In Search of Evidence-Based Residency Program Candidate Selection Criteria

“In Search of Evidence-Based Residency Program Candidate Selection Criteria” George Velasco MD, George Wennerberg MD, Omar Canaday MD FACP Department of Internal Medicine; University of Nevada, Reno School of Medicine Objective We sought to develop a residency candidate selection tool that was selective for qualitative attributes such as work ethic and motivation. Background/Design Examining residency selection criteria is timely given the switch to a pass/fail USMLE step 1 and the continual need to reassess resident selection and medical school curricula. There is a current need for discussion on qualitative assessment of residency work ethic qualities. We give an example of a resident-lead initiative at a single residency program that may be reproducible at other programs. Methods We completed a literature search to assess trends in residency selection, created a set of ideals for which interview questions will be formulated to assess (Appendix A), and propose metrics to measure outcomes in the future. We reviewed relevant literature on the subject and also examined metrics for measuring recruitment success. Discussion There has been no consensus on a residency application scoring system and most traditional metrics used in residency selection were not associated with performance on ACGME milestones. While desirable characteristics have long been established, programs should also assess for unwanted characteristics and applicant commitment to specialty. Work ethic and joy in medicine, in addition to academic strength, have been identified as values related to residency success. It has been demonstrated that prior nonmedical success predicts future medical success so a selection process should seek out that prior track record. Limitations lie in the fact that there is a paucity of research assessing selection outcomes and more research needs to be done to predict residency success and attrition. Potential assessment metrics could include ACGME milestones, attrition, fellowship match rate, missed work days, specialty engagement, and job placement satisfaction Results and Proposed Interventions Machine learning and AI are being explored as technologies to assess for selected applicant traits within the MSPE, evaluations, activities list, and the personal statement. New assessment methods such as case-based interview protocols, technical tests, multiple mini interviews (MMI), adoption of AI, and psychometric processes including personality testing should be integrated into the candidate selection process. We developed a resident-developed creed, The Nevada Criteria, that was used as guidance during the candidate interview process. Appendix A: The “Nevada Criteria” 1.Work ethic- We seek physicians who strongly believe working hard for their patients, their program, and their education is a good thing and an honorable thing. 2.Commitment to the specialty- We seek physicians who love internal medicine and honor it as a complex and exciting field. We are not seeking those who have demonstrated that they preferred another specialty where internal medicine is their back up choice or physicians who were unduly influenced into medicine by family members without choosing this profession on their own accord. 3.Sacrifice- We seek physicians who know that achieving something great long term means giving up some things in the short term 4.Attendance- We seek physicians who understand that training is a special time of growth and that sick days or leaving early limits one's educational opportunities 5.Productivity- We seek physicians who during their time here seek out opportunities such as attending meetings or submitting publications, beyond zero or the minimum 6.Gratitude for educational opportunity- We seek physicians who value lectures, presentations, and guest rotations as a valuable opportunity 7.Being a team player- We seek physicians who avoid adding work to their colleagues either by leaving before work is done or by taking an absence or sick day when they are not sick Conclusion The current literature suggests traditional notions in resident selection were poor prognosticators of actual work performance. Residency selection criteria should better mirror physician job candidate selection criteria that seeks out industriousness and a desire to contribute. New methods of candidate interview assessment from other disciplines are very promising and should be implemented and trialed for efficacy. References 1. Naides AI, Ayyala HS, Lee ES. How Do We Choose? A Review of Residency Application Scoring Systems. J Surg Educ. 2021 Sep-Oct;78(5):1461-1468. 2. Burkhardt JC, Parekh KP, Gallahue FE, London KS, Edens MA, Humbert AJ, Pillow MT, Santen SA, Hopson LR. A Critical Disconnect: Residency Selection Factors Lack Correlation With Intern Performance. J Grad Med Educ. 2020 Dec;12(6):696-704. 3. Busha ME, McMillen B, Greene J, Gibson K, Milnes C, Ziemkowski P. One Institution's evaluation of family medicine residency applicant data for academic predictors of success. BMC Med Educ. 2021 Feb 2;21(1):84. 4. Golden BP, Henschen BL, Liss DT, Kiely SL, Didwania AK. Association Between Internal Medicine Residency Applicant Characteristics and Performance on ACGME Milestones During Intern Year. J Grad Med Educ. 2021 Apr;13(2):213-222. 5. Jordan J, Sternberg K, Haas MRC, He S, Yarris LM, Chan TM, Deiorio NM. Reimagining Residency Selection: Part 3-A Practical Guide to Ranking Applicants in the Post-COVID-19 Era. J Grad Med Educ. 2020 Dec;12(6):666-670. 6. VanOrder T, Robbins W, Zemper E. Residency Program Directors' Interview Methods and Satisfaction With Resident Selection Across Multiple Specialties. J Am Osteopath Assoc. 2017 Apr 1;117(4):226-232. 7. Drum B, Lamb S, Gradick C. Values-Based Resident Selection in an Internal Medicine-Pediatrics Residency Program. J Gen Intern Med. 2022 Nov 7. 8. Hyman JH, Doolittle B. Thriving in Residency: a Qualitative Study. J Gen Intern Med. 2022 Jul;37(9):2173-2179. 9. Vaughan LA, Quick JA. Evidence-Based Selection of Surgical Residents. Surg Clin North Am. 2021 Aug;101(4):667-677. 10. Stephenson-Famy A, Houmard BS, Oberoi S, Manyak A, Chiang S, Kim S. Use of the Interview in Resident Candidate Selection: A Review of the Literature. J Grad Med Educ. 2015 Dec;7(4):539-48. 11. Duckworth, Angela. Grit: The Power of Passion and Perseverance. First Scribner hardcover edition. New York, NY, Scribner, 2016. 12. Drum, B; Gradick, C; Lamb, S; Hurdle, JF. CREATING A VALUES-BASED APPROACH TO RESIDENCY SELECTION USING MACHINE LEARNING. Abstract published at SHM Converge 2021. Abstract 226. Journal of Hospital Medicine 13. Bedzra EKS, Goh JL. The Residency Selection Process in the New World; Time for a Rethink. Semin Thorac Cardiovasc Surg. 2021 Autumn;33(3):825-829. 14. Cullen MJ, Zhang C, Marcus-Blank B, Braman JP, Tiryaki E, Konia M, Hunt MA, Lee MS, Van Heest A, Englander R, Sackett PR, Andrews JS. Improving Our Ability to Predict Resident Applicant Performance: Validity Evidence for a Situational Judgment Test. Teach Learn Med. 2020 Oct-Dec;32(5):508-521. 15. Lund S, D'Angelo JD, Baloul M, Yeh VJ, Stulak J, Rivera M. Simulation as Soothsayer: Simulated Surgical Skills MMIs During Residency Interviews are Associated With First Year Residency Performance. J Surg Educ. 2022 Nov-Dec;79(6):e235-e241. 16. Patel H, Yakkanti R, Bellam K, Agyeman K, Aiyer A. Innovation in Resident Selection: Life Without Step 1. J Med Educ Curric Dev. 2022 Mar 29;9:23821205221084936

