Nighttime resident supervision and education: results of a national survey of internal medicine residency program directors

Over the past several years, the Accreditation Council for Graduate Medical Education (ACGME) has issued new restrictions on resident duty hours while calling for increased supervision to ensure patient safety. To meet these requirements, some hospitals have hired overnight in-house hospitalist physicians, also called nocturnists, while others have continued a traditional model wherein a resident in-house can access a supervisor at home by phone as needed. This study examines the current state of internal medicine resident supervision and teaching at night.Christopher Bruti (Rush University Medical Center), Mathhew Tuck (Veterans Affairs Medical Center), Rebecca Harrison (Oregon Health and Science University School of Medicine), Dustin Smith (Atlanta VA Medical Center), Michael Kisielewski (Alliance for Academic Internal Medicine), Jillian S. Catalanotti (The George Washington University School of Medicine and Health Sciences), Alfred Burger (Icahn School of Medicine)Includes bibliographical reference

Quick QI: A Two-Week Self-Directed Quality Improvement Project

The Accreditation Council for Graduate Medical Education endorses a formal longitudinal quality improvement (QI) curriculum. Our internal medicine program’s tandem-block schedule, in which residents rotate through two-week blocks, creates a unique challenge in teaching QI to internal medicine residents. To overcome the educational barriers of a two-week rotation, we created a short, self-directed QI curriculum to introduce basic QI theory and methods. Through this curriculum, we aim to expose residents to existing QI activities, showcase institutional QI endeavors, foster resident-driven QI projects, and develop teaching experience in the realm of QI and patient safety. The curriculum involves residents in institutional QI endeavors, exposes them to institutional safety priorities and the error reporting systems, fosters development of a QI project, improves resiliency through reflection, and enhances aptitude for teaching through leading QI conferences. Survey data has shown a significant improvement in QI-related knowledge and skills

Telehealth for the Internal Medicine Resident: A 3-Year Longitudinal Curriculum

Aims: Across the United States of America, patients are increasingly receiving healthcare using innovative telehealth technologies. As healthcare continues to shift away from traditional office-based visits, providers face new challenges. Telehealth champions are needed to adapt technologies to meet the needs of patients, providers and communities, especially within the realm of primary care specialties. Given these challenges, this intervention aimed to incorporate telemedicine into internal medicine resident training across multiple training years to prepare them for practice in the current and changing healthcare system. Methods: Education and telehealth leaders at the Medical University of South Carolina identified key topics relevant to telehealth and the provision of general internal medicine services. With this as a framework, we developed a 3-year longitudinal telehealth curriculum for internal medicine resident physicians, consisting of an introduction to telemedicine equipment in the first year, didactic learning through in-person education and online modules in the second year and experiential learning through remote monitoring of chronic disease in the third year. Participants included approximately 100 internal medicine residents per year (2016–2019). Self-perceived knowledge, comfort and ability to provide telehealth services was assessed via a survey completed before and after participation in the curriculum. Results: Resident physicians’ self-reported knowledge of telehealth history, access to care, contributions of telehealth applications and quality of care and communication each improved after completion of the online curriculum. There were also significant improvements in resident comfort and perceived ability to provide telehealth services after participation in the curriculum, as assessed via a survey. Overall, 41% of residents felt their ability to utilize telehealth as part of their current or future practice was greater than average after completion of the online modules compared to only 2% at baseline (p\u3c0.01). Results also show residents accurately identify barriers to telehealth adoption at the healthcare system level, including the lack of clinical time to implement services (67% post- vs 47% pre-curriculum, p = 0.02), unfamiliarity with concepts (65% post- vs 21% pre-curriculum, p\u3c−0.01) and concerns about consistent provider reimbursement (74% post- vs 39% pre-curriculum, p \u3c 0.01). Conclusion: Telemedicine and remote patient monitoring are an increasingly prevalent form of healthcare delivery. Internal medicine residents must be adept in caring for patients utilizing this technology. This curriculum was effective in improving resident comfort and self-efficacy in providing care through telehealth and provided residents with hands-on opportunities through supervised inclusion in remote patient-monitoring services. This curriculum model could be employed and evaluated within other internal medicine residency programmes to determine the feasibility at institutions with and without advanced telehealth centres

Home Visits In Internal Medicine Graduate Medical Education

Home-based care training is largely absent from internal medicine (IM) graduate medical education, and home-based care program evaluation largely focuses on resident attitudes and satisfaction, rather than impact on practice or the patient experience. In the 2015-16 academic year, the Yale Primary Care Internal Medicine residency program (YPC) incorporated required home visits for all PGY-1s and PGY-2s. These visits are intended to build unique clinical skillsets, enhance education about the role of psychosocial determinants of health, and potentially impact resident wellbeing. A qualitative method was used to evaluate this program with the goal of characterizing the impact of one-time home visits as an educational intervention for resident trainees, and as a home-based clinical care experience for patients. From July –Oct 2016 semi-structured interviews were conducted with YPC residents who had participated in home visits (n=9) and with visited patients from the resident panels (n=10). Patient and randomly chosen control charts were also reviewed for socio-demographics, healthcare utilization and co-morbidities (Charlson Co-morbidity Index) and data was analyzed using chi-squared significance testing. Interview analysis identified emerging themes. Key provider topics included: 1. Educational value; 2. Patient impact; and 3. Impact on burnout. Key patient topics included: 1. Provider relationship impact; 2. Improved communication; and 3. Resource connections. This work is unique in evaluating the impact that one-time visits with residents, can have for patients. As time investment and funding are often obstacles to program implementation in graduate medical education, this implies that even infrequent home visit opportunities can be a worthwhile addition to residency training for both residents and patients

