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1.  Impact of subspecialty elective exposures on outcomes on the American board of internal medicine certification examination 
BMC Medical Education  2012;12:94.
Background
The American Board of Internal Medicine Certification Examination (ABIM-CE) is one of several methods used to assess medical knowledge, an Accreditation Council for Graduate Medical Education (ACGME) core competency for graduating internal medicine residents. With recent changes in graduate medical education program directors and internal medicine residents are seeking evidence to guide decisions regarding residency elective choices. Prior studies have shown that formalized elective curricula improve subspecialty ABIM-CE scores. The primary aim of this study was to evaluate whether the number of subspecialty elective exposures or the specific subspecialties which residents complete electives in impact ABIM-CE scores.
Methods
ABIM-CE scores, elective exposures and demographic characteristics were collected for MedStar Georgetown University Hospital internal medicine residents who were first-time takers of the ABIM-CE in 2006–2010 (n=152). Elective exposures were defined as a two-week period assigned to the respective subspecialty. ABIM-CE score was analyzed using the difference between the ABIM-CE score and the standardized passing score (delta-SPS). Subspecialty scores were analyzed using percentage of correct responses. Data was analyzed using GraphPad Prism version 5.00 for Windows.
Results
Paired elective exposure and ABIM-CE scores were available in 131 residents. There was no linear correlation between ABIM-CE mean delta-SPS and the total number of electives or the number of unique elective exposures. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures (143.4 compared to 129.7, p=0.051). Repeated electives in individual subspecialties were not associated with significant difference in mean ABIM-CE delta-SPS.
Conclusions
This study did not demonstrate significant positive associations between individual subspecialty elective exposures and ABIM-CE mean delta-SPS score. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures suggesting there may be an “ideal” number of elective exposures that supports improved ABIM-CE performance. Repeated elective exposures in an individual specialty did not correlate with overall or subspecialty ABIM-CE performance.
doi:10.1186/1472-6920-12-94
PMCID: PMC3480921  PMID: 23057635
Resident education; Gender; Elective; Subspecialty; Graduate medical education
2.  Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training? 
Background
Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Purposes
Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.
Methods
We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990–1999 for IM residency program graduates from a training program.
Results
Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4–3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.
Conclusions
Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM’s action to remove resident procedural competence from the monthly ABIM-MEF ratings.
doi:10.1007/s11606-006-0068-1
PMCID: PMC1824756  PMID: 17356968
procedural skills; Internal Medicine residency training program; ABIM evaluation
3.  Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training? 
Background
Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Purposes
Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.
Methods
We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990–1999 for IM residency program graduates from a training program.
Results
Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4–3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.
Conclusions
Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM’s action to remove resident procedural competence from the monthly ABIM-MEF ratings.
doi:10.1007/s11606-006-0068-1
PMCID: PMC1824756  PMID: 17356968
procedural skills; Internal Medicine residency training program; ABIM evaluation
4.  A nomogram to predict the probability of passing the American Board of Internal Medicine examination 
Medical Education Online  2012;17:10.3402/meo.v17i0.18810.
Background
Although the American Board of Internal Medicine (ABIM) certification is valued as a reflection of physicians’ experience, education, and expertise, limited methods exist to predict performance in the examination.
Purpose
The objective of this study was to develop and validate a predictive tool based on variables common to all residency programs, regarding the probability of an internal medicine graduate passing the ABIM certification examination.
Methods
The development cohort was obtained from the files of the Cleveland Clinic internal medicine residents who began training between 2004 and 2008. A multivariable logistic regression model was built to predict the ABIM passing rate. The model was represented as a nomogram, which was internally validated with bootstrap resamples. The external validation was done retrospectively on a cohort of residents who graduated from two other independent internal medicine residency programs between 2007 and 2011.
Results
Of the 194 Cleveland Clinic graduates used for the nomogram development, 175 (90.2%) successfully passed the ABIM certification examination. The final nomogram included four predictors: In-Training Examination (ITE) scores in postgraduate year (PGY) 1, 2, and 3, and the number of months of overnight calls in the last 6 months of residency. The nomogram achieved a concordance index (CI) of 0.98 after correcting for over-fitting bias and allowed for the determination of an estimated probability of passing the ABIM exam. Of the 126 graduates from two other residency programs used for external validation, 116 (92.1%) passed the ABIM examination. The nomogram CI in the external validation cohort was 0.94, suggesting outstanding discrimination.
Conclusions
A simple user-friendly predictive tool, based on readily available data, was developed to predict the probability of passing the ABIM exam for internal medicine residents. This may guide program directors’ decision-making related to program curriculum and advice given to individual residents regarding board preparation.
doi:10.3402/meo.v17i0.18810
PMCID: PMC3475012  PMID: 23078794
board examination; in-training examination; internal medicine; residents; program directors
5.  Development of an Ambulatory Geriatrics Knowledge Examination for Internal Medicine Residents 
Background
The number of older adults needing primary care exceeds the capacity of trained geriatricians to accommodate them. All physicians should have basic knowledge of optimal outpatient care of older adults to enhance the capacity of the system to serve this patient group. To date, there is no knowledge-assessment tool that focuses specifically on geriatric ambulatory care.
Objective
We developed an examination to assess internal medicine residents' knowledge of ambulatory geriatrics.
Methods
A consensus panel developed a 30-question examination based on topics in the American Board of Internal Medicine (ABIM) Certification Examination Blueprint, the ABIM in-training examinations, and the American Geriatrics Society Goals and Objectives. Questions were reviewed, edited, and then administered to medical students, internal medicine residents, primary care providers, and geriatricians.
