Evaluation of a longitudinal subspecialty clinic for internal medicine residents.

BACKGROUND: The traditional model for subspecialty education in internal medicine (IM) residencies is a short inpatient consult rotation, which often lacks outpatient exposure and continuity with faculty. Our IM residency program developed a longitudinal subspecialty clinic (LSC) experience, which pairs categorical IM residents with a faculty preceptor in their subspecialty of interest. Residents work in their preceptor's clinic for one half-day per week during ambulatory blocks throughout the PGY2 year. OBJECTIVE: To evaluate the LSC program's educational impact and determine best practices for successful implementation. METHODS: From May to July 2019, we surveyed residents and preceptors who participated in an LSC between 2014 and 2019, gathering quantitative and qualitative data on their experiences. RESULTS: Survey response rates were 66.4% (N=93/140) for residents, 57.7% (N=15/26) for preceptors. Most residents and preceptors were very or extremely satisfied with their LSC experience (83.3% and 71.4%, respectively). Most residents and preceptors reported that the LSC experience was very or extremely effective in enabling residents to explore their subspecialty of interest (76.0%, 86.7%), form a mentoring relationship with their preceptor (71.3%, 80.0%), obtain a letter of recommendation (76.1%, 64.3%), prepare for fellowship (76.3%, 66.7%), gain exposure to outpatient subspecialty practice (90.0%, 73.3%), and gain medical knowledge (84.6%, 80.0%). CONCLUSIONS: Our data showed that LSCs are effective in facilitating longitudinal subspecialty career exploration, mentorship, and education for residents. Opportunities for improvement include developing a more structured curriculum, addressing scheduling issues, and adding the option to extend the experience to the PGY3 year.

Factors Associated with a Career in Primary Care Medicine: Continuity Clinic Experience Matters.

BACKGROUND: Due to concerns of inadequate primary care access, national agencies like the Health Resources and Services Administration (HRSA) support primary care (PC) residencies. Recent research demonstrates that up to 35% of PC alumni lost interest in PC during residency. These alumni who lost interest noted that their continuity clinic experience influenced their career choice. The purpose of this study was to identify the specific aspects of PC residency experience that influenced career choice. METHODS: We conducted a cross-sectional electronic survey of a PC internal medicine alumni cohort (2000-2015) from a large, academic residency. Our primary predictor was PC career and our primary outcome was influential factors on career choice. We performed chi-squared or Fisher's exact tests for categorical variables and t tests for continuous variables. RESULTS: Of the 317 PC alumni in the last 15 years, 305 were contacted. One hundred seventy-two (56%) responded with 94 (55%) reporting current careers in PC and 78 (45%) in non-PC fields. Ninety-four percent of respondents expressed interest prior to residency, while only 68% remained interested at the conclusion of residency. Sixty-one percent of PC alumni rated the overall clinic experience as the most influential factor towards their ultimate career choice. The patient-physician relationship was the most frequently endorsed positively influential factor in career choice in both groups (95% of PC alumni, 76% non-PC). There was no difference among all alumni in common frustrations of clinic including clerical duties, encounter documentation, or visit length. Similarly, resident debt did not differ between groups. CONCLUSIONS: Strong interpersonal relationships with patients and clinic mentors were associated with a PC career. These factors may compensate for the reported frustrations of clinic. Enhancing patient and mentor relationships may increase the retention of PC residents in ambulatory careers and may help address the current and projected shortage of primary care physicians.

Decisions in the Dark: An Educational Intervention to Promote Reflection and Feedback on Night Float Rotations.

BACKGROUND: Night float rotations, where residents admit patients to the hospital, are opportunities for practice-based learning. However, night float residents receive little feedback on their diagnostic and management reasoning, which limits learning. AIM: Improve night float residents' practice-based learning skills through feedback solicitation and chart review with guided reflection. SETTING/PARTICIPANTS: Second- and third-year internal medicine residents on a 1-month night float rotation between January and August 2017. PROGRAM DESCRIPTION: Residents performed chart review of a subset of patients they admitted during a night float rotation and completed reflection worksheets detailing patients' clinical courses. Residents solicited feedback regarding their initial management from day team attending physicians and senior residents. PROGRAM EVALUATION: Sixty-eight of 82 (83%) eligible residents participated in this intervention. We evaluated 248 reflection worksheets using content analysis. Major themes that emerged from chart review included residents' identification of future clinical practice changes, evolution of differential diagnoses, recognition of clinical reasoning gaps, and evaluation of resident-provider interactions. DISCUSSION: Structured reflection and feedback during night float rotations is an opportunity to improve practice-based learning through lessons on disease progression, clinical reasoning, and communication.

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine?

