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1.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety 
Long working hours and sleep deprivation have been a facet of physician training in the US since the advent of the modern residency system. However, the scientific evidence linking fatigue with deficits in human performance, accidents and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years. This evidence has also spawned regulations to help ensure public safety across safety-sensitive industries, with the notable exception of medicine.
In late 2007, at the behest of the US Congress, the Institute of Medicine embarked on a year-long examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The Institute of Medicine’s report, entitled “Resident duty hours: Enhancing sleep, supervision and safety”, published in January 2009, recommended new limits on resident physician work hours and workload, increased supervision, a heightened focus on resident physician safety, training in structured handovers and quality improvement, more rigorous external oversight of work hours and other aspects of residency training, and the identification of expanded funding sources necessary to implement the recommended reforms successfully and protect the public and resident physicians themselves from preventable harm.
Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. It is likewise important to integrate the perspectives of resident physicians, policy makers, and other constituencies in designing new policies. However, since its release, discussion of the Institute of Medicine report has been largely confined to the medical education community, led by the Accreditation Council for Graduate Medical Education (ACGME).
To begin gathering these perspectives and developing a plan to implement safer work hours for resident physicians, a conference entitled “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” was held at Harvard Medical School on June 17–18, 2010. This White Paper is a product of a diverse group of 26 representative stakeholders bringing relevant new information and innovative practices to bear on a critical patient safety problem. Given that our conference included experts from across disciplines with diverse perspectives and interests, not every recommendation was endorsed by each invited conference participant. However, every recommendation made here was endorsed by the majority of the group, and many were endorsed unanimously. Conference members participated in the process, reviewed the final product, and provided input before publication. Participants provided their individual perspectives, which do not necessarily represent the formal views of any organization.
In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference. In particular, the ACGME only applied the limitation of 16 hours to first-year resident physicans. Thus, it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require. We hope this White Paper will serve as a guide and provide encouragement for that effort.
Resident physician workload and supervision
By the end of training, a resident physician should be able to practice independently. Yet much of resident physicians’ time is dominated by tasks with little educational value. The caseload can be so great that inadequate reflective time is left for learning based on clinical experiences. In addition, supervision is often vaguely defined and discontinuous. Medical malpractice data indicate that resident physicians are frequently named in lawsuits, most often for lack of supervision. The recommendations are: The ACGME should adjust resident physicians workload requirements to optimize educational value. Resident physicians as well as faculty should be involved in work redesign that eliminates nonessential and noneducational activity from resident physician dutiesMechanisms should be developed for identifying in real time when a resident physician’s workload is excessive, and processes developed to activate additional providersTeamwork should be actively encouraged in delivery of patient care. Historically, much of medical training has focused on individual knowledge, skills, and responsibility. As health care delivery has become more complex, it will be essential to train resident and attending physicians in effective teamwork that emphasizes collective responsibility for patient care and recognizes the signs, both individual and systemic, of a schedule and working conditions that are too demanding to be safeHospitals should embrace the opportunities that resident physician training redesign offers. Hospitals should recognize and act on the potential benefits of work redesign, eg, increased efficiency, reduced costs, improved quality of care, and resident physician and attending job satisfactionAttending physicians should supervise all hospital admissions. Resident physicians should directly discuss all admissions with attending physicians. Attending physicians should be both cognizant of and have input into the care patients are to receive upon admission to the hospitalInhouse supervision should be required for all critical care services, including emergency rooms, intensive care units, and trauma services. Resident physicians should not be left unsupervised to care for critically ill patients. In settings in which the acuity is high, physicians who have completed residency should provide direct supervision for resident physicians. Supervising physicians should always be physically in the hospital for supervision of resident physicians who care for critically ill patientsThe ACGME should explicitly define “good” supervision by specialty and by year of training. Explicit requirements for intensity and level of training for supervision of specific clinical scenarios should be providedCenters for Medicare and Medicaid Services (CMS) should use graduate medical education funding to provide incentives to programs with proven, effective levels of supervision. Although this action would require federal legislation, reimbursement rules would help to ensure that hospitals pay attention to the importance of good supervision and require it from their training programs
Resident physician work hours
Although the IOM “Sleep, supervision and safety” report provides a comprehensive review and discussion of all aspects of graduate medical education training, the report’s focal point is its recommendations regarding the hours that resident physicians are currently required to work. A considerable body of scientific evidence, much of it cited by the Institute of Medicine report, describes deteriorating performance in fatigued humans, as well as specific studies on resident physician fatigue and preventable medical errors.
