaluate for the presence of nonresponse bias. METHOD: The authors performed a comprehensive analysis of all articles published in Academic Medicine, Medical Education, and Advances in Health Sciences Education in 2013, recording response rates. Additionally, they reviewed nonresponse bias analyses and factors suggested in other fields to affect response rate including survey delivery method, prenotification, and incentives. RESULTS: The search yielded 732 total articles; of these, 356 were research articles, and of these, 185 (52.0%) used at least one survey. Of these, 66 articles (35.6%) met inclusion criteria and yielded 73 unique surveys. Of the 73 surveys used, investigators reported a response rate for 63.0% of them; response rates ranged from 26.6% to 100%, mean (standard deviation) 71.3% (19.5%). Investigators reported using incentives for only 16.4% of the 73 surveys. The only survey methodology factor significantly associated with response rate was single- vs. multi-institutional surveys (respectively, 74.6% [21.2%] vs. 62.0% [12.8%], P = .022). Notably, statistical power for all analyses was limited. No articles evaluated for nonresponse bias. CONCLUSIONS: Approximately half of the articles evaluated used a survey as part of their methods. Limited data are available to establish a baseline response rate among health professions trainees and inform researchers which strategies are associated with higher response rates. Journals publishing survey-based health professions education research should improve reporting of response rate, nonresponse bias, and other survey factors.

Medical Students' Perspectives on Careers in Hospital Medicine: A National Study.

This article was migrated. The article was marked as recommended. Purpose: Concerns over burnout and other factors may influence whether students pursue hospital medicine as a career. We investigate whether there are certain predictive factors that ultimately play a role in medical students' career interest in hospital medicine. Methods: In January 2011, 960 third-year medical students from 24 U.S. allopathic medical schools were surveyed at baseline, and six to nine months later when they became fourth-years at follow-up. Hospitalist-oriented students were categorized as those students who indicated interest in the specialties of family medicine, internal medicine, or pediatrics, and who indicated that they were "very likely" or "somewhat likely" to become a hospitalist. Respondents were also asked to respond to a list of seven factors that potentially influenced their specialty choice. Results: Adjusted response rate for the fourth-year survey was 50% (n=463/919). Medical students considering hospitalist careers were more likely to report that perceived burnout between various specialties played an important influential role in their specialty decision-making (49.7% [42.2-57.2%], vs. non-hospitalists 39.9% [32.8-47.0%], P=0.03). Conclusions: Given that students are reporting burnout as a factor in their decision-making in favor of hospitalist careers, further studies are needed to explore what aspects of a hospitalist career are appealing to students.