Exploring US internal medicine resident career preferences: a Q-methodology study.

Career selection in medicine is a complex and underexplored process. Most medical career studies performed in the U.S. focused on the effect of demographic variables and medical education debt on career choice. Considering ongoing U.S. physician workforce shortages and the trilateral adaptive model of career decision making, a robust assessment of professional attitudes and work-life preferences is necessary. The objective of this study was to explore and define the dominant viewpoints related to career choice selection in a cohort of U.S. IM residents. We administered an electronic Q-sort in which 218 IM residents sorted 50 statements reflecting the spectrum of opinions that influence postgraduate career choice decisions. Participants provided comments that explained the reasoning behind their individual responses. In the final year of residency training, we ascertained participating residents' chosen career. Factor analysis grouped similar sorts and revealed four distinct viewpoints. We characterized the viewpoints as "Fellowship-Bound-Academic," "Altruistic-Longitudinal-Generalist," "Inpatient-Burnout-Aware," and "Lifestyle-Focused-Consultant." There is concordance between residents who loaded significantly onto a viewpoint and their ultimate career choice. Four dominant career choice viewpoints were found among contemporary U.S. IM residents. These viewpoints reflect the intersection of competing priorities, personal interests, professional identity, socio-economic factors, and work/life satisfaction. Better appreciation of determinants of IM residents' career choices may help address workforce shortages and enhance professional satisfaction.

What motivates residents to teach? The Attitudes in Clinical Teaching study.

CONTEXT: Graduate medical trainees have a critical role in the teaching of other trainees. Improving their teaching requires an understanding of their attitudes towards teaching and their motivation to teach. Both have been incompletely explored in this population. We aimed to better understand graduate medical trainees' attitudes towards teaching and motivation to teach in the clinical setting in order to inform modifications to resident-as-teacher (RAT) programmes and enhance teaching practices. METHODS: We applied Q methodology, an established sorting method, to identify and quantify the factors that have an impact on trainees' engagement in teaching. We invited house officers at our institution to rank-order 47 statements regarding their attitudes to and motivation for teaching. Respondents explained their Q-sort rankings in writing and completed a demographic questionnaire. By-person factor analysis yielded groups of individuals with similar attitudes. RESULTS: One hundred and seven trainees completed the Q-sort. We found three primary groups of attitudes towards teaching in the clinical setting: enthusiasm, reluctance and rewarded. Enthusiastic teachers are committed and make time to teach. Teaching increases their job satisfaction. Reluctant teachers have enthusiasm but are earlier in training and feel limited by clinical workload and unprepared. Rewarded teachers feel teaching is worthwhile and derive satisfaction from the rewards and recognition they receive for teaching. CONCLUSIONS: This improved understanding of common attitudes shared by groups of residents will help curriculum designers create RAT programmes to further reinforce and encourage attitudes that promote teaching as well as improve trainees' motivation to teach. Designing RAT programmes that acknowledge the attitudes to and motivations for teaching should help develop effective teachers to improve educational outcomes. Directed efforts to enhance motivation for reluctant teachers and encourage more positive attitudes in rewarded teachers may lead to improved teaching behaviours among residents.

Exploring student preferences with a Q-sort: the development of an individualized renal physiology curriculum.

Medical education reform is underway, but the optimal course for change has yet to be seen. While planning for the redesign of a renal physiology course at the Duke School of Medicine, the authors used a Q-sort survey to assess students' attitudes and learning preferences to inform curricular change. The authors invited first-year medical students at the Duke School of Medicine to take a Q-sort survey on the first day of renal physiology. Students prioritized statements related to their understanding of renal physiology, learning preferences, preferred course characteristics, perceived clinical relevance of renal physiology, and interest in nephrology as a career. By-person factor analysis was performed using the centroid method. Three dominant factors were strongly defined by learning preferences: "readers" prefer using notes, a textbook, and avoid lectures; "social-auditory learners" prefer attending lectures, interactivity, and working with peers; and "visual learners" prefer studying images, diagrams, and viewing materials online. A smaller, fourth factor represented a small group of students with a strong predisposition against renal physiology and nephrology. In conclusion, the Q-sort survey identified and then described in detail the dominant viewpoints of our students. Learning style preferences better classified first-year students rather than any of the other domains. A more individualized curriculum would simultaneously cater to the different types of learners in the classroom.

Distressed Work: Chronic Imperatives and Distress in Covid-19 Critical Care.

This ethnographic study introduces the term "distressed work" to describe the emergence of chronic frictions between moral imperatives for health care workers to keep working and the dramatic increase in distress during the Covid-19 pandemic. Interviews and observant participation conducted in a hospital intensive care unit during the Covid-19 pandemic reveal how health care workers connected job duties with extraordinary emotional, physical, and moral burdens. We explore tensions between perceived obligations of health care professionals and the structural contexts of work. Key findings cluster around the moral imperatives of health care work and the distress that work engendered as work spaces, senses of vocation, patient and family interactions, and end-of-life care shifted. While the danger of working beyond limits has long been an ordinary feature of health care work, it has now become a chronic crisis. Assessing this problem in terms of distressed work and its structural contexts can better address effective, worker-informed responses to current health care labor dilemmas.

Thrombolytic therapy for venous thromboembolism: current clinical practice.

BACKGROUND: Venous thromboembolism (VTE) is a life-threatening condition for which thrombolytic therapy may be beneficial. The appropriate setting for the use of thrombolytic therapy remains controversial. More than 10 years ago we described the case-based practice patterns for the use of thrombolytics in VTE, and now, in the context of recent studies and guidelines, we sought to reevaluate the use of thrombolytics and to determine whether beliefs have changed. METHODS: Active pulmonologists in 11 southeastern states were selected to complete a web-based questionnaire that included background questions and hypothetical case scenarios involving VTE and potential treatment with thrombolytics. RESULTS: Eighty-one physicians completed the survey and 84% reported using thrombolytic therapy for VTE within the last 2 years. In the absence of absolute contraindications, 99% of respondents would strongly consider using systemic thrombolytic therapy for massive pulmonary embolism (PE) with hypotension, 83% would strongly consider thrombolysis for a large PE with severe hypoxemia, and 62% would strongly consider thrombolysis for PE with echocardiographic evidence of right ventricular dysfunction. In a patient with massive PE and hypotension with certain contraindications, 91% of respondents would still strongly consider thrombolysis. CONCLUSIONS: Most practicing pulmonologists would strongly consider administering thrombolytic therapy for massive PE with hypotension or hypoxemia, and a majority favor thrombolysis for PE in the setting of echocardiographic evidence of right heart dysfunction. Despite the evolving data and guidelines for the management of VTE, our findings are similar to prior survey results, emphasizing the need for further physician education and future randomized trials to clarify the therapy for this potentially deadly condition.