Updating the Military Unique Curriculum for a Ready Medical Force.

INTRODUCTION: Previous conflicts have demonstrated the impact of physician readiness on early battlefield mortality rates. To prepare for the lethal nature of today's threat environment and the rapid speed with which conflict develops, our medical force needs to sustain a high level of readiness in order to be ready to "fight tonight." Previous approaches that have relied on on-the-job training, just-in-time predeployment training, or follow-on courses after residency are unlikely to satisfy these readiness requirements. Sustaining the successes in battlefield care achieved in Iraq and Afghanistan requires the introduction of effective combat casualty care earlier and more often in physician training. This needs assessment seeks to better understand the requirements, challenges, and opportunities to include the Military Unique Curriculum (MUC) during graduate medical education. MATERIALS AND METHODS: This needs assessment used a multifaceted methodology. First, a literature review was performed to assess how Military Unique Curricula have evolved since their initial conception in 1988. Next, to determine their current state, a needs-based assessment survey was designed for trainees and program directors (PDs), each consisting of 18 questions with a mixture of multiple choice, ranking, Likert scale, and free-text questions. Cognitive interviewing and expert review were employed to refine the survey before distribution. The Housestaff Survey was administered using an online format and deployed to Internal Medicine trainees at the Walter Reed National Military Medical Center (WRNMMC). The Program Director Survey was sent to all Army and Navy Internal Medicine Program Directors. This project was deemed to not meet the definition of research in accordance with 32 Code of Federal Regulation 219.102 and Department of Defense Instruction 3216.02 and was therefore registered with the WRNMMC Quality Management Division. RESULTS: Out of 64 Walter Reed Internal Medicine trainees who received the survey, 32 responses were received. Seven of nine PDs completed their survey. Only 12.5% of trainees felt significantly confident that they would be adequately prepared for a combat deployment upon graduation from residency with the current curriculum. Similarly, only 14.29% of PDs felt that no additional training was needed. A majority of trainees were not satisfied with the amount of training being received on any MUC topic. When incorporating additional training on MUC topics, respondents largely agreed that simulation and small group exercises were the most effective modalities to employ, with greater than 50% of both trainees and PDs rating these as most or second most preferred among seven options. Additionally, there was a consensus that training should be integrated into the existing curriculum/rotations as much as possible. CONCLUSIONS: Current Military Unique Curricula do not meet the expected requirements of future battlefields. Several solutions to incorporate more robust military unique training without creating any significant additional time burdens for trainees do exist. Despite the limitation of these results being limited to a single institution, this needs assessment provides a starting point for improvement to help ensure that we limit the impact of any "peacetime effect."

Read to Lead: Developing a Leadership Book Club Curriculum for Graduate Medical Education.

Background: The importance of effective leadership for improving patient care and physician well-being is gaining increased attention in medicine. Despite this, few residency programs have formalized education on leadership in medicine. The most effective ways to train graduate medical education (GME) trainees in leadership are unclear. Methods: Our large internal medicine residency program implemented a book club to develop leadership skills in residency. Through independent reading of the selected book and resident-led small group discussions, we facilitated dialogue on the challenges of leading effectively. Results: A survey-based curricular evaluation demonstrated that 61% of respondents felt that the book club influenced their thoughts about leadership and that 66% of participants would recommend the book club to other residency programs. Lack of time was the main barrier to participation while addition of complementary media or alternative book formats were identified as possible solutions to increase engagement. Conclusions: Leadership book clubs are a practical and effective way to teach leadership during residency. More research is needed to identify the best formats for book club discussion and to develop additional tools to foster future physician leaders.

Building Individual and Organizational Wellness Through Effective Followership.

Burnout is widespread across the healthcare industry. Physician burnout has been linked to significant decrements in personal wellness, patient satisfaction, patient outcomes, and organizational financial losses. Appropriately, burnout has been identified as an important issue for leaders in the field as it can lead to physician turnover and loss of talent. In this article, we address how burnout is related to followership. We assert that physicians can utilize effective followership to increase wellness not only for themselves, but also for their leaders and organizations.