Results
Ninety-eight individuals (20 fourth-year medical students, 57 internal medicine residents, 11 primary care faculty members, and 10 geriatrics fellowship-trained physicians) took the examination. Based on psychometric analysis of the results, 5 questions were deleted because of poor discriminatory power. The Cronbach α coefficient of the remaining 25 questions was 0.48; however, assessment of interitem consistency may not be an appropriate measure, given the variety of clinical topics on which questions were based. Scores increased with higher levels of training in geriatrics (P < .001).
Conclusion
Our preliminary study suggests that the examination we developed is a reasonably valid method to assess knowledge of ambulatory geriatric care and may be useful in assessing residents.
doi:10.4300/JGME-D-13-00123.1
PMCID: PMC3886473  PMID: 24455023
6.  Procedural Experience and Comfort Level in Internal Medicine Trainees 
BACKGROUND
The American Board of Internal Medicine (ABIM) has recommended a specific number of procedures be done as a minimum standard for ensuring competence in various medical procedures. These minimum standards were determined by consensus of an expert panel and may not reflect actual procedural comfort or competence.
OBJECTIVE
To estimate the minimum number of selected procedures at which a majority of internal medicine trainees become comfortable performing that procedure.
DESIGN
Cross-sectional, self-administered survey.
SETTING
A military-based, a community-based, and 2 university-based programs.
PARTICIPANTS
Two hundred thirty-two internal medicine residents.
MEASUREMENTS
Survey questions included number of specific procedures performed, comfort level with performing specific procedures, and whether respondents desired further training in specific procedures. The comfort threshold for a given procedure was defined as the number of procedures at which two thirds or more of the respondents reported being comfortable or very comfortable performing that procedure.
RESULTS
For three of seven procedures selected, residents were comfortable performing the procedure at or below the number recommended by the ABIM as a minimum requirement. However, residents needed more procedures than recommended by the ABIM to feel comfortable with central venous line placement, knee joint aspiration, lumbar puncture, and thoracentesis. Using multivariate logistic regression analysis, variables independently associated with greater comfort performing selected procedures included increased number performed, more years of training, male gender, career goals, and for skin biopsy, training in the community-based program. Except for skin biopsy, comfort level was independent of training site. A significant number of advanced-year house officers in some programs had little experience in performing selected common ambulatory procedures.
CONCLUSION
Minimum standards for certifying internal medicine residents may need to be reexamined in light of house officer comfort level performing selected procedures.
doi:10.1046/j.1525-1497.2000.91104.x
PMCID: PMC1495602  PMID: 11089715
ABIM; procedure comfort level; residents
7.  Associations between quality indicators of internal medicine residency training programs 
BMC Medical Education  2011;11:30.
Background
Several residency program characteristics have been suggested as measures of program quality, but associations between these measures are unknown. We set out to determine associations between these potential measures of program quality.
Methods
Survey of internal medicine residency programs that shared an online ambulatory curriculum on hospital type, faculty size, number of trainees, proportion of international medical graduate (IMG) trainees, Internal Medicine In-Training Examination (IM-ITE) scores, three-year American Board of Internal Medicine Certifying Examination (ABIM-CE) first-try pass rates, Residency Review Committee-Internal Medicine (RRC-IM) certification length, program director clinical duties, and use of pharmaceutical funding to support education. Associations assessed using Chi-square, Spearman rank correlation, univariate and multivariable linear regression.
Results
Fifty one of 67 programs responded (response rate 76.1%), including 29 (56.9%) community teaching and 17 (33.3%) university hospitals, with a mean of 68 trainees and 101 faculty. Forty four percent of trainees were IMGs. The average post-graduate year (PGY)-2 IM-ITE raw score was 63.1, which was 66.8 for PGY3s. Average 3-year ABIM-CE pass rate was 95.8%; average RRC-IM certification was 4.3 years. ABIM-CE results, IM-ITE results, and length of RRC-IM certification were strongly associated with each other (p < 0.05). PGY3 IM-ITE scores were higher in programs with more IMGs and in programs that accepted pharmaceutical support (p < 0.05). RRC-IM certification was shorter in programs with higher numbers of IMGs. In multivariable analysis, a higher proportion of IMGs was associated with 1.17 years shorter RRC accreditation.
Conclusions
Associations between quality indicators are complex, but suggest that the presence of IMGs is associated with better performance on standardized tests but decreased duration of RRC-IM certification.
doi:10.1186/1472-6920-11-30
PMCID: PMC3126786  PMID: 21651768
program quality; Residency Review Committee; American Board of Internal Medicine Certifying Examination
8.  Teaching Internal Medicine Residents Quality Improvement Techniques using the ABIM’s Practice Improvement Modules 
Summary
Introduction/aim
Standard curricula to teach Internal Medicine residents about quality assessment and improvement, important components of the Accreditation Council for Graduate Medical Education core competencies practiced-based learning and improvement (PBLI) and systems-based practice (SBP), have not been easily accessible.
Program description
Using the American Board of Internal Medicine’s (ABIM) Clinical Preventative Services Practice Improvement Module (CPS PIM), we have incorporated a longitudinal quality assessment and improvement curriculum (QAIC) into the 2 required 1-month ambulatory rotations during the postgraduate year 2. During the first block, residents complete the PIM chart reviews, patient, and system surveys. The second block includes resident reflection using PIM data and the group performing a small test of change using the Plan–Do–Study–Act (PDSA) cycle in the resident continuity clinic.
Program Evaluation
To date, 3 resident quality improvement (QI) projects have been undertaken as a result of QAIC, each making significant improvements in the residents’ continuity clinic. Resident confidence levels in QI skills (e.g., writing an aim statement [71% to 96%, P < .01] and using a PDSA cycle [9% to 89%, P < .001]) improved significantly.
