Exploring Competency-Based Medical Education Through the Lens of the UME-GME Transition: A Qualitative Study.

PURPOSE: Competency-based medical education (CBME) represents a shift to a paradigm with shared definitions, explicit outcomes, and assessments of competence. The groundwork has been laid to ensure all learners achieve the desired outcomes along the medical education continuum using the principles of CBME. However, this continuum spans the major transition from undergraduate medical education (UME) to graduate medical education (GME) that is also evolving. This study explores the experiences of medical educators working to use CBME assessments in the context of the UME-GME transition and their perspectives on the existing challenges. METHOD: This study used a constructivist-oriented qualitative methodology. In-depth, semistructured interviews of UME and GME leaders in CBME were performed between February 2019 and January 2020 via Zoom. When possible, each interviewee was interviewed by 2 team members, one with UME and one with GME experience, which allowed follow-up questions to be pursued that reflected the perspectives of both UME and GME educators more fully. A multistep iterative process of thematic analysis was used to analyze the transcripts and identify patterns across interviews. RESULTS: The 9 interviewees represented a broad swath of UME and GME leadership positions, though most had an internal medicine training background. Analysis identified 4 overarching themes: mistrust (a trust chasm exists between UME and GME); misaligned goals (the residency selection process is antithetical to CBME); inadequate communication (communication regarding competence is infrequent, often unidirectional, and lacks a shared language); and inflexible timeframes (current training timeframes do not account for individual learners' competency trajectories). CONCLUSIONS: Despite the mutual desire and commitment to move to CBME across the continuum, mistrust, misaligned goals, inadequate communication, and inflexible timeframes confound such efforts of individual schools and programs. If current efforts to improve the UME-GME transition address the themes identified, educators may be more successful implementing CBME along the continuum.

Chief resident behaviors that lead to effective morning reports, a multisite qualitative study.

BACKGROUND: Morning report is a fundamental component of internal medicine training and often represents the most significant teaching responsibility of Chief Residents. We sought to define Chief Resident behaviors essential to leading a successful morning report. METHODS: In 2016, we conducted a multi-site qualitative study using key informant interviews of morning report stakeholders. 49 residents, Chief Residents, and faculty from 4 Internal Medicine programs participated. Interviews were analyzed and coded by 3 authors using inductive reasoning and thematic analysis. A preliminary code structure was developed and expanded in an iterative process concurrent with data collection until thematic sufficiency was reached and a final structure was established. This final structure was used to recode all transcripts. RESULTS: We identified four themes of Chief Resident behaviors that lead to a successful morning report: report preparation, delivery skills, pedagogical approaches, and faculty participation. Preparation domains include thoughtful case selection, learning objective development, content editing, and report organization. Delivery domains include effective presentation skills, appropriate utilization of technology, and time management. Pedagogical approach domains include learner facilitation techniques that encourage clinical reasoning while nurturing a safe learning environment, as well as innovative teaching strategies. Moderating the involvement of faculty was identified as the final key to morning report effectiveness. Specific behavior examples are provided. CONCLUSION: Consideration of content preparation, delivery, pedagogical approaches, and moderation of faculty participation are key components to Chief Resident-led morning reports. Results from this study could be used to enhance faculty development for Chief Residents.

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.

Students' Experiences With Death and Dying Prior to Medical School: A Content Analysis of Students' Written Reflections.

BACKGROUND: Personal experiences with death and dying are common among medical students, but little is known about student attitudes and emotional responses to these experiences. Our objectives were to ascertain matriculating medical students' experiences with death and dying, describe the range of students' emotional responses, and identify reactions, behaviors, and perceived roles related to these and future experiences with death. METHODS: We provided a writing prompt to newly matriculated medical students asking them to "reflect on experiences you may have had with family or friends near the end of life." Content analysis was performed to identify themes in the responses. RESULTS: The 104 students in the entering class submitted 90 individual free-text responses (87%). Most (57%) students specifically mentioned at least 1 personal experience with death, with a range of emotional responses including sadness (29%), surprise (14%), and guilt (12%). Distinct themes emerged on content analysis including personal experiences with death, anticipated response to death in future, changes in body or mind of the dying person, thoughts and observations about others, and cognitive or existential responses. Few students wrote about religion or spirituality (8%) or palliative or hospice care (2%). CONCLUSIONS: An understanding of students' premedical school experiences and emotional reactions to death may help educators frame curricula around end-of-life care. Educators could apply enhanced awareness to help students process their own experiences as they begin caring for patients and to focus on areas that were underrepresented in students' comments, such as religion, spirituality, palliative care, and hospice.

