Prevalence of Women in Medicine Programs at University-Based Internal Medicine Residency Programs.

OBJECTIVE: Women physicians face various forms of inequities during their training process that inhibit them from reaching their full potential. As a response, several academic institutions have established women in medicine (WIM) programs as a support system. Our objective was to investigate the prevalence of WIM programs at university-based Internal Medicine residency programs as of December 2021. METHODS: Using the Fellowship and Residency Electronic Interactive Database, we identified 145 university-based Internal Medicine residency programs. Four independent reviewers reviewed the programs' Web sites, looking for evidence of a WIM program using a standardized checklist of search terms to evaluate and categorize their programs. Categories included whether the program was specific to graduate medical trainees, departments of medicine, or institution-wide. The proportions of programs that had a WIM program, a trainee-specific WIM program, and a Department of Medicine-specific WIM program were then analyzed. RESULTS: Of the 145 programs searched, 58 (40%) had a WIM program. Only 16 (11%) were specific to trainees (11 for only medicine trainees and 5 included trainees graduate medical education-wide). The remaining 42 programs targeted faculty and trainees (5 included only the Department of Medicine and 37 included departments university-wide). CONCLUSIONS: Few university-affiliated Internal Medicine residency programs have a WIM program specific to trainees. Given the gender inequity and evidence that supports early development of leadership skills and support networks, our findings highlight a possible gap in the residency training program infrastructure.

"What do you think about nephrology?" A national survey of internal medicine residents.

BACKGROUND: Interest in nephrology has been declining among internal medicine residents but the reasons behind this observation are not well characterized. Our objective was to evaluate factors influencing residents' choice of subspecialty. METHODS: This is a mixed-method QUAL-QUAN design study that used the results of our previously published qualitative analysis on residents' perception of nephrology to create and pilot a questionnaire of 60 questions. The final questionnaire was distributed to 26 programs across the United States and a total of 1992 residents. We calculated response rates and tabulated participant characteristics and percentage of participant responses. We categorized choice of fellowship into 2 medical categories (Highly Sought After vs. Less Sought After) and fitted a logistic regression model of choosing a highly vs. less sought after fellowship. RESULTS: Four hundred fifteen out of 1992 (21%) US residents responded to the survey. Of the 268 residents planning to pursue fellowship training, 67 (25%) selected a less sought after fellowship. Female sex was associated with significantly higher odds of selecting a less sought after fellowship (OR = 2.64, 95% CI: 1.47, 4.74). Major factors deterring residents from pursuing nephrology were perception of inadequate financial compensation, broad scope of clinical practice and complexity of patient population. We observed a decline in exposure to nephrology during the clinical years of medical school with only 35.4% of respondents rotating in nephrology versus 76.8% in residency. The quality of nephrology education was rated less positively during clinical medical school years (median of 50 on a 0-100 point scale) compared to the pre-clinical years (median 60) and residency (median 75). CONCLUSION: Our study attempts to explain the declining interest in nephrology. Results suggest potential targets for improvement: diversified trainee exposure, sub-specialization of nephrology, and increased involvement of nephrologists in the education of trainees.

Integrating Women's Health Education into the Internal Medicine Residency Program Curriculum.