Discussion
The ABIM CPS PIM can be used by Internal Medicine residency programs to introduce QI concepts into their residents’ outpatient practice through encouraging practice-based learning and improvement and systems-based practice.
doi:10.1007/s11606-008-0549-5
PMCID: PMC2517947  PMID: 18449612
Internal Medicine residents; quality improvement; practiced-based learning and improvement; systems-based practice; practice improvement module
9.  Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training 
Background
The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice.
Intervention
In November 2007, the American Board of Internal Medicine (ABIM) and the ACGME initiated the development of milestones for internal medicine residency training. ABIM and ACGME convened a 33-member milestones task force made up of program directors, experts in evaluation and quality, and representatives of internal medicine stakeholder organizations. This article reports on the development process and the resulting list of proposed milestones for each ACGME competency.
Outcomes
The task force adopted the Dreyfus model of skill acquisition as a framework the internal medicine milestones, and calibrated the milestones with the expectation that residents achieve, at a minimum, the “competency” level in the 5-step progression by the completion of residency. The task force also developed general recommendations for strategies to evaluate the milestones.
Discussion
The milestones resulting from this effort will promote competency-based resident education in internal medicine, and will allow program directors to track the progress of residents and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking, and assist remediation by facilitating identification of specific deficits. Finally, by making explicit the profession's expectations for graduates and providing a degree of national standardization in evaluation, the milestones may improve public accountability for residency training.
doi:10.4300/01.01.0003
PMCID: PMC2931179  PMID: 21975701
10.  Description of a Developmental Criterion-Referenced Assessment for Promoting Competence in Internal Medicine Residents 
Rationale
End-of- rotation global evaluations can be subjective, produce inflated grades, lack interrater reliability, and offer information that lacks value. This article outlines the generation of a unique developmental criterion-referenced assessment that applies adult learning theory and the learner, manager, teacher model, and represents an innovative application to the American Board of Internal Medicine (ABIM) 9-point scale.
Intervention
We describe the process used by Southern Illinois University School of Medicine to develop rotation-specific, criterion-based evaluation anchors that evolved into an effective faculty development exercise.
Results
The intervention gave faculty a clearer understanding of the 6 Accreditation Council for Graduate Medical Education competencies, each rotation's educational goals, and how rotation design affects meaningful work-based assessment. We also describe easily attainable successes in evaluation design and pitfalls that other institutions may be able to avoid. Shifting the evaluation emphasis on the residents' development of competence has made the expectations of rotation faculty more transparent, has facilitated conversations between program director and residents, and has improved the specificity of the tool for feedback. Our findings showed the new approach reduced grade inflation compared with the ABIM end-of-rotation global evaluation form.
Discussion
We offer the new developmental criterion-referenced assessment as a unique application of the competences to the ABIM 9-point scale as a transferable model for improving the validity and reliability of resident evaluations across graduate medical education programs.
doi:10.4300/01.01.0012
PMCID: PMC2931180  PMID: 21975710
11.  Protocol-directed care in the ICU: making a future generation of intensivists less knowledgeable? 
Critical Care  2012;16(2):307.
Expanded abstract
Citation
Prasad M, Holmboe ES, Lipner RS, Hess BJ, Christie JD, Bellamy SL, Rubenfeld GD, Kahn JM. Clinical Protocols and Trainee Knowledge About Mechanical Ventilation. JAMA. 2011; 306(9):935-941. PubMed PMID: 21900133 This is available on http://www.pubmed.gov
Background
Clinical protocols are associated with improved patient outcomes; however, they may negatively affect medical education by removing trainees from clinical decision making.
Methods
Objective: To study the relationship between critical care training with mechanical ventilation protocols and subsequent knowledge about ventilator management.
Design: A retrospective cohort equivalence study linking a national survey of mechanical ventilation protocol availability with knowledge about mechanical ventilation. Exposure to protocols was defined as high intensity if an intensive care unit had 2 or more protocols for at least 3 years and as low intensity if 0 or 1 protocol.
Setting: Accredited US pulmonary and critical care fellowship programs.
Subjects: First-time examinees of the American Board of Internal Medicine (ABIM) Critical Care Medicine Certification Examination in 2008 and 2009.
Intervention: N/A
Outcomes: Knowledge, measured by performance on examination questions specific to mechanical ventilation management, calculated as a mechanical ventilation score using item response theory. The score is standardized to a mean (SD) of 500 (100), and a clinically important difference is defined as 25. Variables included in adjusted analyses were birth country, residency training country, and overall first-attempt score on the ABIM Internal Medicine Certification Examination.
Results
The 90 of 129 programs (70%) responded to the survey. Seventy seven programs (86%) had protocols for ventilation liberation, 66 (73%) for sedation management, and 54 (60%) for lung-protective ventilation at the time of the survey. Eighty eight (98%) of these programs had trainees who completed the ABIM Critical Care Medicine Certification Examination, totaling 553 examinees. Of these 88 programs, 27 (31%) had 0 protocols, 19 (22%) had 1 protocol, 24 (27%) had 2 protocols, and 18 (20%) had 3 protocols for at least 3 years. 42 programs (48%) were classified as high intensity and 46 (52%) as low intensity, with 304 trainees (55%) and 249 trainees (45%), respectively. In bi-variable analysis, no difference in mean scores was observed in high-intensity (497; 95% CI, 486-507) vs low-intensity programs (497; 95% CI, 485-509). Mean difference was 0 (95% CI, -16 to 16), with a positive value indicating a higher score in the high-intensity group. In multivariable analyses, no association of training was observed in a high-intensity program with mechanical ventilation score (adjusted mean difference, -5.36; 95% CI, -20.7 to 10.0).