How do doctors use information in real-time? A qualitative study of internal medicine resident precepting

Background  Despite the importance of evidence-based medicine in medical education, little observational research exists on how doctors-in-training seek and use evidence from information resources in ambulatory care. Objective  To describe information exchange behaviour by internal medicine residents and attendings in ambulatory resident clinic precepting rooms. Design  We observed resident behaviour and audiotaped resident–attending doctor interactions during precepting sessions. Participants  Participating residents included 70 of an eligible 89 residents and 28 of 34 eligible attendings from one large academic internal medicine residency programme in the Midwestern USA. Residents were observed during 95 separate precepting interactions at four ambulatory sites. Approach  Using a qualitative approach, we analysed transcripts and field notes of observed behaviours and interactions looking for themes of information exchange. Coders discussed themes which were refined using feedback from an interdisciplinary panel. Results  Four themes of information exchange behaviour emerged: (i) questioning behaviours that were used as part of the communication process in which the resident and attending doctor could reason together; (ii) searching behaviour of non-human knowledge sources occurred in a minority of precepting interations; (iii) unsolicited knowledge offering and (iv) answering behaviours were important means of exchanging information. Conclusions  Most clinic interactions between resident and attending doctors relied heavily on spoken deliberation without resorting to the scientific literature or other published information resources. These observations suggest a range of factors that may moderate information exchange behaviour in the precepting context including relationships, space and efficiency. Future research should aim to more readily adapt information resources to the relationships and practice context of precepting.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72879/1/j.1365-2753.2006.00752.x.pd

The Canada-Guyana medical education partnership: using videoconferencing to supplement post-graduate medical education among internal medicine trainees

Background: A Guyana-based, internal medicine (IM) post-graduate medical education program was established in 2013. However, lack of formal teaching sessions are barriers to the program’s success.Objective: To describe the partnership between the University of Calgary and the University of Guyana’s internal medicine residency programs (IMRP). This partnership was created to support the Guyana’s IM academic half-day and is characterized by mutually beneficial, resident-led videoconference teaching sessions.Methods: Calgary medical residents volunteered to create and present weekly teaching presentations to Guyanese residents via videoconference. Questionnaires were completed by Guyanese residents and provided to Calgary residents as feedback on their teaching and presentation skills. A similar survey was completed by Calgary residents.Lessons learned: Twenty-four videoconference teaching sessions were conducted over eight months with a total of 191 and 16 surveys completed by Guyana and Calgary residents, respectively. Over 92% of both Guyana and Calgary residents agreed that the sessions enhanced their learning and over 93% reported increased interest in becoming more involved in international collaborations. 88% of Calgary residents felt the sessions improved their teaching skills.Conclusion: The formation of a resident-led, videoconference teaching series is a mutually beneficial partnership for Canadian and Guyanese medical residents and fosters international collaboration in medical education.

Plugging gaps in professionalism education: a resident-generated curriculum

Background: Professionalism is often taught to residents and medical students in case-based sessions using faculty-developed curriculum and faculty-led discussion. Resident-generated curriculum has been rarely published. After professional misconduct by a faculty member and reports of unprofessional conduct by residents from internal surveys of medical students, we surveyed our internal medicine residents to ask about gaps in professionalism training and optimal venues for professionalism education. Purpose: To develop case-based discussions within the morning report structure for resident-led discussion on professionalism topics that were not addressed by our standard faculty-generated curriculum. Description: A paper-based 9 item survey was distributed to residents at an attendance-required educational conference. 39 residents returned the survey. The survey revealed that a significant number of residents had engaged in less than ideal standards of professionalism at some time and that many residents had observed unprofessional behavior among attendings. Based on the results of this survey, one of the authors (RM) wrote 7 clinical cases involving ethical or professional dilemmas faced by residents that were infrequently addressed in our program. Topics addressed in these scenarios included respect for patients (specifically use of disparaging comments or labels), placing patient care needs above individual physicians needs, working through conflicts with other admitting services, providing medical care to a family member or significant other, inter-professional relationships with consulting residents, appropriate means of dealing with non-compliant patients who frequently \u27bounce,\u27 patient ownership when one resident admits a patient to another team\u27s service, appropriate use of social media, and appropriate use of cut-and-paste function in the electronic health record. All of the scenarios also discussed responding to colleagues (including faculty) who were observed to engage in the unprofessional conduct highlighted in the case. Once per month instead of our usual morning report, one resident chose one or two cases of their choice and led discussion with residents and students. Faculty were invited to attend, but the chief resident requested that their input be restricted to posing questions instead of leading discusions. Over the course of twelve months, all cases were discussed at least once. Cases discussing respect for patients and appropriate use of social media were especially popular and chosen for over 50% of the sessions. Compared to our regular ethics conferences, these sessions were better attended and had more discussion by medical students. Conclusions: Resident-led discussion of resident-generated scenarios addressed perceived gaps in professionalism education in our internal medicine training program. Respect for patients and appropriate use of social media were the most frequently discussed topics.\u2