Learning to Lead: 10 Leadership Lessons From Operation Bushmaster.

Medical students at the Uniformed Services University of the Health Sciences participate in a leadership curriculum designed to develop leadership skills. Operation Bushmaster is a 5-day field practicum designed to test these skills. In this article, we describe 10 leadership lessons learned during Operation Bushmaster applicable to all leaders.

Recognizing Gender Parity in Military Medicine: An Analysis of Plenary Speakers and Award Recipients at Military American College of Physicians Chapter Meetings.

INTRODUCTION: Despite the advances toward gender parity in medicine, a gap exists in the recognition of women physicians at academic and subspecialty medical conferences as plenary speakers and award winners. Conferences are cornerstones in the practice of medicine because they serve as platforms to showcase physicians' successes and disseminate work. The selection of who is honored at such events can impact an individual's career by creating networks that may lead to future opportunities. Additionally, the trend of who is honored may create expectations in the minds of trainees and early career physicians about what qualities help an individual achieve success. Our group sought to determine whether there was a gender gap in award recognition and speakership opportunities at the American College of Physicians (ACP) annual military chapter meetings. METHODS: This was a cross-sectional study with data extracted from publicly available conference programs for the Army-Air Force annual ACP meetings and the Navy annual ACP meetings. Five years of data erewere reviewed for invited plenary speakers. Ten years of data were reviewed for award recipients. For an award to be included, it had to have a preset description and criteria for recipient selection. Awards not given annually or awards given for less than 3 years were excluded. Individuals' gender was determined based on the first name and confirmed through internet searches of pronoun descriptors from professional websites. Comparisons were done using Fisher's exact test and chi-square tests when appropriate, with statistical significance set at a two-tailed P-value of <.05. RESULTS: Women comprised 26-30% of the chapter membership and there was no significant difference in gender distribution between the chapters. Fourteen of the 69 plenary speakers were women (20%), with significantly fewer women presenters in the Navy as compared to men. Thirty-six of the 134 award winners were women (27%), which was not significantly different from the overall chapter gender distributions. While women recipients of lifetime, teaching, research, and medical student awards were not significantly different from chapter gender distribution, women faculty were significantly more likely to receive an award for teaching than for research, with women receiving 13 of the 28 teaching awards (41%), and none of the 10 faculty research awards. CONCLUSIONS: The military chapter ACP meetings reviewed mirrored civilian data in many ways, although military plenary speaker and award recipient distributions were more representative of the gender distribution of the branches. Review of the nomination process, planning committee selection, and opportunities for diversity training could be optimized to ensure that future conferences have a gender-balanced representation of individuals being honored. Improving upon current practices is important for the growth and retention of women military physicians.

A Faculty Development Model for Academic Leadership Education Across A Health Care Organization.

Academic leadership in undergraduate and graduate medical education requires a specific set of leadership and managerial skills that are unique to academic leadership positions. While leadership development training programs exist for traditional leadership roles such as department chairs, executives, and deans, there are fewer models of leadership training specifically geared for academic leadership positions such as program and clerkship directors, and designated institutional officials. There are academic programs at the national level, but there is sparse literature on the specific decisions required to create such programs locally. With growing regulatory and accreditation requirements as well as the challenges of balancing the clinical and educational missions, effective leadership is needed across the spectrum of academic medicine. To meet this need for the military health care system in the United States, we used Kern's six-step framework for curriculum development to create a 1-week academic leadership course. This paper describes the process of development, implementation, outcomes, and lessons learned following the initial 3 years of courses. Specific discussions regarding who to train, which faculty to use, content, and other elements of course design are reviewed. The course and process outlined in the paper offer a model for other organizations desiring to establish an academic leadership course.

Leadership Training in Graduate Medical Education: Time for a Requirement?