Conclusions
Among first-time ABIM Critical Care Medicine Certification Examination examinees, training in a high-intensity ventilator protocol environment compared with a low-intensity environment was not associated with worse performance on examination questions about mechanical ventilation management.
doi:10.1186/cc11257
PMCID: PMC3681378  PMID: 22494787
12.  Predicting Pass Rates on the American Board of Internal Medicine Certifying Examination 
Our objective was to determine the ability of the internal medicine In-Training Examination (ITE) to predict pass or fail outcomes on the American Board of Internal Medicine (ABIM) certifying examination and to develop an externally validated predictive model and a simple equation that can be used by residency directors to provide probability feedback for their residency programs. We collected a study sample of 155 internal medicine residents from the three Virginia internal medicine programs and a validation sample of 64 internal medicine residents from a residency program outside Virginia. Scores from both samples were collected across three class cohorts. The Kolmogorov-Smirnov z test indicated no statistically significant difference between the distribution of scores for the two samples (z = 1.284, p = .074). Results of the logistic model yielded a statistically significant prediction of ABIM pass or fail performance from ITE scores (Wald = 35.49, SE = 0.036, df = 1, p < .005) and overall correct classifications for the study sample and validation sample at 79% and 75%, respectively. The ITE is a useful tool in assessing the likelihood of a resident's passing or failing the ABIM certifying examination but is less predictive for residents who received ITE scores between 49 and 66.
doi:10.1046/j.1525-1497.1998.00122.x
PMCID: PMC1496976  PMID: 9669571
certifying examination; in-training examination; education; predictions; residents
13.  Teaching Internal Medicine Residents to Sustain Their Improvement Through the Quality Assessment and Improvement Curriculum 
ABSTRACT
INTRODUCTION
Although sustainability is a key component in the evaluation of continuous quality improvement (CQI) projects, medicine resident CQI projects are often evaluated by immediate improvements in targeted areas without addressing sustainability.
AIM/SETTING
To assess the sustainability of resident CQI projects in an ambulatory university-based clinic.
PROGRAM DESCRIPTION
During their ambulatory rotation, all second year internal medicine residents use the American Board of Internal Medicine’s Clinical Preventive Services (CPS) Practice Improvement Modules (PIM) to complete chart reviews, patient surveys, and a system survey. The residents then develop a group CQI project and collect early post data. Third year residents return to evaluate their original CQI project during an ambulatory rotation two to six months later and complete four plan-do-study-act (PDSA) cycles on each CQI project.
PROGRAM EVALUATION
From July 2006 to June 2009, 64 (100%) medicine residents completed the CQI curriculum. Residents completed six group projects and examined their success using early (2 to 6 weeks) and late (2 to 6 months) post-intervention data. Three of the projects demonstrated sustainable improvement in the resident continuity clinic.
DISCUSSION
When residents are taught principles of sustainability and spread and asked to complete multiple PDSA cycles, they are able to identify common themes that may contribute to success of QI projects over time.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1547-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1547-y
PMCID: PMC3019318  PMID: 21053089
resident education; quality improvement; sustainability; practice-based learning and improvement; system-based practice
14.  Impact of personal goals on the internal medicine R4 subspecialty match: a Q methodology study 
BMC Medical Education  2013;13:171.
Background
There has been a decline in interest in general internal medicine that has resulted in a discrepancy between internal medicine residents’ choice in the R4 subspecialty match and societal need. Few studies have focused on the relative importance of personal goals and their impact on residents’ choice. The purpose of this study was to assess if internal medicine residents can be grouped based on their personal goals and how each group prioritizes these goals compared to each other. A secondary objective was to explore whether we could predict a resident’s desired subspecialty choice based on their constellation of personal goals.
Methods
We used Q methodology to examine how postgraduate year 1–3 internal medicine residents could be grouped based on their rankings of 36 statements (derived from our previous qualitative study). Using each groups’ defining and distinguishing statements, we predicted their subspecialties of interest. We also collected the residents’ first choice in the subspecialty match and used a kappa test to compare our predicted subspecialty group to the residents’ self-reported first choice.
Results
Fifty-nine internal medicine residents at the University of Alberta participated between 2009 and 2010 with 46 Q sorts suitable for analysis. The residents loaded onto four factors (groups) based on how they ranked statements. Our prediction of each groups’ desired subspecialties with their defining and/or distinguishing statements are as follows: group 1 – general internal medicine (variety in practice); group 2 – gastroenterology, nephrology, and respirology (higher income); group 3 – cardiology and critical care (procedural, willing to entertain longer training); group 4 – rest of subspecialties (non-procedural, focused practice, and valuing more time for personal life). There was moderate agreement (kappa = 0.57) between our predicted desired subspecialty group and residents’ self-reported first choice (p < 0.001).
Conclusion
This study suggests that most residents fall into four groups based on a constellation of personal goals when choosing an internal medicine subspecialty. The key goals that define and/or distinguish between these groups are breadth of practice, lifestyle, desire to do procedures, length of training, and future income potential. Using these groups, we were able to predict residents’ first subspecialty group with moderate success.
doi:10.1186/1472-6920-13-171
PMCID: PMC3879426  PMID: 24359484
Career choice; Internal medicine; Q methodology; Postgraduate medical education; Specialization; Canada
15.  The Effect of Reducing Maximum Shift Lengths to 16 Hours on Internal Medicine Interns’ Educational Opportunities 
Purpose
To evaluate educational experiences of internal medicine interns before and after maximum shift lengths were decreased from 30 hours to 16 hours.