The question before this conference was what work redesign and cultural changes are needed to reform work hours as recommended by the Institute of Medicine’s evidence-based report? Extensive scientific data demonstrate that shifts exceeding 12–16 hours without sleep are unsafe. Several principles should be followed in efforts to reduce consecutive hours below this level and achieve safer work schedules. The recommendations are: Limit resident physician work hours to 12–16 hour maximum shiftsA minimum of 10 hours off duty should be scheduled between shiftsResident physician input into work redesign should be actively solicitedSchedules should be designed that adhere to principles of sleep and circadian science; this includes careful consideration of the effects of multiple consecutive night shifts, and provision of adequate time off after night work, as specified in the IOM reportResident physicians should not be scheduled up to the maximum permissible limits; emergencies frequently occur that require resident physicians to stay longer than their scheduled shifts, and this should be anticipated in scheduling resident physicians’ work shiftsHospitals should anticipate the need for iterative improvement as new schedules are initiated; be prepared to learn from the initial phase-in, and change the plan as neededAs resident physician work hours are redesigned, attending physicians should also be considered; a potential consequence of resident physician work hour reduction and increased supervisory requirements may be an increase in work for attending physicians; this should be carefully monitored, and adjustments to attending physician work schedules made as needed to prevent unsafe work hours or working conditions for this group“Home call” should be brought under the overall limits of working hours; work load and hours should be monitored in each residency program to ensure that resident physicians and fellows on home call are getting sufficient sleepMedicare funding for graduate medical education in each hospital should be linked with adherence to the Institute of Medicine limits on resident physician work hours
Moonlighting by resident physicians
The Institute of Medicine report recommended including external as well as internal moonlighting in working hour limits. The recommendation is: All moonlighting work hours should be included in the ACGME working hour limits and actively monitored. Hospitals should formalize a moonlighting policy and establish systems for actively monitoring resident physician moonlighting
Safety of resident physicians
The “Sleep, supervision and safety” report also addresses fatigue-related harm done to resident physicians themselves. The report focuses on two main sources of physical injury to resident physicians impaired by fatigue, ie, needle-stick exposure to blood-borne pathogens and motor vehicle crashes. Providing safe transportation home for resident physicians is a logistical and financial challenge for hospitals. Educating physicians at all levels on the dangers of fatigue is clearly required to change driving behavior so that safe hospital-funded transport home is used effectively. Fatigue-related injury prevention (including not driving while drowsy) should be taught in medical school and during residency, and reinforced with attending physicians; hospitals and residency programs must be informed that resident physicians’ ability to judge their own level of impairment is impaired when they are sleep deprived; hence, leaving decisions about the capacity to drive to impaired resident physicians is not recommendedHospitals should provide transportation to all resident physicians who report feeling too tired to drive safely; in addition, although consecutive work should not exceed 16 hours, hospitals should provide transportation for all resident physicians who, because of unforeseen reasons or emergencies, work for longer than consecutive 24 hours; transportation under these circumstances should be automatically provided to house staff, and should not rely on self-identification or request
Training in effective handovers and quality improvement
Handover practice for resident physicians, attendings, and other health care providers has long been identified as a weak link in patient safety throughout health care settings. Policies to improve handovers of care must be tailored to fit the appropriate clinical scenario, recognizing that information overload can also be a problem. At the heart of improving handovers is the organizational effort to improve quality, an effort in which resident physicians have typically been insufficiently engaged. The recommendations are: Hospitals should train attending and resident physicians in effective handovers of careHospitals should create uniform processes for handovers that are tailored to meet each clinical setting; all handovers should be done verbally and face-to-face, but should also utilize written toolsWhen possible, hospitals should integrate hand-over tools into their electronic medical records (EMR) systems; these systems should be standardized to the extent possible across residency programs in a hospital, but may be tailored to the needs of specific programs and services; federal government should help subsidize adoption of electronic medical records by hospitals to improve signoutWhen feasible, handovers should be a team effort including nurses, patients, and familiesHospitals should include residents in