INTRODUCTION: The need for all physicians to function as leaders in their various roles is becoming more widely recognized. There are increasing opportunities for physicians at all levels including Graduate Medical Education (GME) to gain leadership skills, but most of these opportunities are only for those interested. Although not an Accreditation Council for Graduate Medical Education (ACGME) requirement, some US graduate medical education programs have incorporated leadership training into their curricula. Interestingly, the Royal College of Physicians and Surgeons of Canada adopted the Leader role in its 2015 CanMEDS physician training model and requires leadership training. We sought to understand the value of a leadership training program in residency in our institution. MATERIALS AND METHODS: Our 2017 pilot leadership training program for senior military internal medicine residents consisted of four one-hour sessions of mini-lectures, self-assessments, case discussions, and small group activities. The themes were: Introduction to Leadership, Emotional Intelligence, Teambuilding, and Conflict Management. Participants were given an 18-question survey (14 Likert scale multiple-choice questions and 4 open-ended response questions) to provide feedback about the course. The Brooke Army Medical Center Institutional Review Board approved this project as a Quality Improvement effort. RESULTS: The survey response rate was 48.1% (26 of 54). The majority of respondents (84.6%) agreed the leadership training sessions were helpful and relevant. Following the sessions, 80.8% saw a greater role for physicians to function as leaders. Most (88.4%) agreed that these sessions helped them understand the importance of their roles as leaders, with 80.8% feeling more empowered to be leaders in their areas, 76.9% gaining a better understanding of their own strengths and weaknesses as leaders, and 80.8% feeling better prepared to meet challenges in the future. After exposure to leadership training, 73.1% indicated a plan to pursue additional leadership development opportunities. All respondents agreed that internists should be able to lead and manage a clinical team, and every respondent agreed that leadership principles should be taught in residency. CONCLUSIONS: This pilot project supports the premise that leadership training should be integrated into GME. Initial results suggest training can improve leadership skills and inspire trainees to seek additional leadership education. Moreover, much like the published literature, residents believe they should learn about leadership during residency. While more effort is needed to determine the best approach to deliver and evaluate this content, it appears even small interventions can make a difference. Next steps for this program include developing assessment tools for observation of leadership behaviors during routine GME activities, which would allow for reinforcement of the principles being taught. Additionally, our experience has led our institution to make leadership training a requirement in all of our GME programs, and we look forward to reporting future progress. Finally, an ACGME requirement to incorporate leadership training into GME programs nationwide would prove useful, as doing so would reinforce its importance, accelerate implementation, and expand knowledge of best approaches on a national level.

The Rising Physicians Program: A Novel Approach for Mentoring Medical Students.

INTRODUCTION: The transition to medical school is a particularly challenging time for new students as they are faced with significant academic responsibilities. Moreover, for many students at the Uniformed Services University they are adjusting to being on active duty in the military. Mentoring has been considered a way to help with the transition and professional development. Prior to 2015, there was no formal mentoring program for new students at the Uniformed Services University. MATERIALS AND METHODS: In order to address the demands and challenges facing matriculating medical students, the Rising Physicians Program was created. This student initiated program enabled pre-clerkship medical students to connect with residents at the Walter Reed National Military Medical Center via a secure database with resident profiles. Residents were recruited and voluntarily agreed to serve as mentors. Students were then able to access the database and reach out to mentors based on their specific goals. The program was introduced to students during orientation and student participation was completely voluntary. A survey was designed using best survey practices and sent to the 175 students participating in the program for the 2015 academic (class of 2019) year to determine participation and characteristics of the program. RESULTS: Sixty-four percent (112/175) of the students from the class of 2019 participated in the post-implementation survey. Fifteen percent of the class (26/175) reported participating in the voluntary mentoring program. The three most commonly used communication methods with mentors in precedence were in-person, e-mail, and text messages. The majority of the students found their interactions in this program were beneficial and did not get in the way of their academic performance. The most common topics of discussion were academics (20%), mentor's past experience (22%), military lifestyle (7%), medical school pathways (23%), and specialty selections (23%). Limitations of the program included a lack of U.S. Air Force mentors and mentors within certain residency specialties. CONCLUSIONS: The Rising Physician Program provides a near-peer mentoring model for new medical students. Students preferred to communicate with their mentors in person, but the flexibility of communication appears to be important. New students have a variety of academic and professional development concerns that could partially be addressed through mentoring by residents.

