Development of a Chief Resident Medical Procedure Service: a 10-Year Experience.

BACKGROUND: Lack of experienced faculty to supervise internal medicine (IM) residents is a significant barrier to establishing a medical procedure service (MPS). AIM: Describe the development and 10-year outcomes of an MPS led by IM chief residents. SETTING: University-based IM residency program affiliated with a county and Veterans Affairs hospital. PARTICIPANTS: Categorical IM interns (n=320) and 4th-year IM chief residents (n=48) from 2011 to 2022. PROGRAM DESCRIPTION: The MPS operated on weekdays, 8 am-5 pm. After training and sign-off by the MPS director, chief residents trained and supervised interns in ultrasound-guided procedures during a 4-week rotation. PROGRAM EVALUATION: From 2011 to 2022, our MPS received 5967 consults and 4465 (75%) procedures were attempted. Overall procedure success, complication, and major complication rates were 94%, 2.6%, and 0.6%, respectively. Success and complication rates for paracentesis (n=2285) were 99% and 1.1%, respectively; 99% and 4.2% for thoracentesis (n=1167); 76% and 4.5% for lumbar puncture (n=883); 83% and 1.2% for knee arthrocentesis (n=85); and 76% and 0% for central venous catheterization (n=45). The rotation was rated 4.6 out of 5 for overall learning quality. DISCUSSION: A chief resident-led MPS is a practical and safe approach for IM residency programs to establish an MPS when experienced attending physicians are unavailable.

Immunologic resilience and COVID-19 survival advantage.

BACKGROUND: The risk of severe coronavirus disease 2019 (COVID-19) varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). OBJECTIVE: We sought to examine whether deficits in IR that antedate or are induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection independently predict COVID-19 mortality. METHODS: IR levels were quantified with 2 novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n = 522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n = 13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to COVID-19 outcomes. RESULTS: IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection was associated with underrepresentation of IHG-I (21%) versus overrepresentation (77%) of IHG-II or IHG-IV, especially in males versus females (P < .01). Presentation with IHG-I was associated with 88% lower mortality, after controlling for age and sex; reduced risk of hospitalization and respiratory failure; lower plasma IL-6 levels; rapid clearance of nasopharyngeal SARS-CoV-2 burden; and gene expression signatures correlating with survival that signify immunocompetence and controlled inflammation. In non-COVID-19 cohorts, IR-preserving metrics were associated with resistance to progressive influenza or HIV infection, as well as lower 9-year mortality in the Framingham Heart Study, especially in females. CONCLUSIONS: Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19.

A Cross-Sectional Survey of Internal Medicine Residents' Knowledge, Attitudes, and Current Practices Regarding Patient Transitions to Post-Acute Care.

OBJECTIVES: Prior studies have found suboptimal knowledge about post-acute care (PAC) among inpatient providers and poor communication at discharge that can lead to unsafe discharge transitions, but little is known about residents and the PAC transition. The aim of this study is to assess internal medicine residents' knowledge, attitudes, and current practice regarding patient transitions to PAC. DESIGN: A multisite, cross-sectional 36-question survey. SETTING AND PARTICIPANTS: Internal Medicine and Medicine-Pediatrics residents at 3 university-based Internal Medicine training programs in the United States. METHODS: Survey delivered electronically to residents in 2018 and 2019. Survey responses were described by collapsing 4-point Likert responses into dichotomous variables, and thematic content analysis was used to evaluate free text responses. RESULTS: Of 482 residents surveyed, 236 responded (49%). Despite high reported confidence in their ability to transition patients to PAC, only 31% of residents knew how often patients received skilled therapies at skilled nursing facilities (SNFs) and 23% knew how frequently nursing services are provided. The majority of residents (79%) identified the discharge summary as the main way they communicated care instructions to the SNF, but only 55% reported always completing it prior to discharge. Upper-level residents were more likely to know how much therapy patients received at a SNF, but resident knowledge about PAC did not vary by residency year in other domains. Residents who experienced a clinical rotation at a SNF had higher levels of knowledge compared to residents who did not. CONCLUSIONS: This national survey of internal medicine residents identified common knowledge gaps regarding PAC. These knowledge gaps did not improve throughout residency without deliberate exposure to PAC environments. This suggests a need for dedicated curriculum development as discharges to PAC continue to rise exponentially.

Fecal Occult Blood Testing in Hospitalized Patients with Upper Gastrointestinal Bleeding.

A 47-year-old man with a history of alcohol abuse, cirrhosis, and grade II esophageal varices is admitted for treatment of alcohol withdrawal. He reports having some dark-colored stools a week prior to admission, but his stools since then have been normal in color. A repeat hemoglobin is stable, but a fecal occult blood test is positive. What should be done next?

Observing trainee encounters using a one-way mirror.

BACKGROUND: Direct observation of patient encounters is a key component of evaluating residents during training, but there are scarce data on the various methods of observation. AIM: To implement a novel method for direct observation of out-patient encounters via a one-way mirror in an internal medicine resident practice, and to assess the feasibility and acceptance of this method. METHODS: Each selected resident-patient encounter was directly observed by a preceptor through a one-way mirror. The preceptor provided feedback to the resident at the conclusion of each encounter. A post-visit survey assessed resident satisfaction and comfort with this method of observation. RESULTS: Using a one-way mirror was a feasible method of observation. Fifty residents had a clinic visit that was directly observed, and 42 (84%) completed the post-visit survey. Residents reported that they preferred direct observation through a one-way mirror compared with other methods, including videotaped encounters or having a preceptor physically present in the room. They also felt that having a preceptor observing through the one-way mirror had no negative effect on the clinic visit. Direct observation of patient encounters is a key component of evaluating residents CONCLUSIONS: Direct observation through a one-way mirror is a viable method in the out-patient setting, and might be preferable for evaluating certain skills.

Internal medicine physicians' knowledge of health care charges.

BACKGROUND: Concerns over the rising costs of health care have increased interest in educating residents about the cost impact of medical decisions. While many programs educate residents about the effectiveness of care, little is known about how well residents and faculty know charges of diagnostic tests or both groups' interest in this topic. METHODS: We surveyed internal medicine residents and faculty at an academic tertiary care hospital. Both groups rated their agreement with a series of statements about health care charges on a Likert scale of 1 (strongly disagree) to 9 (strongly agree), and they estimated the charges for 15 commonly ordered diagnostic tests. Estimates within 25% of the true charge were considered correct. The Wilcoxon rank sum test was used to compare responses between residents and faculty. RESULTS: Seventy of 126 eligible participants (56%) returned surveys. Participants showed poor knowledge of health care charges but expressed a desire to learn more. Physicians also felt that cost-effectiveness should be considered when ordering diagnostic tests, although faculty members felt more strongly about this than did residents. In estimating the charges for diagnostic tests, less than a quarter of all responses were within 25% of the true charge. CONCLUSIONS: Internal medicine physicians poorly estimate the charges for diagnostic tests but have a strong desire to improve their knowledge, suggesting a possible intervention to improve the cost-effectiveness of medical care.