Variable Clinical Presentation of an MUC1

BACKGROUND AND OBJECTIVES: The genetic cause of medullary cystic kidney disease type 1 was recently identified as a cytosine insertion in the variable number of tandem repeat region of MUC1 encoding mucoprotein-1 (MUC1), a protein that is present in skin, breast, and lung tissue, the gastrointestinal tract, and the distal tubules of the kidney. The purpose of this investigation was to analyze the clinical characteristics of families and individuals with this mutation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Families with autosomal dominant interstitial kidney disease were referred for genetic analysis over a 14-year period. Families without UMOD or REN mutations prospectively underwent genotyping for the presence of the MUC1 mutation. Clinical characteristics were retrospectively evaluated in individuals with the MUC1 mutation and historically affected individuals (persons who were both related to genetically affected individuals in such a way that ensured that they could be genetically affected and had a history of CKD stage IV or kidney failure resulting in death, dialysis, or transplantation). RESULTS: Twenty-four families were identified with the MUC1 mutation. Of 186 family members undergoing MUC1 mutational analysis, the mutation was identified in 95 individuals, 91 individuals did not have the mutation, and111 individuals were identified as historically affected. Individuals with the MUC1 mutation suffered from chronic kidney failure with a widely variable age of onset of end stage kidney disease ranging from 16 to >80 years. Urinalyses revealed minimal protein and no blood. Ultrasounds of 35 individuals showed no medullary cysts. There were no clinical manifestations of the MUC1 mutation detected in the breasts, skin, respiratory system, or gastrointestinal tract. CONCLUSION: MUC1 mutation results in progressive chronic kidney failure with a bland urinary sediment. The age of onset of end stage kidney disease is highly variable, suggesting that gene–gene or gene–environment interactions contribute to phenotypic variability

Thrombin-receptor antagonist vorapaxar in acute coronary syndromes

BACKGROUND Vorapaxar is a new oral protease-activated–receptor 1 (PAR-1) antagonist that inhibits thrombin-induced platelet activation. METHODS In this multinational, double-blind, randomized trial, we compared vorapaxar with placebo in 12,944 patients who had acute coronary syndromes without ST-segment elevation. The primary end point was a composite of death from cardiovascular causes, myocardial infarction, stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization. RESULTS Follow-up in the trial was terminated early after a safety review. After a median follow-up of 502 days (interquartile range, 349 to 667), the primary end point occurred in 1031 of 6473 patients receiving vorapaxar versus 1102 of 6471 patients receiving placebo (Kaplan–Meier 2-year rate, 18.5% vs. 19.9%; hazard ratio, 0.92; 95% confidence interval [CI], 0.85 to 1.01; P = 0.07). A composite of death from cardiovascular causes, myocardial infarction, or stroke occurred in 822 patients in the vorapaxar group versus 910 in the placebo group (14.7% and 16.4%, respectively; hazard ratio, 0.89; 95% CI, 0.81 to 0.98; P = 0.02). Rates of moderate and severe bleeding were 7.2% in the vorapaxar group and 5.2% in the placebo group (hazard ratio, 1.35; 95% CI, 1.16 to 1.58; P<0.001). Intracranial hemorrhage rates were 1.1% and 0.2%, respectively (hazard ratio, 3.39; 95% CI, 1.78 to 6.45; P<0.001). Rates of nonhemorrhagic adverse events were similar in the two groups. CONCLUSIONS In patients with acute coronary syndromes, the addition of vorapaxar to standard therapy did not significantly reduce the primary composite end point but significantly increased the risk of major bleeding, including intracranial hemorrhage