The Changing Face of HIV Care: Expanding HIV Training in an Internal Medicine Residency Program.

PROBLEM: People with HIV/AIDS are living longer and are at an increased risk of comorbidities. A qualified physician workforce is needed to care for this growing population. APPROACH: In 2012, a novel three-year HIV training track (HIV TT) was implemented as part of the Yale Primary Care Residency Program. To prepare for the implementation of this program, a needs assessment was performed, a web-based curriculum and 12 HIV-specific entrustable professional activities (EPAs) were created, and adequate clinical training opportunities in HIV and primary care were established. Program evaluation included process, learner, and outcome evaluations from 2012 to 2017. OUTCOMES: Since its inception, the HIV TT has enrolled a total of 11 residents (6-7 at a time), with 5 graduating to date. Residents delivered high-quality HIV and primary care for a diverse panel of patients; improved their knowledge and performance in HIV care, including according to the HIV-specific EPAs; and were highly satisfied with the program. All faculty remained with the program, and patients indicated satisfaction. NEXT STEPS: Next steps include enhanced coordination of residents' schedules, improved EPA documentation, evaluation of residents' HIV and non-HIV competence beyond residency, and monitoring graduates' career trajectories. Expanding HIV training within internal medicine residency programs is feasible and effective and has the potential to alleviate the shortage of physicians trained to provide HIV care and primary care in a single setting.

Proposed Performance-Based Metrics for the Future Funding of Graduate Medical Education: Starting the Conversation.

Graduate medical education (GME) in the United States is financed by contributions from both federal and state entities that total over $15 billion annually. Within institutions, these funds are distributed with limited transparency to achieve ill-defined outcomes. To address this, the Institute of Medicine convened a committee on the governance and financing of GME to recommend finance reform that would promote a physician training system that meets society's current and future needs. The resulting report provided several recommendations regarding the oversight and mechanisms of GME funding, including implementation of performance-based GME payments, but did not provide specific details about the content and development of metrics for these payments. To initiate a national conversation about performance-based GME funding, the authors asked: What should GME be held accountable for in exchange for public funding? In answer to this question, the authors propose 17 potential performance-based metrics for GME funding that could inform future funding decisions. Eight of the metrics are described as exemplars to add context and to help readers obtain a deeper understanding of the inherent complexities of performance-based GME funding. The authors also describe considerations and precautions for metric implementation.

First confirmation by PCR of Jaagsiekte sheep retrovirus in Ireland and prevalence of ovine pulmonary adenocarcinoma in adult sheep at slaughter.

BACKGROUND: Ovine pulmonary adenocarcinoma (OPA), caused by Jaagsiekte sheep retrovirus (JSRV), is characterised by the development of invariably fatal lung tumours primarily in adult sheep. High infection rates and disease prevalence can develop during initial infection of flocks, leading to on-farm economic losses and animal welfare issues in sheep with advanced disease. The disease has been reported in Ireland and is notifiable, but the presence of JSRV has never been confirmed using molecular methods in this country. Additionally, due to the difficulties in ante-mortem diagnosis (especially of latently-infected animals, or those in the very early stages of disease), accurate information regarding national prevalence and distribution is unavailable. This study aimed to confirm the presence of JSRV in Ireland and to obtain estimates regarding prevalence and distribution by means of an abattoir survey utilising gross examination, histopathology, JSRV-specific reverse transcriptase polymerase chain reaction (RT-PCR) and SU protein specific immunohistochemistry (IHC) to examine the lungs of adult sheep. RESULTS: Lungs from 1911 adult sheep were examined macroscopically in the abattoir and 369 were removed for further testing due to the presence of gross lesions of any kind. All 369 were subject to histopathology and RT-PCR, and 46 to IHC. Thirty-one lungs (31/1911, 1.6%) were positive for JSRV by RT-PCR and/or IHC but only ten cases of OPA were confirmed (10/1911, 0.5%) Four lung tumours not associated with JSRV were also identified. JSRV-positive sheep tended to cluster within the same flocks, and JSRV-positive sheep were identified in the counties of Donegal, Kerry, Kilkenny, Offaly, Tipperary, Waterford and Wicklow. CONCLUSIONS: The presence of JSRV has been confirmed in the Republic of Ireland for the first time using molecular methods (PCR) and IHC. In addition, an estimate of OPA prevalence in sheep at slaughter and information regarding distribution of JSRV infection has been obtained. The prevalence estimate appears similar to that of the United Kingdom (UK). Results also indicate that the virus has a diverse geographical distribution throughout Ireland. These data highlights the need for further research to establish national control and monitoring strategies.

Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE).

BACKGROUND: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic. DESCRIPTION: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty. EVALUATION: Anonymous, voluntary survey of all participants and comparison of expenditures by training level were used to assess this pilot program. The educational quality of the I-CARE was rated higher than the prior format of Morning Report by participants (10-point Likert scale; 8.57, 6.81 respectively; p < .001). Open-ended comments were overwhelmingly supportive from faculty and trainees. Cost was lower for attending physicians than for trainees ($1,027.45 vs. $4,264.00, p = .02) and diagnostic accuracy was also highest for attending physicians. CONCLUSIONS: The I-CARE is easy and quick to implement, and the preliminary results show a popular cost-awareness educational experience for internal medicine trainees. Further study is needed to determine change in practice habits.

Quality of discharge practices and patient understanding at an academic medical center.

IMPORTANCE: With growing national focus on reducing readmissions, there is a need to comprehensively assess the quality of transitional care, including discharge practices, patient perspectives, and patient understanding. OBJECTIVE: To conduct a multifaceted evaluation of transitional care from a patient-centered perspective. DESIGN: Prospective observational cohort study, May 2009 through April 2010. SETTING: Urban, academic medical center. PARTICIPANTS: Patients 65 years and older discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MAIN OUTCOMES AND MEASURES: Discharge practices, including presence of follow-up appointment and patient-friendly discharge instructions; patient understanding of diagnosis and follow-up appointment; and patient perceptions of and satisfaction with discharge care. RESULTS: The 395 enrolled patients (66.7% of those eligible) had a mean age of 77.2 years. Although 349 patients (95.6%) reported understanding the reason they had been in the hospital, only 218 patients (59.6%) were able to accurately describe their diagnosis in postdischarge interviews. Discharge instructions routinely included symptoms to watch out for (98.4%), activity instructions (97.3%), and diet advice (89.7%) in lay language; however, 99 written reasons for hospitalization (26.3%) did not use language likely to be intelligible to patients. Of the 123 patients (32.6%) discharged with a scheduled primary care or cardiology appointment, 54 (43.9%) accurately recalled details of either appointment. During postdischarge interviews, 118 patients (30.0%) reported receiving less than 1 day's advance notice of discharge, and 246 (66.1%) reported that staff asked whether they would have the support they needed at home before discharge. CONCLUSIONS AND RELEVANCE: Patient perceptions of discharge care quality and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear. However, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor. Patient perceptions and written documentation do not adequately reflect patient understanding of discharge care.

Comprehensive quality of discharge summaries at an academic medical center.

BACKGROUND: Discharge summaries are essential for safe transitions from hospital to home. OBJECTIVE: To conduct a comprehensive quality assessment of discharge summaries. DESIGN: Prospective cohort study. SUBJECTS: Three hundred seventy-seven patients discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MEASURES: Discharge summaries were assessed for timeliness of dictation, transmission of the summary to appropriate outpatient clinicians, and presence of key content including elements required by The Joint Commission and elements endorsed by 6 medical societies in the Transitions of Care Consensus Conference (TOCCC). RESULTS: A total of 376 of 377 patients had completed discharge summaries. A total of 174 (46.3%) summaries were dictated on the day of discharge; 93 (24.7%) were completed more than a week after discharge. A total of 144 (38.3%) discharge summaries were not sent to any outpatient physician. On average, summaries included 5.6 of 6 The Joint Commission elements and 4.0 of 7 TOCCC elements. Summaries dictated by hospitalists were more likely to be timely and to include key content than summaries dictated by housestaff or advanced practice nurses. Summaries dictated on the day of discharge were more likely to be sent to outside physicians and to include key content. No summary met all 3 quality criteria of timeliness, transmission, and content. CONCLUSIONS: Discharge summary quality is inadequate in many domains. This may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes. However, improving discharge summary timeliness may also improve content and transmission.