Method
The authors compared educational experiences of internal medicine interns at Vanderbilt University Medical Center before (2010, 47 interns) and after (2011, 50 interns) duty hour restrictions were implemented in July 2011. The authors compared number of inpatient encounters, breadth of concepts in notes, exposure to five common presenting problems, procedural experience, and attendance at teaching conferences.
Results
Following the duty hour restrictions, interns cared for more unique patients (mean 118 versus 140 patients per intern, P = .005) and wrote more history and physicals (mean 73 versus 88, P = .005). Documentation included more total concepts after the 16-hour maximum shift implementation, with a 14% increase for history and physicals (338 versus 387, P < .001) and a 10% increase for progress notes (316 versus 349, P < .001). There was no difference in the median number of selected procedures performed (6 versus 6, P = .94). Attendance was higher at the weekly chief resident conference (60% versus 68% of expected attendees, P < .001) but unchanged at morning report conferences (79% versus 78%, P = .49).
Conclusions
Intern clinical exposure did not decrease after implementation of the 16-hour shift length restriction. In fact, interns saw more patients, produced more detailed notes, and attended more conferences following duty hour restrictions.
doi:10.1097/ACM.0b013e318285800f
PMCID: PMC3638874  PMID: 23425987
16.  Prescription Medicines and the Risk of Road Traffic Crashes: A French Registry-Based Study 
PLoS Medicine  2010;7(11):e1000366.
Using three nationwide databases in France, Ludivine Orriols, Emmanuel Lagarde, and colleagues provide evidence that prescribed medicines contribute to the risk of experiencing a road traffic crash.
Background
In recent decades, increased attention has been focused on the impact of disabilities and medicinal drug use on road safety. The aim of our study was to investigate the association between prescription medicines and the risk of road traffic crashes, and estimate the attributable fraction.
Methods and Findings
We extracted and matched data from three French nationwide databases: the national health care insurance database, police reports, and the national police database of injurious crashes. Drivers identified by their national health care number involved in an injurious crash in France, between July 2005 and May 2008, were included in the study. Medicines were grouped according to the four risk levels of the French classification system (from 0 [no risk] to 3 [high risk]). We included 72,685 drivers involved in injurious crashes. Users of level 2 (odds ratio [OR]  = 1.31 [1.24–1.40]) and level 3 (OR  = 1.25 [1.12–1.40]) prescription medicines were at higher risk of being responsible for a crash. The association remained after adjustment for the presence of a long-term chronic disease. The fraction of road traffic crashes attributable to levels 2 and 3 medications was 3.3% [2.7%–3.9%]. A within-person case-crossover analysis showed that drivers were more likely to be exposed to level 3 medications on the crash day than on a control day, 30 days earlier (OR  = 1.15 [1.05–1.27]).
Conclusion
The use of prescription medicines is associated with a substantial number of road traffic crashes in France. In light of the results, warning messages appear to be relevant for level 2 and 3 medications and questionable for level 1 medications. A follow-up study is needed to evaluate the impact of the warning labeling system on road traffic crash prevention.
Please see later in the article for the Editors' Summary
Editors' Summary
About 1.3 million people die each year on the world's road. 90% of road traffic deaths occur in developing countries, with pedestrians, cyclists, and users of two-wheel vehicles (scooters, motorbikes) the most vulnerable road users. Although the use of prescribed benzodiazepines has already been documented to be associated with road traffic accidents in industrialized countries, the effects of other medicines have not been well studied or have inconsistent results (for example opioids and antidepressant medications). In the European Union, it is mandatory for pharmaceutical companies to provide data about the effect of a medicine on ability to drive. In France, a multidisciplinary group of experts was appointed to classify all medicines into four levels of risk (from level 0, no or negligible risk, to level 3, major risk), in terms of their effect on driving performances. In 2006, the International Council on Alcohol, Drugs and Traffic Safety proposed a classification list similar to the French classification system.
Why Was This Study Done? There is a pressing need to understand the association between prescribed medicines and the risk of road traffic crashes and also to have a more accurate picture of the fraction of road traffic crashes that are attributable to the use of prescribed medicines. This large French study aimed to advance knowledge in this important area.
What Did the Researchers Do and Find? The researchers used three data sources to find the information they needed: the national health care insurance database (which covers the whole French population and includes data on reimbursed prescription medicines), police reports, and the national police database of injurious road traffic crashes. Drivers involved in road traffic crashes (identified by their national healthcare number) between July 2005 and May 2008 were included in the study. The researchers used a statistical model to conduct a responsibility analysis, which determined factors associated with each driver responsible for the road traffic crash and each driver who was not responsible (controls). In addition, the researchers compared medicine exposure during a period immediately before the crash (case period) with exposure during an earlier period (control period) for each driver involved in a crash. The researchers retrieved data on reimbursed medicines, dispensed within six months of the road traffic crash, by linking included drivers to the national health care insurance database using their national ID, gender, and date of birth and grouped all prescribed medicines according to the four risk levels of the French classification system.
During the study period, 72,685 drivers involved in injurious road traffic crashes were included. The researchers found that drivers who had been prescribed level 2 and level 3 medicines were at higher risk (odds ratio 1.31 and OR 1.25, respectively) of being responsible for the road traffic crash, an association that remained after the researchers adjusted for the presence of chronic diseases. Furthermore, the researchers found that the fraction of road traffic crashes attributable to the use of (prescriptions for) level 2 and 3 medicines was 3.3% and that drivers were more likely to be exposed to level 3 medicines on the day of the road traffic crash than on a control day.