OBJECTIVES: National guidelines and the American Board of Internal Medicine have highlighted critical areas of women's health (WH) that are important to the training of Internal Medicine (IM) residents. Our objective was to assess and improve WH education in a large academic community-based IM residency program. METHODS: An anonymous online survey was sent to IM residents to assess their perceived comfort, knowledge, and importance, and exposure to 34 WH topics identified as critical to the training of an internist. To meet the critical learning needs of our residents, a new longitudinal WH curriculum was designed using active instructional methods. Retrospective pre-post surveys were conducted after interactive education workshops to measure their effectiveness. RESULTS: IM residents identified 13 of 34 WH topics that were critically important to their training. Of these, residents believed they had insufficient clinical exposure to prescribing contraceptives, evaluating breast symptoms, managing menopause, performing Papanicolaou tests and pelvic examinations, and polycystic ovary syndrome. Residents identified osteoporosis as their single greatest learning need. There was a strong and statistically significant correlation between residents' knowledge, comfort, and clinical exposure to WH topics. In response to these findings, the curricular methods we developed, such as problem-based learning workshops, multidisciplinary case conferences, and small-group case discussions, were found to be effective. CONCLUSIONS: Our study highlighted significant gaps in our WH curriculum. Based on our findings, we redesigned our educational and experiential WH curriculum to augment knowledge, comfort, perceived importance of, and exposure to areas of need. Enhancing education and increasing clinical exposure to fundamental WH issues will promote higher quality care for women patients.

Wellness and Work: Mixed Messages in Residency Training.

Resident physicians are at higher risk for depression, anxiety, and burnout when compared with same-age peers, resulting in substantive personal and professional consequences. Training programs across the country have acknowledged the gravity of this situation and many have implemented programs and curricula that address wellness and resilience, yet the benefits of such initiatives are still largely unknown. While the development of wellness programming is well intentioned, it is often incongruent with the residency training environment. The mixed messaging that occurs when wellness programs are implemented in environments that do not support self-care may unintentionally cause resident distress. Indeed, outside of the time dedicated to wellness curricula, residents are often rewarded for self-sacrifice. In this commentary, we describe how the complexities of the medical system and culture contribute to mixed messaging and we explore the potential impact on residents. We offer recommendations to strengthen wellness programs through efforts to promote structural change in the training environment.

Frequency, Timing, and Types of Medication Ordering Errors Made by Residents in the Electronic Medical Records Era.

OBJECTIVES: To describe associations between resident level of training, timing of medication orders, and the types of inpatient medication ordering errors made by internal medicine residents. METHODS: This study reviewed all inpatient medication orders placed by internal medicine residents at a tertiary care academic medical center from July 2011 to June 2015. Medication order errors were measured by pharmacists' reporting of an error via the electronic medical record during real-time surveillance of orders. Multivariable regression models were constructed to assess associations between resident training level (postgraduate year [PGY]), medication order timing (time of day and month of year), and rates of medication ordering errors. RESULTS: Of 1,772,462 medication orders placed by 335 residents, 68,545 (3.9%) triggered a pharmacist intervention in the electronic medical record. Overall and for each PGY level, renal dose monitoring/adjustment was the most common order error (40%). Ordering errors were less frequent during the night and transition periods versus daytime (adjusted odds ratio [aOR] 0.93, 95% confidence interval [CI] 0.91-0.96, and aOR 0.93, 95% CI 0.90-0.95, respectively). Errors were more common in July and August compared with other months (aOR 1.05, 95% CI 1.01-1.09). Compared with PGY2 residents, both PGY1 (aOR 1.06, 95% CI 1.03-1.10), and PGY3 residents (aOR 1.07, 95% CI, 1.03-1.10) were more likely to make medication ordering errors. Throughout the course of the academic year, the odds of a medication ordering error decreased by 16% (aOR 0.84, 95% CI 0.80-0.89). CONCLUSIONS: Despite electronic medical records, medication ordering errors by trainees remain common. Additional supervision and resident education regarding medication orders may be necessary.

The SGIM TEACH Program: A Curriculum for Teachers of Clinical Medicine.

