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.

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.

Retaining interest in caring for underserved patients among future medicine subspecialists: Underserved Medicine and Public Health (UMPH) program.

BACKGROUND: Accessing subspecialty care is hard for underserved patients in the U.S. Published curricula in underserved medicine for Internal Medicine residents target future-primary care physicians, with unknown impact on future medicine subspecialists. METHODS: The aim was to retain interest in caring for underserved patients among Internal Medicine residents who plan for subspecialist careers at an urban university hospital. The two-year Underserved Medicine and Public Health (UMPH) program features community-based clinics, evening seminars, reflection assignments and practicum projects for 3-7 Internal Medicine residents per year. All may apply regardless of anticipated career plans after residency. Seven years of graduates were surveyed. Data were analyzed using descriptive statistics. RESULTS: According to respondents, UMPH provided a meaningful forum to discuss important issues in underserved medicine, fostered interest in treating underserved populations and provided a sense of belonging to a community of providers committed to underserved medicine. After residency, 48% of UMPH graduates pursued subspecialty training and 34% practiced hospitalist medicine. 65% of respondents disagreed that "UMPH made me more likely to practice primary care" and 59% agreed "UMPH should target residents pursuing subpecialty careers." CONCLUSIONS: A curriculum in underserved medicine can retain interest in caring for underserved patients among future-medicine subspecialists. Lessons learned include [1] building relationships with local community health centers and community-practicing physicians was important for success and [2] thoughtful scheduling promoted high resident attendance at program events and avoided detracting from other activities required during residency for subspecialist career paths. We hope Internal Medicine residency programs consider training in underserved medicine for all trainees. Future work should investigate sustainability, whether training results in improved subspecialty access, and whether subspecialists face unique barriers caring for underserved patients. Future curricula should include advocacy skills to target systemic barriers.

Barriers to Accessing Nighttime Supervisors: a National Survey of Internal Medicine Residents.

BACKGROUND: Single-center studies have reported residents experience barriers to accessing supervising physicians overnight, but no national dataset has described barriers perceived by residents or the association between supervision models and perceived barriers. OBJECTIVE: To explore residents' perception of barriers to accessing overnight supervision. DESIGN: Questions about overnight supervision and barriers to accessing it were included on the American College of Physicians Internal Medicine In-Training Examination® (IM-ITE®) Resident Survey in Fall 2017. PARTICIPANTS: All US-based internal medicine residents who completed the 2017 IM-ITE®. Responses from 20,744 residents (84%) were analyzed. MAIN MEASURES: For our main outcome, we calculated percentages of responses for eight barriers and tested for association with the presence or absence of nocturnists. For our secondary outcome, we categorized free-text responses enumerating barriers from all residents into the five Systems Engineering Initiative for Patient Safety (SEIPS) categories to elucidate future areas for study or intervention. KEY RESULTS: Internal medicine residents working in hospitals without nocturnists more commonly reported having at least one barrier to accessing a supervising physician "always" or "most of the time" (5075/9842, 51.6%) compared to residents in hospitals with nocturnists (3074/10,902, 28.2%, p < 0.001). Among residents in hospitals without nocturnists, the most frequently reported barrier to accessing attending supervision was attendings not being present in the hospital (30.4% "always" or "most of the time"); residents in hospitals with nocturnists most frequently reported desire to make their own decisions as a barrier to contacting attendings (15.7% "always" or "most of the time"). Free-text responses from residents with and without nocturnists most commonly revealed organization (47%) barriers to accessing supervision; 28% cited person barriers, and 23% cited tools/technology barriers. CONCLUSIONS: Presence of nocturnists is associated with fewer reported barriers to contacting supervising physicians overnight. Organizational culture, work schedules, desire for independence, interpersonal interactions, and technology may present important barriers.

Using Team Census Caps to Optimize Education, Patient Care, and Wellness: A Survey of Internal Medicine Residency Program Directors.

PURPOSE: To discover whether internal medicine (IM) residency program directors use lower-than-required caps on general medicine wards, critical care units, and inpatient subspecialty wards; describe justifications for lower-than-required general medicine ward caps and strategies for when caps have been exceeded or the number of patients is a detriment to critical thinking or education; and assess whether caps were associated with program characteristics. METHOD: From August to December 2016, the Association of Program Directors in Internal Medicine surveyed all member program directors about team caps and their effects on the learning environment. Responses were appended with publicly available or licensed third-party data. Programs were categorized by type, size, and region. RESULTS: Overall response rate was 65.7% (251/382 programs). Nearly all (244/248; 98.4%) reported caps for general medicine ward teams (mean = 17.0 [standard deviation (SD) = 4.2]). Fewer (171/247; 69.2%) had caps for critical care teams (mean = 13.8 [SD = 5.4]). Fewer still (131/225; 58.2%) had caps for inpatient subspecialty ward teams (mean = 14.8 [SD = 6.0]). Fewer first-quartile programs (0-28 residents) reported having caps on inpatient subspecialty teams (P < .001). Directors reported higher caps compromised education (109/130; 83.8%), patient care (89/130; 68.5%), and/or resident wellness (77/130; 59.2%). Nonteaching services (181/249; 72.7%), patient transfers (110/249; 44.2%), or "backup" residents (67/249; 26.9%) were used when caps are reached or the number of patients is detrimental to critical thinking or education. CONCLUSIONS: IM program directors frequently exercise discretion when setting caps. Accrediting bodies should explicitly encourage such adjustments and allow differentiation by setting.