their quality improvement and patient safety efforts; the ACGME should specify in their core competency requirements that resident physicians work on quality improvement projects; likewise, the Joint Commission should require that resident physicians be included in quality improvement and patient safety programs at teaching hospitals; hospital administrators and residency program directors should create opportunities for resident physicians to become involved in ongoing quality improvement projects and root cause analysis teams; feedback on successful quality improvement interventions should be shared with resident physicians and broadly disseminatedQuality improvement/patient safety concepts should be integral to the medical school curriculum; medical school deans should elevate the topics of patient safety, quality improvement, and teamwork; these concepts should be integrated throughout the medical school curriculum and reinforced throughout residency; mastery of these concepts by medical students should be tested on the United States Medical Licensing Examination (USMLE) stepsFederal government should support involvement of resident physicians in quality improvement efforts; initiatives to improve quality by including resident physicians in quality improvement projects should be financially supported by the Department of Health and Human Services
Monitoring and oversight of the ACGME
While the ACGME is a key stakeholder in residency training, external voices are essential to ensure that public interests are heard in the development and monitoring of standards. Consequently, the Institute of Medicine report recommended external oversight and monitoring through the Joint Commission and Centers for Medicare and Medicaid Services (CMS). The recommendations are: Make comprehensive fatigue management a Joint Commission National Patient Safety Goal; fatigue is a safety concern not only for resident physicians, but also for nurses, attending physicians, and other health care workers; the Joint Commission should seek to ensure that all health care workers, not just resident physicians, are working as safely as possibleFederal government, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, should encourage development of comprehensive fatigue management programs which all health systems would eventually be required to implementMake ACGME compliance with working hours a “ condition of participation” for reimbursement of direct and indirect graduate medical education costs; financial incentives will greatly increase the adoption of and compliance with ACGME standards
Future financial support for implementation
The Institute of Medicine’s report estimates that $1.7 billion (in 2008 dollars) would be needed to implement its recommendations. Twenty-five percent of that amount ($376 million) will be required just to bring hospitals into compliance with the existing 2003 ACGME rules. Downstream savings to the health care system could potentially result from safer care, but these benefits typically do not accrue to hospitals and residency programs, who have been asked historically to bear the burden of residency reform costs. The recommendations are: The Institute of Medicine should convene a panel of stakeholders, including private and public funders of health care and graduate medical education, to lay down the concrete steps necessary to identify and allocate the resources needed to implement the recommendations contained in the IOM “Resident duty hours: Enhancing sleep, supervision and safety” report. Conference participants suggested several approaches to engage public and private support for this initiativeEfforts to find additional funding to implement the Institute of Medicine recommendations should focus more broadly on patient safety and health care delivery reform; policy efforts focused narrowly upon resident physician work hours are less likely to succeed than broad patient safety initiatives that include residency redesign as a key componentHospitals should view the Institute of Medicine recommendations as an opportunity to begin resident physician work redesign projects as the core of a business model that embraces safety and ultimately saves resourcesBoth the Secretary of Health and Human Services and the Director of the Centers for Medicare and Medicaid Services should take the Institute of Medicine recommendations into consideration when promulgating rules for innovation grantsThe National Health Care Workforce Commission should consider the Institute of Medicine recommendations when analyzing the nation’s physician workforce needs
Recommendations for future research
Conference participants concurred that convening the stakeholders and agreeing on a research agenda was key. Some observed that some sectors within the medical education community have been reluctant to act on the data. Several logical funders for future research were identified. But above all agencies, Centers for Medicare and Medicaid Services is the only stakeholder that funds graduate medical education upstream and will reap savings downstream if preventable medical errors are reduced as a result of reform of resident physician work hours.
doi:10.2147/NSS.S19649
PMCID: PMC3630963  PMID: 23616719
resident; hospital; working hours; safety
2.  Creation of an Innovative Inpatient Medical Procedure Service and a Method to Evaluate House Staff Competency 
Journal of General Internal Medicine  2004;19(5 Pt 2):510-513.