Anonymous Feedback: What Should a Leader Do?

Leaders are required to evaluate and provide feedback to those they lead. This often involves giving feedback on direct observations, but at times can result from feedback brought to them via other pathways. When a leader is given feedback from a subordinate about another subordinate, they must decide how to best proceed. Often they must collect more data in order to make an informed decision. Followers continuously observe how leaders handle feedback from subordinates, which will directly impact mission success and unit morale. The following case highlights one junior officer's challenge related to anonymous feedback she received.

Factors Influencing Selection of Infectious Diseases Training for Military Internal Medicine Residents.

Background: Applications to infectious diseases fellowships have declined nationally; however, the military has not experienced this trend. In the past 6 years, 3 US military programs had 58 applicants for 52 positions. This study examines military resident perceptions to identify potential differences in factors influencing career choice, compared with published data from a nationwide cohort. Methods: An existing survey tool was adapted to include questions unique to the training and practice of military medicine. Program directors from 11 military internal medicine residencies were asked to distribute survey links to their graduating residents from December 2016 to January 2017. Data were categorized by ID interest. Result: The response rate was 51% (n = 68). Of respondents, 7% were ID applicants, 40% considered ID but reconsidered, and 53% were uninterested. Of those who considered ID, 73% changed their mind in their second and third postgraduate years and cited salary (22%), lack of procedures (18%), and training length (18%) as primary deterrents to choosing ID. Active learning styles were used more frequently by ID applicants to learn ID concepts than by those who considered or were uninterested in ID (P = .02). Conclusions: Despite differences in the context of training and practice among military trainees compared with civilian colleagues, residents cited similar factors affecting career choice. Interest in global health was higher in this cohort. Salary continues to be identified as a deterrent to choosing ID. Differences between military and civilian residents' desire to pursue ID fellowship are likely explained by additional unmeasured factors deserving further study.

Leadership Training in Graduate Medical Education: A Systematic Review.

BACKGROUND: Leadership is a critical component of physician competence, yet the best approaches for developing leadership skills for physicians in training remain undefined. OBJECTIVE: We systematically reviewed the literature on existing leadership curricula in graduate medical education (GME) to inform leadership program development. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we searched MEDLINE, ERIC, EMBASE, and MedEdPORTAL through October 2015 using search terms to capture GME leadership curricula. Abstracts were reviewed for relevance, and included studies were retrieved for full-text analysis. Article quality was assessed using the Best Evidence in Medical Education (BEME) index. RESULTS: A total of 3413 articles met the search criteria, and 52 were included in the analysis. Article quality was low, with 21% (11 of 52) having a BEME score of 4 or 5. Primary care specialties were the most represented (58%, 30 of 52). The majority of programs were open to all residents (81%, 42 of 52). Projects and use of mentors or coaches were components of 46% and 48% of curricula, respectively. Only 40% (21 of 52) were longitudinal throughout training. The most frequent pedagogic methods were lectures, small group activities, and cases. Common topics included teamwork, leadership models, and change management. Evaluation focused on learner satisfaction and self-assessed knowledge. Longitudinal programs were more likely to be successful. CONCLUSIONS: GME leadership curricula are heterogeneous and limited in effectiveness. Small group teaching, project-based learning, mentoring, and coaching were more frequently used in higher-quality studies.

Taking Charge: Moving from Peer to Supervisor.