BACKGROUND: Demand for faculty with teaching expertise is increasing as medical education is becoming well established as a career pathway. Junior faculty may be expected to take on teaching responsibilities with minimal training in teaching skills. AIM: To address the faculty development needs of junior clinician-educators with teaching responsibilities and those changing their career focus to include teaching. SETTING: Sessions at two Society of General Internal Medicine (SGIM) annual meetings combined with local coaching and online learning during the intervening year. PARTICIPANTS: Eighty-nine faculty scholars in four consecutive annual cohorts from 2013 to 2016. PROGRAM DESCRIPTION: Scholars participate in a full-day core teaching course as well as selective workshops at the annual meetings. Between meetings they receive direct observation and feedback on their teaching from a local coach and participate in an online discussion group. PROGRAM EVALUATION: Sessions were evaluated using a post-session survey. Overall content rating was 4.48 (out of 5). Eighty-nine percent of participants completed all requirements. Of these, 100% agreed that they had gained valuable knowledge and skills. DISCUSSION: The TEACH certificate program provides inexperienced faculty teachers an opportunity to develop core skills. Satisfaction is high. Future research should focus on the impact that this and similar programs have on teaching skills.

Succeeding as a Clinician Educator: useful tips and resources.

Clinician Educators (CEs) play an essential role in the education and patient care missions of academic medical centers. Despite their crucial role, academic advancement is slower for CEs than for other faculty. Increased clinical productivity demands and financial stressors at academic medical centers add to the existing challenges faced by CEs. This perspective seeks to provide a framework for junior CEs to consider with the goal of maximizing their chance of academic success. We discuss six action areas that we consider central to flourishing at academic medical centers: 1. Clarify what success means and define goals; 2. Seek mentorship and be a responsible mentee; 3. Develop a niche and engage in relevant professional development; 4. Network; 5. Transform educational activities into scholarship; and 6. Seek funding and other resources.

Outpatient Evaluation of Knee Pain.

Knee pain is present in up to 20% of the adult general population and can be significantly debilitating to patients. A thorough history and physical examination can help localize the source of inflammation or injury to further determine if imaging, physical therapy, specialty referral, or surgery is necessary. By following a systematic approach to evaluating knee pain, primary care physicians can make the correct diagnosis and formulate an appropriate therapeutic strategy for patients.

Contraception choices in women with underlying medical conditions.

Primary care physicians often prescribe contraceptives to women of reproductive age with comorbidities. Novel delivery systems (e.g., contraceptive patch, contraceptive ring, single-rod implantable device) may change traditional risk and benefit profiles in women with comorbidities. Effective contraceptive counseling requires an understanding of a woman's preferences and medical history, as well as the risks, benefits, adverse effects, and contraindications of each method. Noncontraceptive benefits of combined hormonal contraceptives, such as oral contraceptive pills, include regulated menses, decreased dysmenorrhea, and diminished premenstrual dysphoric disorder. Oral contraceptive pills may be used safely in women with a range of medical conditions, including well-controlled hypertension, uncomplicated diabetes mellitus, depression, and uncomplicated valvular heart disease. However, women older than 35 years who smoke should avoid oral contraceptive pills. Contraceptives containing estrogen, which can increase thrombotic risk, should be avoided in women with a history of venous thromboembolism, stroke, cardiovascular disease, or peripheral vascular disease. Progestin-only contraceptives are recommended for women with contraindications to estrogen. Depo-Provera, a long-acting injectable contraceptive, may be preferred in women with sickle cell disease because it reduces the frequency of painful crises. Because of the interaction between antiepileptics and oral contraceptive pills, Depo-Provera may also be considered in women with epilepsy. Implanon, the single-rod implantable contraceptive device, may reduce symptoms of dysmenorrhea. Mirena, the levonorgestrel-containing intrauterine contraceptive system, is an option for women with menorrhagia, endometriosis, or chronic pelvic pain.

AAIM Recommendations for the 2020-2021 Internal Medicine Residency Application Cycle in Response to the COVID-19 Pandemic.

This statement was released in June 2020 by the Alliance for Academic Internal Medicine to provide guidance for the 2020-2021 residency application cycle in light of the COVID-19 pandemic. While many of the recommendations are specific to this cycle, others, such as the Department Summary Letter of Evaluation, are meant to be an enduring change to the internal medicine residency application process. AAIM realizes that some schools may not yet have the tools or resources to implement the template fully this cycle and look toward collaboration within the internal medicine education community to facilitate adoption in the cycles to come.