Internal medicine residency training for unhealthy alcohol and other drug use: recommendations for curriculum design

<p>Abstract</p> <p>Background</p> <p>Unhealthy substance use is the spectrum from use that risks harm, to use associated with problems, to the diagnosable conditions of substance abuse and dependence, often referred to as substance abuse disorders. Despite the prevalence and impact of unhealthy substance use, medical education in this area remains lacking, not providing physicians with the necessary expertise to effectively address one of the most common and costly health conditions. Medical educators have begun to address the need for physician training in unhealthy substance use, and formal curricula have been developed and evaluated, though broad integration into busy residency curricula remains a challenge.</p> <p>Discussion</p> <p>We review the development of unhealthy substance use related competencies, and describe a curriculum in unhealthy substance use that integrates these competencies into internal medicine resident physician training. We outline strategies to facilitate adoption of such curricula by the residency programs. This paper provides an outline for the actual implementation of the curriculum within the structure of a training program, with examples using common teaching venues. We describe and link the content to the core competencies mandated by the Accreditation Council for Graduate Medical Education, the formal accrediting body for residency training programs in the United States. Specific topics are recommended, with suggestions on how to integrate such teaching into existing internal medicine residency training program curricula.</p> <p>Summary</p> <p>Given the burden of disease and effective interventions available that can be delivered by internal medicine physicians, teaching about unhealthy substance use must be incorporated into internal medicine residency training, and can be done within existing teaching venues.</p

Sustainability of physical exam skills in a resident-led curriculum in a large internal medicine program with competency based medical education

Background: Competency Based Medical Education (CBME) designates physical examination competency as an Entrustable Professional Activity (EPA). Considerable concern persists regarding the increased time burden CBME may place on educators. We developed a novel physical examination curriculum that shifted the burden of physical examination case preparation and performance assessment from faculty to residents. Our first objective was to determine if participation led to sustainable improvements in physical examination skills. The second objective was to determine if resident peer assessment was comparable to faculty assessment.    Methods: We selected physical exam case topics based on the Objectives of Training in the Specialty of Internal Medicine as prescribed by the Royal College of Physicians and Surgeons of Canada. Internal Medicine residents compiled evidence-based physical exam checklists that faculty reviewed before distribution to all learners. Physical exam practice sessions with whole-group demonstration followed by small-group practice sessions were performed weekly. We evaluated this pilot curriculum with a formative OSCE, during which a resident peer and a faculty member simultaneously observed and assessed examinee performance by .Results: Participation in the novel curriculum practice sessions improved OSCE performance (faculty score mean 78.96 vs. 62.50, p&lt;0.05). Peer assessment overestimated faculty scores (76.2 vs. 65.7, p&lt;0.001), but peer and faculty assessments were highly correlated (R2 = 0.73 (95% CI 0.50-0.87).Conclusion: This novel physical examination curriculum leads to sustainable improvement of physical examination skills. Peer assessment correlated well with the gold standard faculty assessment. This resident-led physical examination curriculum enhanced physical examination skills in a CBME environment, with minimal time commitment from faculty members

Perceived Importance of Ultrasound Vascular Access Education among Residents

Background: Peripheral intravenous catheter (PIVC) failure and difficult intravenous access (DIVA) are pervasive issues causing patient suffering and increased costs. Despite their prevalence, there is a gap in internal medicine and pediatric resident training to manage these challenges effectively. Objective: This study aimed to assess the value of ultrasound-guided-PIVC (USGPIVC) education for internal medicine and pediatric residents and the impact of a 1-hour multidisciplinary workshop on their knowledge and confidence. Methods: A cross-sectional survey study was conducted at an academic medical center in 2022 to assess residents’ perceptions of USG-PIVC education. This was followed by a USG-PIVC simulation-based workshop with limited enrollment (11-slots). Pre- and postworkshop assessments were used to evaluate changes in knowledge and confidence. Data were analyzed using descriptive statistics. Results: Of the 136 residents surveyed, 68 (50%) responded. Most respondents (78%) reported encountering situations where no one could obtain DIVA. While 71% (n=48) of residents considered USG-PIVC placement a useful skill, only 13% (n=9) had prior experience. Following the workshop, the 11 participants had improvement in both confidence (mean pre-assessment score of 38.2 ±8.3 increased to 56.6 ±6.4, p Conclusions: Most internal medicine and pediatric residents at an academic medical center lack experience with USG-PIVC insertion and express interest in acquiring this skill. A one-hour multidisciplinary workshop may be an effective strategy to increase their knowledge and confidence, making it a promising avenue for enhancing residency curricula