Leadership transitions occur frequently, and these times can be challenging for the individual and those they lead. Leaders must develop new knowledge and skills required of the position. Leaders also assume a new formal leadership role over prior peers. This can be a difficult task for junior leaders. The following article illustrates an example case faced by a junior Navy Medical Corps Officer and how one might respond.

Military Internal Medicine Resident Decision to Apply to Fellowship and Extend Military Commitment.

Introduction: Nationally, the number of internal medicine physicians practicing in primary care has decreased amidst increasing interest in hospitalist medicine. Current priorities in the Military Health System include access to primary care and retention of trained personnel. Recently, we have conducted a study of military internal medicine residents' decision to enter infectious disease. As part of our larger effort, we saw an opportunity to characterize factors impacting decision making of internal medicine residents' desire to apply for subspecialty training and to extend active duty service obligations. Materials and Methods: Questions were developed after discussion with various military graduate medical education and internal medicine leaders, underwent external review, and were added to a larger question set. The survey link was distributed electronically to all U.S. military affiliated residencies' graduating internal medicine residents in December 2016-January 2017. Data were analyzed by decision to apply to fellowship and decision to extend military obligation using Fisher's exact test or Pearon's chi-square test. Results: Sixty-eight residents from 10 of 11 military residency programs responded, for a response rate of 51%. The majority (62%) applied to fellowship to start after residency completion. Reasons cited for applying to fellowship included wanting to become a specialist as soon as possible (74%), wishing to avoid being a general internist (57%), and because they are unable to practice as a hospitalist in the military (52%). Fellowship applicants were more likely to plan to extend their military obligation than non-applicants, as did those with longer duration of military commitments. No other factors, including Uniformed Services University attendance or participation in undergraduate military experiences, were found to impact plan to extend active duty service commitment. Conclusion: The majority of graduating internal medicine residents apply for fellowship and report a desire to avoid being a general internist. Prospective fellows anticipate extending their active duty commitment, as do those with longer commitments.

Recognizing the Importance of Leadership: A Recent Graduate Develops a Corpsman.

There is a growing interest in leadership development within the field of medicine both within the military and the larger medical community. Recognition of the importance of leadership training during graduate medical education has grown, but many residents and faculty still argue that residency training should focus on clinical skills and medical knowledge. Most graduates of training programs in the military quickly find themselves in formal leadership positions or they must informally lead in their clinical practice. As these new graduates enter practice, they quickly realize the need to be able to effectively lead. In order to highlight some of the leadership challenges that junior military physicians face, Military Medicine is starting a new column called "Leadership Lessons from the Field." This article is the first in the series and discusses a recent graduate's experience in dealing with an underperforming corpsman. The article reviews the importance of emotional intelligence, feedback, and goal setting.

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.

Moving Beyond Accidental Leadership: A Graduate Medical Education Leadership Curriculum Needs Assessment.

BACKGROUND: Despite calls for greater physician leadership, few medical schools, and graduate medical education programs provide explicit training on the knowledge, skills, and attitudes necessary to be an effective physician leader. Rather, most leaders develop through what has been labeled "accidental leadership." A survey was conducted at Walter Reed to define the current status of leadership development and determine what learners and faculty perceived as key components of a leadership curriculum. METHODS: A branching survey was developed for residents and faculty to assess the perceived need for a graduate medical education leadership curriculum. The questionnaire was designed using survey best practices and established validity through subject matter expert reviews and cognitive interviewing. The survey instrument assessed the presence of a current leadership curriculum being conducted by each department, the perceived need for a leadership curriculum for physician leaders, the topics that needed to be included, and the format and timing of the curriculum. Administered using an online/web-based survey format, all 2,041 house staff and educators at Walter Reed were invited to participate in the survey. Descriptive statistics were conducted using SPSS (version 22). RESULTS: The survey response rate was 20.6% (421/2,041). Only 17% (63/266) of respondents stated that their program had a formal leadership curriculum. Trainees ranked their current leadership abilities as slightly better than moderately effective (3.22 on a 5-point effectiveness scale). Trainee and faculty availability were ranked as the most likely barrier to implementation. Topics considered significantly important (on a 5-point effectiveness scale) were conflict resolution (4.1), how to motivate a subordinate (4.0), and how to implement change (4.0). Respondents ranked the following strategies highest in perceived effectiveness on a 5-point scale (with 3 representing moderate effectiveness): leadership case studies (3.3) and small group exercises (3.2). Online power points were reported as only slightly effective (1.9). Free text comments suggest that incorporating current duties, a mentoring and coaching component, and project based would be valuable to the curriculum. DISCUSSION: Few training programs at Walter Reed have a dedicated leadership curriculum. The survey data provide important information for programs considering implementing a leadership development curriculum in terms of content and delivery.

