Not Just Hocus POCUS: Implementation of a Point of Care Ultrasound Curriculum for Internal Medicine Trainees at a Large Residency Program.

INTRODUCTION: In 2018, the American College of Physicians formally acknowledged the importance of Point of Care Ultrasound (POCUS) to the practice of internal medicine (IM). For the military internist, POCUS training is critical for care of the trauma patient in austere environments, mass casualty events and natural disasters. While emergency medicine and critical care training programs have adopted POCUS education, few IM programs have integrated POCUS into their core curricula. We designed and implemented an iterative POCUS curriculum for trainees at a large military IM residency program over a two-year period. METHODS: In collaboration with our critical care and simulation departments, we developed a pilot curriculum consisting of five, 60-minute courses offered on a voluntary basis at monthly intervals throughout 2017. Based on the pilot's success we incorporated a POCUS curriculum into the core academics received by all IM trainees during the 2017-2018 academic year. Trainees attended seven, 3-hour sessions during their scheduled academic time taught by subspecialists with POCUS expertise in an on-site simulation center. Baseline surveys and knowledge assessment examinations were administered during orientation and repeated at the end of the academic year. Comparison of results before and after the POCUS curriculum was the primary outcome evaluated. RESULTS: Intervention #1: Pilot, 2016-2017 Academic Year45 trainees attended at least one course with an average of 1.8 sessions per trainee. Baseline survey data showed 91% of trainees believe POCUS is quite or extremely beneficial for their patients, but 73% feel slightly or not at all confident in POCUS knowledge. The pre-test mean and median scores were 71% and 77% respectively, which both increased to a post-test mean and median of 81%. Post-test mean percentage correct for trainees attending 1, 2, or 3 courses was 74%, 82%, and 91% respectively. Intervention #2: Incorporation of POCUS into Core Academics, 2017-2018 Academic YearAll 75 trainees participated in training with an average of 3.77 sessions attended per trainee. Survey analysis revealed significant improvement in confidence of performing ultrasound-guided procedures (p = 0.0139), and a 37% absolute increase in respondents who anticipate using ultrasound in their clinical practice (p = 0.0003). The mean pre-test score was 67.8% with median of 63.6% while mean and median post-test scores were 82.1% and 81.8%, with an absolute improvement of 14.3% and 18.2% respectively (p = 0.0004). CONCLUSION: A structured POCUS curriculum was successfully incorporated at a large multiservice military IM residency program, with demonstrated retention of knowledge, improved confidence in performance of ultrasound guided invasive procedures, and increased interest in the use of POCUS in future clinical practice. Similar programs should be implemented across all IM programs in military graduate medical education to enhance operational readiness and battlefield care.

Nighthawk: Making Night Float Education and Patient Safety Soar.

BACKGROUND: Some residency programs responded to duty hour restrictions by implementing night rotations. Night supervision models can vary, resulting in potential patient safety issues and educational voids for residents. OBJECTIVE: We evaluated the impact of multiple evidence-based interventions on resident satisfaction with supervision, perception of the education value of night rotations, and residents' use of online educational materials. METHODS: The night team was augmented with an intern to assist with admissions and a senior resident (the "nighthawk") to supervise inpatient care and deliver a night medicine curriculum. We instituted a "must-call" list, with specific clinical events requiring mandatory attending notification, and reduced conflict in the role of the night float team. We studied patient contact, online curriculum use, residents' perceptions of nighthawk involvement, exposure to educational materials, and satisfaction with supervision. RESULTS: During the first half of academic year 2016-2017, 51% (64 of 126) of trainees were on the night medicine rotation. The nighthawk reviewed 1007 intern plans (15 per night; range, 6-36) and supervised 215 hands-on evaluations, including codes and rapid responses (3 per night; range, 0-12). The number of users of the online education materials increased by 85% (13 to 24), and instances of use increased 35% (85 to 115). The majority of residents (79%, 27 of 34) favored the new system. CONCLUSIONS: A nighthawk rotation, a must-call list, and reducing conflict in night team members' roles improved resident satisfaction with supervision and the night medicine rotation, resulting in increased communication.

Results of a Formal Mentorship Program for Internal Medicine Residents: Can We Facilitate Genuine Mentorship?

BACKGROUND: Mentorship programs are perceived as valuable, yet little is known about the effect of program design on mentoring effectiveness. INTERVENTION: We developed a program focused on mentoring relationship quality and evaluated how subsequent relationships compared to preexisting informal pairings. METHODS: Faculty members were invited by e-mail to participate in a new mentoring program. Participants were asked to complete a biography, subsequently provided to second- and third-year internal medicine residents. Residents were instructed to contact available mentors, and ultimately designate a formal mentor. All faculty and residents were provided a half-day workshop training, written guidelines, and e-mails. Reminders were e-mailed and announced in conferences approximately monthly. Residents were surveyed at the end of the academic year. RESULTS: Thirty-seven faculty members completed the biography, and 70% (26 of 37) of residents responded to the survey. Of the resident respondents, 77% (20 of 26) chose a formal mentor. Of the remainder, most had a previous informal mentor. Overall, 96% (25 of 26) of the residents had identified a mentor of some kind compared to 50% (13 of 26) before the intervention (P < .001), and 70% (14 of 20) who chose formal mentors identified them as actual mentors. Similar numbers of residents described their mentors as invested in the mentorship, and there was no statistical difference in the number of times mentors and mentees met. CONCLUSIONS: Facilitated selection of formal mentors produced relationships similar to preexisting informal ones. This model may increase the prevalence of mentorship without decreasing quality.