What Do These Findings Mean? This study provides strong evidence for the contribution of medicines to the risk of experiencing a road traffic crash. The French drug risk classification scheme seems accurate for medicines classified as levels 2 and 3 of risk for road traffic crashes. The effect on driving abilities of level 2 medicines depends both on the pharmacodynamics of the drug and on individual susceptibility, whereas for level 3 medicines, the pharmacodynamic effect seems to be predominant. The effects of level 1 medicines seem to be so dependent on individual susceptibility that effects on driving abilities are rare, which raises questions about the relevance of the labels for these medicines. However, some limitations with the study methodology might affect the interpretation of these findings. For example, the researchers used dispensing dates for medications as a surrogate for ingestion and were not able to check for noncompliance.
However, this study provides some of the strongest evidence to date of the need for health care workers to provide patients with proper information on the potential effect of any medicine that they are prescribed (or take) on their driving abilities.
Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000366.The World Health Organization (WHO) provides information on road traffic accidentsTwo Web sites provide information for drivers about drugs that could affect their ability to driveThe US National Institute on Drug Abuse of the National Institutes of Health has an information sheet on drugged driving
doi:10.1371/journal.pmed.1000366
PMCID: PMC2981588  PMID: 21125020
17.  Morning Report: Can an Established Medical Education Tradition Be Validated? 
Background
Morning report is accepted as an essential component of residency education throughout different parts of the world.
Objective
To review the evidence of the educational value, purpose, methods, and outcomes of morning report.
Methods
A literature search of PubMed, Ovid, and the Cochrane Library for English-language studies published between January 1, 1966, and October 31, 2011, was performed. We searched for keywords and Medical Subject Heading terms related to medical education, methods, attitudes, and outcomes in regard to “morning report.” Title and abstract review, followed by a full-text review by 3 authors, was performed to identify all pertinent articles.
Results
We identified 71 citations; 40 articles were original studies and 31 were commentaries, editorials, or review articles; 56 studies (79%) originated from internal medicine residency programs; 6 studies (8%) focused on ambulatory morning report; and 63 (89%) originated from the United States. Identified studies varied in objectives, methods, and outcome measures, and were not suitable for meta-analysis. Main outcome measures were resident satisfaction, faculty satisfaction, preparation for professional examinations, use of evidence-based medicine, clinical effects on patient care, adverse event detection, and utilization of a curriculum in case selection.
Conclusions
Morning report has heterogeneous purposes, methods, and settings. As an educational tool, morning report is challenging to define, its outcome is difficult to measure, and this precludes firm conclusions about its contribution to resident education or patient care. Residency programs should tailor morning report to meet their own unique educational objectives and needs.
doi:10.4300/JGME-D-12-00199.1
PMCID: PMC3771165  PMID: 24404299
18.  Setting a Fair Performance Standard for Physicians’ Quality of Patient Care 
Background
Assessing physicians’ clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable.
Objective
Determine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients.
Design
Retrospective cohort study.
Participants
Nine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty.
Main Measures
The ABIM Diabetes Practice Improvement Module was used to collect data on ten clinical and two patient experience measures. A panel of eight internists/subspecialists representing essential perspectives of clinical practice applied an adaptation of the Angoff method to judge how physicians who provide minimally-acceptable care would perform on individual measures to establish performance thresholds. Panelists then rated each measure’s relative importance and the Dunn–Rankin method was applied to establish scoring weights for the composite measure. Physician characteristics were used to support the standard-setting outcome.
Key Results
Physicians abstracted 20,131 patient charts and 18,974 patient surveys were completed. The panel established reasonable performance thresholds and importance weights, yielding a standard of 48.51 (out of 100 possible points) on the composite measure with high classification accuracy (0.98). The 38 (4%) outlier physicians who did not meet the standard had lower ratings of overall clinical competence and professional behavior/attitude from former residency program directors (p = 0.01 and p = 0.006, respectively), lower Internal Medicine certification and maintenance of certification examination scores (p = 0.005 and p < 0.001, respectively), and primarily worked as solo practitioners (p = 0.02).
Conclusions
The standard-setting method yielded a credible, defensible performance standard for diabetes care based on informed judgment that resulted in a reasonable, reproducible outcome. Our method represents one approach to identifying outlier physicians for intervention to protect patients.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1572-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1572-x
PMCID: PMC3077491  PMID: 21104453
clinical performance assessment; standard setting; composite measures; diabetes care
19.  Changing Habits of Practice 
Journal of General Internal Medicine  2005;20(12):1181-1187.
Purpose
The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.
Methods
The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.
Results
Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.
Conclusion
This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.
doi:10.1111/j.1525-1497.2005.0248.x
PMCID: PMC1490278  PMID: 16423112
ambulatory; graduate medical education; curriculum; faculty development; internal medicine
20.  Impact of a Veterans Affairs Continuity Clinic on Resident Competencies in Women's Health 
BACKGROUND
Education in women's health is now considered a core curricular component during residency training in Internal Medicine. There is potential for insufficient training in women's health for residents with a continuity clinic based at a Veterans Affairs (VA) hospital.
OBJECTIVE
To determine the impact of a 3-year continuity clinic based at a VA hospital on residents' self-reported competencies in women's health.
DESIGN
Cross sectional survey using an internal website.
SETTING
University-based residency program in Ann Arbor, Michigan.
MEASUREMENTS AND MAIN RESULTS
Comparison of residents with a VA clinic with residents with non-VA clinics (university and community) in self-reported competencies in knowledge base, counseling, and physical exam skills in the area of women's health. Responses were obtained from 66% (n = 72) of eligible residents. When compared to residents with either a university hospital– or community-based clinic site, VA-based residents reported less confidence in the majority of competencies surveyed. Clinic site had the strongest impact in the knowledge base domain, accounting for between 17% and 33% of the variance in each specific competency. For estimated number of Pap smears and breast exams done in the prior year, VA-based residents reported doing, on average, less than 5 of each per year while non-VA residents reported doing between 11 and 20 of each exam.