Integrating Adverse Event Reporting Into a Free-Text Mobile Application Used in Daily Workflow Increases Adverse Event Reporting by Physicians.

Adverse event (AE) reporting is a key component of patient safety and physicians are known to underreport. The authors hypothesized that integrating AE reporting into a mobile application used in daily physician workflow would increase physician reporting of AEs. After integrating AE reporting into a free-text mobile application used for daily workflow, the change in AE reporting by physicians was analyzed using Mann-Whitney U tests. AE reporting by physicians increased more than 37-fold (21 to 806; U = 7.5, P < .0001). AE reporting by physicians as a proportion of all AE reports received increased 120-fold (from 0.1% to 12% of all reports, U = 10, P < .0001). Integrating AE reporting into a free-text mobile application used in daily physician workflow markedly increased their reporting of AEs. This approach shifted time burden from physicians to quality officers. Implementation should be coupled with physician education about identifying AEs and content to include in reports.

Azathioprine-induced pancytopenia with normal TPMT activity presenting with HSV oral ulcers.

A 65-year-old man with treatment-resistant psoriatic arthritis, hypertension, dyslipidaemia and benign prostatic hyperplasia (BPH) presented with herpes simplex virus (HSV) oral ulcers and a recent 15 lb weight loss due to reduced consumption. Five weeks previously, his methotrexate was tapered and he had begun taking azathioprine. The patient's thiopurine S-methyltransferase (TPMT) activity level was normal prior to starting azathioprine. He was found to have pancytopenia with normal folate levels and azathioprine was discontinued. His pancytopenia worsened, with a nadir 8 days after stopping azathioprine, before returning to normal levels. His oral ulcers improved and he was able to tolerate solid food. This case illustrates that decreased TPMT activity is not the only risk factor for pancytopenia as an adverse reaction to azathioprine. Furthermore, HSV stomatitis may be the presenting symptom of pancytopenia. The timeline of improvement in cell counts illustrated in this patient has implications for the management of suspected azathioprine-induced pancytopenia.

Public health training in internal medicine residency programs: a national survey.

BACKGROUND: The IOM recommends public health training for all physicians. Data characterizing such training of internal medicine (IM) residents are lacking. PURPOSE: To describe the current state of public health education at IM residency programs, characterize programs offering public health education, and quantify interest in expanding training opportunities. METHODS: IM residency program directors from the 380 Accreditation Council for Graduate Medical Education-accredited residency programs in the U.S were invited to participate in a cross-sectional survey. Responses were received from 127 programs (33%). Data were collected July-December 2012 and analyzed in January 2013. Participants were queried on domestic public health training offered, perceived resident interest in and satisfaction with this training, and interest in expanding training. RESULTS: Eighty-four respondents (66%) provide some form of public health training, but structure and content vary widely. In many programs offering public health training, few residents (<10%) receive it. Although 93 programs (73%) integrate public health into core curricula, only three topics were common to a majority of these programs. Sixty-six respondents (52%) offer clinical training at community-based health centers. Most residency program directors (90%) are very or somewhat interested in expanding their public health training. CONCLUSIONS: This study characterizes the structures and content of public health training across IM residency programs. The wide range highlights the diverse definition of "public health training" used by IM residency program directors and lack of universal public health competencies required for IM physicians. Opportunities exist for collaboration among residency programs and between IM and public health educators to share best practices.

Evaluating oral case presentations using a checklist: how do senior student-evaluators compare with faculty?

PURPOSE: Previous studies have shown student-evaluators to be reliable assessors of some clinical skills, but this model has not been studied for oral case presentations (OCPs). The purpose of this study was to examine the validity of student-evaluators in assessing OCP by comparing them with faculty. METHOD: In 2010, the authors developed a dichotomous checklist. They trained 30 fourth-year medical students (student-evaluators) to use it to assess 170 second-year medical students' OCPs in real time during a year-end objective structured clinical examination. Ten faculty physicians then scored videos of a random sample of these OCPs. After discarding items with poor faculty reliability, the authors assessed agreement between faculty and student-evaluators on 18 individual items, total scores, and pass/fail decisions. RESULTS: The total score correlation between student-evaluators and faculty was 0.84 (P < .001) and was somewhat better than the faculty-faculty intraclass correlation (r = 0.71). Using a 70% pass/fail cutoff, faculty and student-evaluator agreement was 74% (Kappa = 0.46; 95% CI, 0.20-0.72). Overall, student-evaluator scores were more lenient than faculty scores (72% versus 56% pass rates; P = .03). CONCLUSIONS: Senior student-evaluators were able to reliably assess second-year medical students' OCP skills. The results support the use of student-evaluators for peer assessment of OCPs in low-stakes settings, but evidence of leniency compared with faculty assessment suggests caution in using student-evaluators in high-stakes settings. Extending peer assessment to OCPs provides a practical approach for low-resource evaluation of this essential skill.

Mouse ascites Golgi mucin expression abnormalities in natural cycle endometrial biopsies predict subsequent in vitro fertilization-embryo transfer (IVF-ET) failure in patients with previous IVF-ET failures.

We performed a double-blinded retrospective cohort study to determine whether endometrial expression of mouse ascites Golgi mucin in a natural, unmedicated cycle predicts subsequent IVF-ET outcome among women with prior IVF-ET failure and poor pre-embryo quality. We found a statistically significant decrease in clinical pregnancy rate among women with abnormal mouse ascites Golgi expression, a test which was found to have high positive predictive value for failed IVF-ET.