PURPOSE: Professional and governmental organizations recommend an ideal US physician workforce composed of at least 40 % primary care physicians. They also support primary care residencies to promote careers in primary care. Our study examines the relationship between graduation from a primary care or categorical internal medicine residency program and subsequent career choice. METHODS: We conducted a cross-sectional electronic survey of a cohort of internal medicine residency alumni who graduated between 2001 and 2010 from a large academic center. Our primary predictor was graduation from a primary care versus a categorical internal medicine program and our primary outcome is current career role. We performed chi-square analysis comparing responses of primary care and categorical residents. RESULTS: We contacted 481 out of 513 alumni, of whom 322 responded (67 %). We compared 106 responses from primary care alumni to 169 responses from categorical alumni. Fifty-four percent of primary care alumni agreed that the majority of their current clinical work is in outpatient primary care vs. 20 % of categorical alumni (p < 0.001). While 92.5 % of primary-care alumni were interested in a primary care career prior to residency, only 63 % remained interested after residency. Thirty of the 34 primary care alumni (88 %) who lost interest in a primary care career during residency agreed that their ambulatory experience during residency influenced their subsequent career choice. CONCLUSIONS: A higher percentage of primary care alumni practice outpatient primary care as compared to categorical alumni. Some alumni lost interest in primary care during residency. The outpatient clinic experience may impact interest in primary care.

Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review.

BACKGROUND: Malignant pleural effusions (MPE) are a frequent cause of dyspnea and discomfort at the end of cancer patients' lives. The tunneled indwelling pleural catheter (TIPC) was approved by the FDA in 1997 and has been investigated as a treatment for MPE. OBJECTIVE: To systematically review published data on the efficacy and safety of the TIPC for treatment of MPE. DESIGN: We searched the MEDLINE, EMBASE, and ISI Web of Science databases to identify studies published through October 2009 that reported outcomes in adult patients with MPE treated with a TIPC. Data were aggregated using summary statistics when outcomes were described in the same way among multiple primary studies. MAIN MEASURES: Symptomatic improvement and complications associated with use of the TIPC. KEY RESULTS: Nineteen studies with a total of 1,370 patients met criteria for inclusion in the review. Only one randomized study directly compared the TIPC with the current gold standard treatment, pleurodesis. All other studies were case series. Symptomatic improvement was reported in 628/657 patients (95.6%). Quality of life measurements were infrequently reported. Spontaneous pleurodesis occurred in 430/943 patients (45.6%). Serious complications were rare and included empyema in 33/1168 patients (2.8%), pneumothorax requiring a chest tube in 3/51 (5.9%), and unspecified pneumothorax in 17/439 (3.9%). Minor complications included cellulitis in 32/935 (3.4%), obstruction/clogging in 33/895 (3.7%) and unspecified malfunction of the catheter in 11/121 (9.1%). The use of the TIPC was without complication in 517/591 patients (87.5%). CONCLUSIONS: Based on low-quality evidence in the form of case series, the TIPC may improve symptoms for patients with MPE and does not appear to be associated with major complications. Prospective randomized studies comparing the TIPC to pleurodesis are needed before the TIPC can be definitively recommended as a first-line treatment of MPE.

Developing educators, investigators, and leaders during internal medicine residency: the area of distinction program.

BACKGROUND: Professional organizations have called for individualized training approaches, as well as for opportunities for resident scholarship, to ensure that internal medicine residents have sufficient knowledge and experience to make informed career choices. CONTEXT AND PURPOSE: To address these training issues within the University of California, San Francisco, internal medicine program, we created the Areas of Distinction (AoD) program to supplement regular clinical duties with specialized curricula designed to engage residents in clinical research, global health, health equities, medical education, molecular medicine, or physician leadership. We describe our AoD program and present this initiative's evaluation data. METHODS AND PROGRAM EVALUATION: We evaluated features of our AoD program, including program enrollment, resident satisfaction, recruitment surveys, quantity of scholarly products, and the results of our resident's certifying examination scores. Finally, we described the costs of implementing and maintaining the AoDs. RESULTS: AoD enrollment increased from 81% to 98% during the past 5 years. Both quantitative and qualitative data demonstrated a positive effect on recruitment and improved resident satisfaction with the program, and the number and breadth of scholarly presentations have increased without an adverse effect on our board certification pass rate. CONCLUSIONS: The AoD system led to favorable outcomes in the domains of resident recruitment, satisfaction, scholarship, and board performance. Our intervention showed that residents can successfully obtain clinical training while engaging in specialized education beyond the bounds of core medicine training. Nurturing these interests 5 empower residents to better shape their careers by providing earlier insight into internist roles that transcend classic internal medicine training.

Teaching strategies used by internal medicine residents on the wards.