CONCLUSIONS
Our data suggest that despite other clinical opportunities in women's health during ambulatory rotations, regular clinical experiences in women's health in the continuity clinic setting are necessary to improve education in this area.
doi:10.1046/j.1525-1497.2003.20733.x
PMCID: PMC1494876  PMID: 12823648
women's health; residency training; medical education
21.  Feasibility of an innovative third-year chief resident system: an internal medicine residency leadership study 
Introduction
The role of the internal medicine chief resident includes various administrative, academic, social, and educational responsibilities, fulfillment of which prepares residents for further leadership tasks. However, the chief resident position has historically only been held by a few residents. As fourth-year chief residents are becoming less common, we considered a new model for rotating third-year residents as the chief resident.
Methods
Online surveys were given to all 29 internal medicine residents in a single university-based program after implementation of a leadership curriculum and specific job description for the third-year chief resident. Chief residents evaluated themselves on various aspects of leadership. Participation was voluntary. Descriptive statistics were generated using SPSS version 21.
Results
Thirteen junior (first- or second-year) resident responses reported that the chief residents elicited input from others (mean rating 6.8), were committed to the team (6.8), resolved conflict (6.7), ensured efficiency, organization and productivity of the team (6.7), participated actively (7.0), and managed resources (6.6). Responses from senior residents averaged 1 point higher for each item; this pattern repeated itself in teaching evaluations. Chief resident self-evaluators were more comfortable running a morning report (8.4) than with being chief resident (5.8).
Conclusion
The feasibility of preparing internal medicine residents for leadership roles through a rotating PGY-3 (postgraduate year) chief residency curriculum was explored at a small internal medicine residency, and we suggest extending the study to include other programs.
doi:10.3402/jchimp.v4.24511
PMCID: PMC4120049  PMID: 25147630
chief resident; postgraduate year; internal medicine; residents; leadership; skill evaluation; graduate medical education; physician leadership
22.  Emergency medicine residents’ attitudes and opinions of in-training exam preparation 
Purpose
Emergency Medicine (EM) residents take the American Board of Emergency Medicine (ABEM) in-training exam, and performance on this exam has been shown to correlate to performance on the ABEM qualifying exam. Though many residencies have in-training exam preparation activities, there is little data on the effectiveness of these efforts. This study aimed to elicit resident perspectives about the exam and exam preparation in order to generate hypotheses and better inform future preparation efforts.
Methods
Second- and third-year EM residents at a single institution were interviewed using a semi-structured format. Qualitative methodology was used to analyze the data.
Results
Thirteen EM residents participated in the study. Eight major themes and 18 sub-themes were identified. These were further characterized as relating to the exam itself or to exam preparation. Residents generally value the in-training exam. Sixty-nine percent noted that it provided an assessment of their current knowledge and deficiencies. Thirty-eight percent noted that it improved familiarity with the qualifying exam. Regarding exam preparation, residents stated that a question format was preferred, especially when accompanying explanations were of high quality. Additionally, practical considerations, such as portability, impacted resident selection of study tools.
Conclusion
Residents value the in-training exam as a marker of their academic progress and for their ability to gain familiarity with the qualifying exam. They prefer question-based preparation over text-based learning, as long as there is a detailed explanation of each answer. Educators creating structured in-training review may want to focus on question-based material with detailed explanations.
doi:10.2147/AMEP.S49703
PMCID: PMC3780280  PMID: 24062620
examination preparation; graduate medical education; in-training examination; resident education
23.  Quantifying the Impoverishing Effects of Purchasing Medicines: A Cross-Country Comparison of the Affordability of Medicines in the Developing World 
PLoS Medicine  2010;7(8):e1000333.
Laurens Niëns and colleagues estimate the impoverishing effects of four medicines in 16 low- and middle-income countries using the impoverishment method as a metric of affordability and show that medicine purchases could impoverish large numbers of people.
Background
Increasing attention is being paid to the affordability of medicines in low- and middle-income countries (LICs and MICs) where medicines are often highly priced in relation to income levels. The impoverishing effect of medicine purchases can be estimated by determining pre- and postpayment incomes, which are then compared to a poverty line. Here we estimate the impoverishing effects of four medicines in 16 LICs and MICs using the impoverishment method as a metric of affordability.
Methods and Findings
Affordability was assessed in terms of the proportion of the population being pushed below US$1.25 or US$2 per day poverty levels because of the purchase of medicines. The prices of salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab were obtained from facility-based surveys undertaken using a standard measurement methodology. The World Bank's World Development Indicators provided household expenditure data and information on income distributions. In the countries studied, purchasing these medicines would impoverish large portions of the population (up to 86%). Originator brand products were less affordable than the lowest-priced generic equivalents. In the Philippines, for example, originator brand atenolol would push an additional 22% of the population below US$1.25 per day, whereas for the lowest priced generic equivalent this demographic shift is 7%. Given related prevalence figures, substantial numbers of people are affected by the unaffordability of medicines.