INTRODUCTION
Training residents in medical procedures is an area of growing interest. Studies demonstrate that internal medicine residents are inadequately trained to perform common medical procedures, and program directors report residents do not master these essential skills. The American Board of Internal Medicine requires substantiation of competence in procedure skills for all internal medicine residents; however, for most procedures, standards of competence do not exist.
OBJECTIVE
1) Create a new and standardized approach to teaching, performing, and evaluating inpatient medical procedures; 2) Determine the number of procedures required until trainees develop competence, by assessing both clinical knowledge and psychomotor skills; 3) Improve patient safety.
DESIGN
A Medical Procedure Service (MPS), consisting of select faculty who are experts at common inpatient procedures, was established to supervise residents performing medical procedures. Faculty monitor residents’ psychomotor performance, while clinical knowledge is taught through a complementary, comprehensive curriculum. After the completion of each procedure, the trainee and supervising faculty member independently complete online questionnaires.
RESULTS
During this pilot program, 246 procedures were supervised, with a pooled major complication rate of 3.7%. 123 thoracenteses were supervised, with a pneumothorax rate of 3.3%; this compares favorably with a pooled analysis of the literature. 87% of surveyed house staff felt the procedure service helped in their education of medical procedures.
CONCLUSIONS
The “see one, do one, teach one” model of procedure education is dangerously inadequate. Through the development of a Medical Procedure Service, and an associated procedure curriculum and a mechanism of evaluation, we hope to reduce the rate of complications and errors related to medical procedures and to determine at what point competency is achieved for these procedures.
doi:10.1111/j.1525-1497.2004.30161.x
PMCID: PMC1492327  PMID: 15109314
procedures; education; competence; complications
3.  Consolidated Academic and Research Exposition: A Pilot Study of an Innovative Education Method to Increase Residents' Research Involvement 
The Ochsner Journal  2012;12(4):367-372.
Background
Internal medicine residents at the Ochsner Clinic Foundation stay engaged with clinical work and have difficulty initiating and completing research and publishing their scholarly activities. Commonly cited barriers include lack of knowledge about institutional research programs, lack of confidence regarding medical writing skills, lack of time, and failure to understand the value of research. The residency directors at Ochsner initiated the Consolidated Academic and Research Exposition (CARE) program to teach basic research skills and encourage residents' interest and productivity in research.
Methods
The CARE program includes 4 core components: house staff mentoring and the Resident Career Development Program, a journal club, medical writing instruction, and research engagement. Particular emphasis is given to projects that could be completed within a 1-month period and result in publication, enabling residents to use a 1-month elective rotation during their first postgraduate year. The sessions are mandatory for residents, except for those on specified rotations, including the critical care service and the night float rotation and those who are postcall.
Results
In 2010-2011, 6 residents submitted abstracts to the Louisiana Chapter of the American College of Physicians Associates meeting; 2 abstracts were accepted for presentation. In 2011-2012, there were 14 submissions, 4 of which were accepted for presentation. In 2010-2011, there were 4 submissions to the Southern Hospitalist Conference, which increased to 7 submissions in 2011-2012. The second best presentation award at the Southern Hospitalist Conference was also earned by a resident of this institution. The program saw a 110% total increase in scholarly activity from 2010-2011 to 2011-2012.
Discussion
The CARE program has been in existence for approximately 1 year. Preliminary results were tabulated based on research proposals, posters, abstracts, case reports, and presentations submitted and/or accepted at leading medical conferences over the past year as compared to the same period 1 year ago. Residents, based on the Accreditation Council for Graduate Medical Education Resident Survey responses, were more satisfied with the opportunities provided to them to participate in research or scholarly activities. Our preliminary results suggest that an organized, structured research curriculum in internal medicine residency programs is critical to promoting, initiating, and completing scholarly activity during a residency program.