BACKGROUND: Residents serve as teachers to interns and students in most internal medicine residency programs. AIM: The purpose of our study is to explore what internal medicine residents perceive as effective teaching strategies in the inpatient setting and to formulate a guideline for preparing residents to lead their ward teams. METHODS: Housestaff identified as excellent teaching residents were recruited from a large internal medicine residency program. Focus groups were formed and interviews were conducted using open-ended questions. Transcripts of the interviews were reviewed, analyzed, and compared for accuracy by two investigators. The transcripts were then coded to categorize data into similar subjects from which recurrent themes in resident teaching were identified. RESULTS: Twenty-two residents participated in four focus group interviews held in 2008. We identified five principal themes for effective teaching by residents: (T)aking advantage of teaching opportunities, (E)mpowering learners, (A)ssuming the role of leader, (C)reating a learning environment, and (H)abituating the practice of teaching. CONCLUSION: Strategies for effective teaching by residents exist. The TEACH mnemonic is a resident-identified method of instruction. Use of this tool could enable residency programs to create instructional curricula to prepare their residents and interns to take on the roles of team leaders and teachers.

Baseline duty hours recorded with time-cards: a pre-regulation study of internal medicine residents.

OBJECTIVE: The acquisition of data on resident duty hours has been largely dependent on self-report surveys collected in the surgical literature. We sought to implement and describe a simple method for monitoring internal medicine resident duty hours by using time-cards. DESIGN: In 2002, internal medicine residents on a 3-site academic programme were asked to track their duty hours using time-cards prior to the implementation of system changes according to duty hours reform. SETTING: An academic internal medicine residency programme in the USA. RESULTS: Of participating residents (n = 41), 93% worked at least 1 shift longer than 30 hours, 29% worked an average of more than 80 hours per week, and 56% had less than 1 day off per week. No residents were on call more than once every third day. CONCLUSIONS: This study describes the findings and challenges of using time-cards to track duty hours, and shows that many internal medicine residents on this programme were, before implementation of duty hours reforms, in violation of duty hours regulations.

Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents.

BACKGROUND: Although clinicians commonly use computed tomography or ultrasonography to diagnose acute appendicitis, the accuracy of these imaging tests remains unclear. PURPOSE: To review the diagnostic accuracy of computed tomography and ultrasonography in adults and adolescents with suspected acute appendicitis. DATA SOURCES: The authors used MEDLINE, EMBASE, bibliographies, review articles, textbooks, and expert opinion to retrieve English- and non-English-language articles published from 1966 to December 2003. STUDY SELECTION: The authors included prospective studies evaluating computed tomography or ultrasonography followed by surgical confirmation or clinical follow-up in patients at least 14 years of age with suspected appendicitis. DATA EXTRACTION: One assessor (for non-English-language studies) or 2 assessors (for English-language studies) independently reviewed each article to abstract relevant study characteristics and results. DATA SYNTHESIS: Twelve computed tomography studies and 14 ultrasonography studies met inclusion criteria. Computed tomography had an overall sensitivity of 0.94 (95% CI, 0.91 to 0.95), a specificity of 0.95 (CI, 0.93 to 0.96), a positive likelihood ratio of 13.3 (CI, 9.9 to 17.9), and a negative likelihood ratio of 0.09 (CI, 0.07 to 0.12). Ultrasonography had an overall sensitivity of 0.86 (CI, 0.83 to 0.88), a specificity of 0.81 (CI, 0.78 to 0.84), a positive likelihood ratio of 5.8 (CI, 3.5 to 9.5), and a negative likelihood ratio of 0.19 (CI, 0.13 to 0.27). Verification bias and inappropriate blinding of reference standards were noted in all of the included studies. LIMITATIONS: The summary assessment of the diagnostic accuracy for both tests was limited by the small number of studies, heterogeneity among study samples, and poor methodologic quality in the original studies. CONCLUSIONS: Computed tomography is probably more accurate than ultrasonography for diagnosing appendicitis in adults and adolescents. Prospective studies that apply gold standard diagnostic testing to all study participants would more reliably estimate the true diagnostic accuracy of these tests.

Advance directive group education in a VA outpatient clinic.

Advance directive education is an important social work role in many medical settings. Despite its obvious benefit in terms of time-effectiveness, group education around advance directives has received little previous attention in the social work research literature. In a retrospective cohort (n = 13,913), we compared three education strategies in an attempt to evaluate their effectiveness on advance directive completion: (1) participation in a group session, (2) one or more individual sessions with a social worker, and (3) no advance directive education. Social work education of any kind resulted in an overall completion rate of 20% versus 2.1% in the non-intervention group. Group education was twice as effective as an individual social work session, and as effective as multiple sessions, but less time consuming. Our study confirmed previous findings that older patients are more likely to complete advance directives independent of education strategy. Participants in the group sessions were also older than the rest of the cohort, leading us to hypothesize about the particular appeal of group education to older patients. We conclude that group education is an effective as well as time- and cost-efficient social work tool for facilitating completion of advance medical directives, particularly among older patients.