Conclusions
Comparing medicine prices to available income in LICs and MICs shows that medicine purchases by individuals in those countries could lead to the impoverishment of large numbers of people. Action is needed to improve medicine affordability, such as promoting the use of quality assured, low-priced generics, and establishing health insurance systems.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In recent years, the international community has prioritized access to essential medicines, which has required focusing on the accessibility, availability, quality, and affordability of life-saving medicines and the development of appropriate data and research agendas to measure these components. Determining the degree of affordability of medicines, especially in low- and middle-income countries, is a complex process as the term affordability is vague. However, the cost of medicines is a major public health issue, especially as the majority of people in developing countries do not have health insurance and medicines freely provided through the public sector are often unavailable. Therefore, although countries have a legal obligation to make essential medicines available to those who need them at an affordable cost, poor people often have to pay for the medicines that they need when they are ill. Consequently, where medicine prices are high, people may have to forego treatment or they may go into debt if they decide to buy the necessary medicines.
Why Was This Study Done?
The researchers wanted to show the impact of the cost of medicines on poorer populations by undertaking an analysis that quantified the proportion of people who would be pushed into poverty (an income level of US$1.25 or US$2 a day) because their only option is to pay out-of-pocket expenses for the life-saving medicines they need. The researchers referred to this consequence as the “impoverishing effect of a medicine.”
What Did the Researchers Do and Find?
The researchers generated “impoverishment rates” of four medicines in 16 low- and middle-income countries by comparing households' daily per capita income before and after (the hypothetical) purchase of one of the following: a salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab. This selection of drugs covers the treatment/management of three chronic diseases and one acute illness. The cost of each medicine was taken from standardized surveys, which report median patient prices for a selection of commonly used medicines in the private sector (the availability of essential medicines in the public sector is much lower so many people will depend on the private sector for their medicines) for both originator brand and lowest priced generic products. If the prepayment income was above the US$1.25 (or US$2) poverty line and the postpayment income fell below these lines, purchasing these medicines at current prices impoverishes people.
According to the results of this analysis, a substantial proportion (up to 86%) of the population in the countries studied would be pushed into poverty as a result of purchasing one of the four selected medicines. Furthermore, the lowest priced generic versions of each medicine were generally substantially more affordable than originator brand products. For example, in the Philippines, purchasing originator brand atenolol would push an additional 22% of the population below US$1.25 per day compared to 7% if the lowest priced generic equivalent was bought instead. In effect, purchasing essential medicines for both chronic and acute conditions could impoverish large numbers of people, especially if originator brand products are bought.
What Do These Findings Mean?
Although the purchasing of medicines represents only part of the costs associated with the management of an illness, it is clear that the high cost of medicines have catastrophic effects on poor people. In addition, as the treatment of chronic conditions often requires a combination of medicines, the cost of treating and managing a chronic condition such as asthma, diabetes, and cardiovascular disease is likely to be even more unaffordable than what is reported in this study. Therefore concerted action is urgently required to improve medicine affordability and prevent poor populations from being pushed further into poverty. Such action could include: governments, civil society organizations, and others making access to essential medicines more of a priority and to consider this strategy as an integral part of reducing poverty; the development, implementation, and enforcement of sound national and international price policies; actively promoting the use of quality assured, low-cost generic drugs; ensuring the availability of essential medicines in the public sector at little or no charge to poor people; establishing health insurance systems with outpatient medicine benefits; encouraging pharmaceutical companies to differentially price medicines that are still subject to patent restrictions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000333.
For a comprehensive resource for medicine prices, availability, and affordability, see Health Action International
Guidelines about access to essential medicines and pharmaceutical policies can be found at WHO
Transparency Alliance provides more information about medicines
Access to essential medicines has become a key campaign topic; for more information see Médecins Sans Frontières (Doctors without Borders)
doi:10.1371/journal.pmed.1000333
PMCID: PMC2930876  PMID: 20824175
24.  Training family medicine residents to care for children 
Canadian Family Physician  2011;57(2):e46-e50.
Abstract
Problem addressed
There is a lack of consensus around the optimal way to train family medicine residents to care for children.
Objective of program
Evaluation of an ambulatory versus an inpatient pediatrics rotation for family medicine residents.
Program description
A 4-week pediatrics rotation for second-year family medicine residents was introduced involving half-day ambulatory pediatric clinics. A nonequivalent control group evaluation study design was followed. Patient logbook entries, as well as residents’ satisfaction, knowledge, and self-reported confidence outcomes were compared between family medicine residents completing the new ambulatory rotation and those completing a traditional inpatient-ambulatory pediatrics rotation.
Conclusion
An ambulatory rotation in pediatrics is a feasible option for facilitating family medicine resident learning in child health care. Residents report exposure to more patient cases that reflect a family practice office setting and the same level of knowledge and confidence as residents completing an inpatient-ambulatory rotation. Intraprofessional collaboration, flexibility in scheduling, and the support of pediatric preceptors are key factors in the organization and implementation of an ambulatory rotation.
PMCID: PMC3038832  PMID: 21321160
25.  Comprehensive Ambulatory Medicine Training for Categorical Internal Medicine Residents 
It is challenging to create an educational and satisfying experience in the outpatient setting. We developed a 3-year ambulatory curriculum that addresses the special needs of our categorical medicine residents with distinct learning objectives for each year of training and clinical experiences and didactic sessions to meet these goals. All PGY1 residents spend 1 month on a general medicine ambulatory care rotation. PGY2 residents spend 3 months on an ambulatory block focusing on 8 core medicine subspecialties. Third-year residents spend 2 months on an advanced ambulatory rotation. The curriculum was started in July 2000 and has been highly regarded by the house staff, with statistically significant improvements in the PGY2 and PGY3 evaluation scores. By enhancing outpatient clinical teaching and didactics with an emphasis on the specific needs of our residents, we have been able to reframe the thinking and attitudes of a group of inpatient-oriented residents.
doi:10.1046/j.1525-1497.2003.20712.x
PMCID: PMC1494851  PMID: 12709096
medical education; residency training; ambulatory medicine

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