Conclusion
Ochsner's CARE program has appreciably enhanced internal medicine residents' interest in research-related activity, resulting in a significant increase in resident-authored research papers, abstracts, posters, and case reports being accepted at leading national medical conferences.
PMCID: PMC3527867  PMID: 23267266
ACGME requirements; resident research; scholarly activity
4.  Resident and program director perspectives on third-year family medicine programs 
Canadian Family Physician  2009;55(9):904-905.e8.
ABSTRACT
OBJECTIVE
To determine the views of family medicine (FM) program directors, third-year program coordinators, and residents on the factors affecting demand and allocation of postgraduate year 3 (PGY3) positions and the effects of these programs on the professional activities of program graduates.
DESIGN
Cross-sectional surveys and key informant interviews.
SETTING
Ontario (FM residents) and across Canada (program directors) in 2006.
PARTICIPANTS
All FM residents in Ontario and all core program directors and PGY3 program coordinators nationally were eligible to participate in the surveys. Eighteen key informant interviews were conducted, all in Ontario. Interviewees included all FM program directors, selected PGY3 program coordinators, residents, and other community stakeholders.
METHODS
Resident surveys were Web-based; invitations to participate were delivered by FM programs via e-mail lists. The program director and coordinator surveys were postal surveys. Interviews were audiotaped and transcribed, and the authors coded the interviews for themes.
MAIN FINDINGS
Response rates for the surveys were 34% to 39% for residents and 78% for program directors and coordinators. Respondents agreed that programs should include flexible training options of varied duration. Demand for training is determined more by resident need than community or health system factors, and is either increasing or stable. Overall, respondents believed that approximately one-third of core program graduates should have the opportunity for PGY3 training. They thought re-entry from practice should be permitted, but mandatory return-of-service agreements were not desired. Program allocation and resident selection is a complex process with resident merit playing an important role. Respondents expected PGY3 graduates to practise differently than PGY2 graduates and to provide improved quality of care in their fields. They also thought that PGY3 graduates might play larger roles in leadership and teaching than core program graduates.
CONCLUSION
It is likely that PGY3 programs will continue to grow and form an increasingly important part of the FM training system in Canada. Flexible programs that can adapt to changing educational, health system, and community needs are essential. Training programs and national and provincial colleges of FM will also need to ensure that these physicians are provided with opportunities to maintain their links with the rest of the FM community.
PMCID: PMC2743591  PMID: 19752262
5.  Ambulatory care training during core internal medicine residency training: the Canadian experience. 
OBJECTIVE: To determine the status of ambulatory care training of core internal medicine residents in Canada. DESIGN: Mail survey. PARTICIPANTS: All 16 program directors of internal medicine residency training programs in Canada. OUTCOME MEASURES: The nature and amount of ambulatory care training experienced by residents, information about the faculty tutors, and the sources and types of patients seen by the residents. As well, the program directors were asked for their opinions on the ideal ambulatory care program and the kinds of teaching skills required of tutors. RESULTS: All of the directors responded. Fifteen stated that the ambulatory care program is mandatory, and the other stated that it is an elective. Block rotations are more common than continuity-of-care assignments. In 12 of the programs 10% or less of the overall training time is spent in ambulatory care. In 11 the faculty tutors comprise a mixture of generalists and subspecialists. The tutors simultaneously care for patients and teach residents in the ambulatory care setting in 14 of the schools. Most are paid through fee-for-service billing. The respondents felt that the ideal program should contain a mix of general and subspecialty ambulatory care training. There was no consensus on whether it should be a block or continuity-of-care experience, but the directors felt that consultation and communication skills should be emphasized regardless of which type of experience prevails. CONCLUSIONS: Although there is a widespread commitment to provide core internal medicine residents with experience in ambulatory care, there is little uniformity in how this is achieved in Canadian training programs.
PMCID: PMC1485315  PMID: 8324688
6.  Oncology education in Canadian undergraduate and postgraduate medical programs: a survey of educators and learners 
Current Oncology  2014;21(1):e75-e88.