Sepsis Mimicker in an Human Immunodeficiency Virus-Infected Patient.

A 22-year-old human immunodeficiency virus-infected male presented with fever, rash, hypotension, and renal insufficiency 18 days following initiation of therapy with an efavirenz-based antiretroviral regimen. Although rash is a common side effect of efavirenz, severe hypersensitivity reactions are rare. Systemic symptoms can include hepatic toxicity and pneumonitis, and in one instance death. Corticosteroids are the mainstay of treatment.

Phase 1/2a Trial of Plasmodium vivax Malaria Vaccine Candidate VMP001/AS01B in Malaria-Naive Adults: Safety, Immunogenicity, and Efficacy.

BACKGROUND: A vaccine to prevent infection and disease caused by Plasmodium vivax is needed both to reduce the morbidity caused by this parasite and as a key component in efforts to eradicate malaria worldwide. Vivax malaria protein 1 (VMP001), a novel chimeric protein that incorporates the amino- and carboxy- terminal regions of the circumsporozoite protein (CSP) and a truncated repeat region that contains repeat sequences from both the VK210 (type 1) and the VK247 (type 2) parasites, was developed as a vaccine candidate for global use. METHODS: We conducted a first-in-human Phase 1 dose escalation vaccine study with controlled human malaria infection (CHMI) of VMP001 formulated in the GSK Adjuvant System AS01B. A total of 30 volunteers divided into 3 groups (10 per group) were given 3 intramuscular injections of 15 µg, 30 µg, or 60 µg respectively of VMP001, all formulated in 500 µL of AS01B at each immunization. All vaccinated volunteers participated in a P. vivax CHMI 14 days following the third immunization. Six non-vaccinated subjects served as infectivity controls. RESULTS: The vaccine was shown to be well tolerated and immunogenic. All volunteers generated robust humoral and cellular immune responses to the vaccine antigen. Vaccination did not induce sterile protection; however, a small but significant delay in time to parasitemia was seen in 59% of vaccinated subjects compared to the control group. An association was identified between levels of anti-type 1 repeat antibodies and prepatent period. SIGNIFICANCE: This trial was the first to assess the efficacy of a P. vivax CSP vaccine candidate by CHMI. The association of type 1 repeat-specific antibody responses with delay in the prepatency period suggests that augmenting the immune responses to this domain may improve strain-specific vaccine efficacy. The availability of a P. vivax CHMI model will accelerate the process of P. vivax vaccine development, allowing better selection of candidate vaccines for advancement to field trials.

Q Fever.

Q fever is a significant infectious disease threat to US military personnel deployed in the Middle East. Its environmental stability, aerosol transmission, and animal reservoir make it a considerable risk for deployed troops due to its potential for weaponization and risk of natural infection. It presents as a flu-like illness that responds promptly to antimicrobial therapy. Q fever should be suspected in patients presenting with a compatible febrile illness in an endemic area and especially if the individual has been exposed to livestock. Diagnosis is confirmed with serologic blood tests, but empiric therapy should be initiated when Q fever is considered. If left untreated, patients with acute Q fever can develop severe complications as well as chronic disease manifesting several months after the initial infection.