What can we learn from patient dissatisfaction? An analysis of dissatisfying events at an academic medical center.

BACKGROUND: Patient satisfaction is typically measured by quantitative surveys using predetermined domains. However, dissatisfaction may be an entity distinct from satisfaction, may have different determinants, and may better reflect problems in healthcare delivery. OBJECTIVE: The aim of this study was to describe domains of dissatisfaction experienced by patients during hospitalization. SETTING: The setting was a U.S. urban academic medical center. PATIENTS: The patients were adults discharged between July 1, 2007 and June 30, 2008 INTERVENTION: The intervention was a postdischarge telephone interview: "If there was one thing we could have done to improve your experience in the hospital, what would it have been?" MEASUREMENTS: The measurements were standard qualitative analysis of suggestions for improvement. RESULTS: We randomly selected 976 of 9,764 interviews. A total of 439/976 (45.0%) included at least one suggestion for improvement. We identified six major domains of dissatisfaction: ineptitude (7.7%), disrespect (6.1%), waits (15.8%), ineffective communication (7.4%), lack of environmental control (15.6%), and substandard amenities (6.9%). These domains corresponded to six implicit expectations for quality hospital care: safety, treatment with respect and dignity, minimized wait times, effective communication, control over physical surroundings, and high-quality amenities. Some of these expectations, such as for safe care, effective communication between providers, and lack of disrespect, may not be adequately captured in existing patient satisfaction assessments. CONCLUSIONS: The results represent patient-generated priorities for quality improvement in healthcare. These priorities are not all consistently represented in standard patient satisfaction surveys and quality improvement initiatives. Patient input is critical to assessing the quality of hospital care and to identifying areas for improvement.

Update in thrombosis: answers to perplexing questions.

Recent clinical trials are answering some of the perplexing clinical questions about venous thromboembolism (VTE), such as the length and intensity of anticoagulation needed to prevent recurrence. We review some of these clinical trials and their implications for physicians and patients.

The effect of antibiotic therapy for patients infected with Helicobacter pylori who have chronic urticaria.

BACKGROUND: Several small trails looking at antibiotic therapy targeted at Helicobacter pylori for the treatment of chronic urticaria have been published and have had conflicting results. We conducted a systematic review of existing studies to help answer the clinical question of whether this therapy has a role in the treatment of chronic urticaria. METHODS: We identified studies published in the English language with searches of MEDLINE, PREMEDLINE, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effectiveness, and Cochrane Libraries using the key words "Helicobacter pylori" and "urticaria." Relevant studies from bibliography reviews were also included. Studies included met the following criteria: (1) patients had urticaria for at least 6 weeks; (2) other known causes of urticaria were excluded by appropriate testing; (3) the initial diagnosis of H pylori infection was made by either serology, urea breath test, or upper endoscopy; and (4) an adequate trial of an antibiotic with known activity against H pylori was completed. RESULTS: In all, 10 studies met our inclusion criteria. The rate of remission of urticaria when H pylori was eradicated was 30.9% (59/191) compared with 21.7% (18/83) when H pylori was not eradicated; the background remission rate among control subjects without H pylori infection was 13.5% (10/74). When data from the 10 studies were combined, eradication of H pylori was both quantitatively and statistically associated with remission of urticaria (odds ratio 2.9; 95% confidence interval 1.4-6.8; P =.005). CONCLUSION: We found that resolution of urticaria was more likely when antibiotic therapy was successful in eradication of H pylori infection than when patients who were infected did not achieve eradication. These results suggest that clinicians, after considering other causes of urticaria, should constitute (1) testing for H pylori; (2) treating with appropriate antibiotics if H pylori is present; and (3) confirming successful eradication of infection.