Using an Adaptive, Self-Directed Web-Based Learning Module to Enhance Residents' Medical Knowledge Prior to a New Clinical Rotation.

BACKGROUND: The effect of self-directed adaptive learning on internal medicine residents' knowledge prior to a new clinical rotation is not known. METHODS: We developed an adaptive, online, self-directed spaced repetition module and determined the effect on medical knowledge acquisition. We randomized postgraduate year 1 internal medicine residents into two groups. The intervention group (n = 27) received an electronic version of the clinical rotation curriculum as portable document format (PDF) files and participated in the online module, delivered via Moodle, a free, open-source learning management system. The non-intervention group (n = 27) only received the PDF files. All residents participated in a medical knowledge test at baseline and 3 months later. RESULTS: Both groups were similar at study baseline in terms of age, trainee type, years since graduation, results at United States Medical Licensing Examination (USMLE) Step 1, 2, In-Training Examination (ITE), and pre-intervention evaluation. There was a statistically significant improvement in scores on the post-intervention medical knowledge assessment for the intervention group when compared with the non-intervention group (24.2 ± 15.4% vs. 8.6 ± 9.9%, p < 0.001). CONCLUSION: An online, self-directed, adaptive spaced repetition-learning module can offer a simple and effective method to increase the medical knowledge present at the start of residents' clinical rotations.

Primary care program directors' perceptions of women's health education: a gap in graduate medical education persists.

BACKGROUND: Previous studies found that internal medicine residents are not adequately prepared to provide comprehensive primary care to women. The impact of subsequent national guidelines emphasizing women's health education during residency is unknown. METHODS: We conducted a cross-sectional survey of primary care internal medicine residency program directors (PDs) in the United States. We asked the directors to provide information about themselves and their programs, to rate how strongly they agreed that residents should master each of 13 women's health competencies, to estimate the proportion of their residents who actually master each competency by the end of their residency, and to indicate means by which each competency was taught (articles, lectures, patient care, specialty clinic, other). RESULTS: Of 69 directors contacted, 42 (61%) responded. Most respondents agreed that residents should master all 13 competencies. However, there were significant discrepancies (p < 0.001) between the proportion of respondents who believed their residents should master competencies concerning 10 of 13 women's health topics and the proportion who believed their residents actually did master them. More than one third of PDs estimated that the majority of their residents would not gain the knowledge to diagnose, treat, or counsel women with incontinence, vaginitis, domestic violence, preconception planning, or birth control needs by the end of residency training. Of 18 potential predictors of quality education, only 2 proved significant: number of years the respondent served as program director (p = 0.02) and number of competencies taught by lecture (p = 0.007). CONCLUSIONS: Despite national guidelines endorsing women's health education, a large discrepancy persists between what PDs believe their residents should master and what they estimate their residents actually master. This study suggests a need for substantial improvements in internal medicine residency training to adequately prepare residents to care for women.

The Residency Match: Interview Experiences, Postinterview Communication, and Associated Distress.

BACKGROUND: Interview experiences and postinterview communication during the residency match process can cause distress for applicants, and deserve further study. OBJECTIVE: We both quantified and qualified the nature of various interview behaviors during the 2015-2016 National Resident Matching Program (NRMP) Match and collected applicant perspectives on postinterview communication and preferences for policy change. METHODS: An anonymous, 31-question survey was sent to residency candidates applying to 8 residency programs at a single academic institution regarding their experiences at all programs where they interviewed. RESULTS: Of 6693 candidates surveyed, 2079 (31%) responded. Regarding interview experiences, applicants reported being asked at least once about other interviews, marital status, and children at the following rates: 72%, 38%, and 17%, respectively, and such questions arose at a reported mean of 25%, 14%, and 5% of programs, respectively. Female applicants were more frequently asked about children than male applicants (22% versus 14%, P < .0001). Overall, 91% of respondents engaged in postinterview communication. A total of 70% of respondents informed their top program that they had ranked it highly; 70% of this subset reported associated distress, and 78% reported doing this to improve match success. A total of 71% would feel relief if postinterview communication was actively discouraged, and 51% would prefer applicants to be prohibited from notifying programs of their rank. CONCLUSIONS: Applicants to several residency programs reported being asked questions that violate the NRMP Code of Conduct. The majority of applicants would prefer postinterview communication to be more regulated and less prevalent.