Achieving balance on the inpatient internal medicine wards: a performance improvement project to restructure resident work hours at a tertiary care center.

PROBLEM: In an era of increasing duty hours restrictions, a growing body of literature describes how fatigue and handoffs affect patient care and educational experience. Although many studies examine these elements independently, there remains little understanding of how they interact. Previously reported interventions have yielded unexpected results that are likely dependent on local factors. APPROACH: The authors collected data on admissions, emergency department disposition, and team continuity during an 8-day period before and a 12-day period after changing from a night float system to a resident long-call system with a graded transition to a night team. House staff and attendings were surveyed afterwards. OUTCOMES: The intervention increased the portion of patients admitted to their primary resident from 47% (43/91) to 82% (75/91) (P < .01) and improved the percentage of emergency room admissions performed in less than 90 minutes from 39% (7/18) to 70% (39/44) (P = .02). The percentage of self-reported duty hours violations decreased from 55% (16/29) to 6.8% (3/44) (P < .01). Survey respondents reported an improved sense of patient involvement, quality of care, and handoffs. NEXT STEPS: Designing a call system around a brief assessment of admission intensity resulted in better alignment of resident resources with workload and improvements in multiple outcomes. Optimization of inpatient work structure appears to be significantly affected by local factors. Future trials assessing work hour balance will need to take work intensity into account and assess a wide variety of potential consequences.

Association between interest group participation and choice of residency.

BACKGROUND AND OBJECTIVES: While medical student interest groups (IGs, also known as student clubs) are widely offered, their actual use and effectiveness to affect students' specialty choice (eg, increase selection of family medicine) are poorly understood. We performed this study to describe student participation in IGs, association with specialty selection, and perceived benefit of participation. METHODS: An electronic, cross-sectional, quantitative survey of all fourth-year US medical students in 2009 with a Department of Defense service obligation was conducted. Each participant indicated which of 18 listed IGs they attended with a yes or no response. Each participant also rated the overall benefit of IGs on a 9-point scale and provided their top choice for the residency Match. RESULTS: The response rate was 53% (419/797). Students attended an average of 3.5 specialty IGs. For all 18 specialties queried, IG attendance was associated with selection in the Match, and 77% of students attended the IG of their selected specialty. However, IG participation was perceived as having a small effect on specialty choice, as the mean response was 3.6 (standard deviation=2.4) on a 1 to 9 scale. CONCLUSIONS: IG participation is common and is strongly associated with specialty choice, but the benefit appears to be small.

Treatment of excessive anticoagulation with phytonadione (vitamin K): a meta-analysis.

BACKGROUND: Patients taking oral anticoagulants with an international normalized ratio (INR) greater than 4.0 are at increased risk for bleeding. We performed a meta-analysis to determine the effectiveness of phytonadione (vitamin K) in treating excessive anticoagulation. METHODS: The MEDLINE, EMBASE, and Cochrane Library databases were searched (without language restrictions) for articles published between January 1985 and September 2004. Randomized controlled trials or prospective, nonrandomized trials that used vitamin K to treat patients without major hemorrhage with an INR greater than 4.0 due to oral anticoagulant use were included. The primary outcome was achievement of the target INR (1.8-4.0) at 24 hours after vitamin K administration. Summary estimates were calculated using a random effects model. RESULTS: Twenty-one studies (10 randomized and 11 prospective trials) were included. Among oral vitamin K treatment arms (4, n = 75), the proportion with a target INR at 24 hours was 82% (95% confidence interval [CI], 70%-93%), which was similar to intravenous vitamin K treatment arms (6, n = 69; target INR, 77%; 95% CI, 60%-95%). Treatment arms of subcutaneous vitamin K (3, n = 58; 31%; 95% CI, 7%-55%) and placebo/observation (2, n = 27; 20%; 95% CI, 0%-47%) were less likely to achieve target INR at 24 hours. Only 1 of 21 trials appropriately assessed for adverse events, so a summary estimate for bleeding risk could not be generated. CONCLUSIONS: Limited evidence suggests that oral and intravenous vitamin K are equivalent and more effective for excessive anticoagulation than simply withholding warfarin sodium. Subcutaneous vitamin K, however, is inferior to oral and intravenous vitamin K for this indication and is similar to placebo. Whether treatment with vitamin K decreases hemorrhagic events cannot be determined from the published literature.