Do Women's health internal medicine residency tracks make a difference?

BACKGROUND: Women's health tracks (WHTs) were developed to overcome identified deficiencies in residency training. Their effectiveness in preparing residents to manage both gender-neutral and gender-specific medical conditions is unknown. METHODS: Using current guidelines for internal medicine training, we designed a 65-item survey to measure residents' knowledge, comfort levels, and referral patterns concerning two gender-neutral topics (diabetes and thyroid disease) and two gender-specific topics (polycystic ovarian syndrome [PCOS] and menopause). We administered it to postgraduate year 2 (PGY2) and PGY3 internal medicine residents at a large academic medical center and compared the results of WHT and non-WHT residents using chi-square and t tests. RESULTS: Of 61 residents, 50 (82%) responded. Fifty percent of respondents were female, 62% were PGY3, and 36% were WHT. WHT residents had higher mean knowledge scores than non-WHT residents concerning PCOS (60% vs. 45%, p < 0.05) and menopause (73% vs. 60 %, p < 0.01), and they were more likely to report feeling "very comfortable" handling PCOS and menopause issues (43% vs. 18%, p < 0.02), including diagnosing PCOS, managing hot flashes, and managing vaginal atrophy. WHT residents were less likely than non-WHT to immediately recommend referrals if patients had suspected PCOS (0% vs. 19%, p < 0.03) or confirmed PCOS (0% vs. 32%, p < 0.02), and they were more likely to report feeling adequately trained to provide comprehensive ambulatory women's healthcare (73% vs. 7%, p < 0.001). There were no significant differences between WHT and non-WHT residents on gender-neutral topics. CONCLUSIONS: A WHT can help improve competencies in selected areas of women's health without compromising residents' knowledge or comfort concerning two core gender-neutral topics in ambulatory medicine.

A Professionalism Curricular Model to Promote Transformative Learning Among Residents.

BACKGROUND: Using the frameworks of transformational learning and situated learning theory, we developed a technology-enhanced professionalism curricular model to build a learning community aimed at promoting residents' self-reflection and self-awareness. The RAPR model had 4 components: (1) Recognize: elicit awareness; (2) Appreciate: question assumptions and take multiple perspectives; (3) Practice: try new/changed perspectives; and (4) Reflect: articulate implications of transformed views on future actions. OBJECTIVE: The authors explored the acceptability and practicality of the RAPR model in teaching professionalism in a residency setting, including how residents and faculty perceive the model, how well residents carry out the curricular activities, and whether these activities support transformational learning. METHODS: A convenience sample of 52 postgraduate years 1 through 3 internal medicine residents participated in the 10-hour curriculum over 4 weeks. A constructivist approach guided the thematic analysis of residents' written reflections, which were a required curricular task. RESULTS: A total of 94% (49 of 52) of residents participated in 2 implementation periods (January and March 2015). Findings suggested that RAPR has the potential to foster professionalism transformation in 3 domains: (1) attitudinal, with participants reporting they viewed professionalism in a more positive light and felt more empathetic toward patients; (2) behavioral, with residents indicating their ability to listen to patients increased; and (3) cognitive, with residents indicating the discussions improved their ability to reflect, and this helped them create meaning from experiences. CONCLUSIONS: Our findings suggest that RAPR offers an acceptable and practical strategy to teach professionalism to residents.