Background
The oncology education framework currently in use in Canadian medical training programs is unknown, and the needs of learners have not been fully assessed to determine whether they are adequately prepared to manage patients with cancer.
Methods
To assess the oncology education framework currently in use at Canadian medical schools and residency training programs for family (fm) and internal medicine (im), and to evaluate opinions about the content and utility of standard oncology education objectives, a Web survey was designed and sent to educators and learners. The survey recipients included undergraduate medical education curriculum committee members (umeccms), directors of fm and im programs, oncologists, medical students, and fm and im residents.
Results
Survey responses were received from 677 educators and learners. Oncology education was felt to be inadequate in their respective programs by 58% of umeccms, 57% of fm program directors, and 50% of im program directors. For learners, oncology education was thought to be inadequate by 67% of medical students, 86% of fm residents, and 63% of im residents. When comparing teaching of medical subspecialty–related diseases, all groups agreed that their trainees were least prepared to manage patients with cancer. A standard set of oncology objectives was thought to be possibly or definitely useful for undergraduate learners by 59% of respondents overall and by 61% of postgraduate learners.
Conclusions
Oncology education in Canadian undergraduate and postgraduate fm and im training programs are currently thought to be inadequate by a majority of educators and learners. Developing a standard set of oncology objectives might address the needs of learners.
doi:10.3747/co.21.1667
PMCID: PMC3921051  PMID: 24523624
Oncology education; Canada; undergraduate medical programs; postgraduate medical programs
7.  The Structure and Content of the Medical Subinternship 
OBJECTIVE
To describe the educational and administrative structure and content of internal medicine subinternship (SI) programs at medical schools throughout the United States.
DESIGN
A cross-sectional mailed survey of internal medicine SI directors at U.S. medical schools.
MAIN RESULTS
Responses were received from 100 (80%) of 125 eligible programs. Seventy-five percent of schools require a SI for graduation; 26% of these schools require the completion of a medical SI. Nationally, about 75% of all medical students opt to complete a medical SI. Dedicated SI administrative committees exist at 46% of medical schools. A minority of programs provide students with explicit curricula (31%) or exclusive conference time (36%). In 44% of programs, subinterns are used by hospital departments of medicine as intern substitutes. Subinterns are responsible for sign-out and cross-coverage in about half of the programs, and all patient orders entered by subinterns require cosignature. Subintern evaluation criteria include attending evaluation (100%), resident evaluation (80%), case write-ups (27%), supervised clinical examination (20%), written examination (14%), and oral examination (3%).
CONCLUSION
Although most medical schools offer an SI in internal medicine and many require it, the experience often lacks clearly defined curricular goals and often does not provide medical students with house-staff–level responsibilities. In an effort to ease the transition from undergraduate to postgraduate training, further studies are needed to define which educational and structural components of the medicine SI should be developed and emphasized.
doi:10.1046/j.1525-1497.2001.016008550.x
PMCID: PMC1495247  PMID: 11556932
medicine subinternship; acting internship; medical education; curriculum; survey
8.  Training Internal Medicine Residents in Outpatient HIV Care: A Survey of Program Directors 
Background
The care of patients with HIV is increasingly focused on outpatient chronic disease management. It is not known to what extent internal medicine residents in the US are currently being trained in or encouraged to provide primary care for this population of patients.
Objective
To survey internal medicine residency program directors about their attitudes regarding training in outpatient HIV care and current program practices.
Design
Program directors were surveyed first by email. Non-responding programs were mailed up to two copies of the survey.
Subjects
All internal medicine residency program directors in the US.
Main Measures
Program director attitudes and residency descriptions.
Key Results
Of the 372 program directors surveyed, 230 responded (61.8 %). Forty-two percent of program directors agreed that it is important to train residents to be primary care providers for patients with HIV. Teaching outpatient-based HIV curricula was a priority for 45.1%, and 56.5% reported that exposing residents to outpatient HIV clinical care was a high priority. Only 46.5% of programs offer a dedicated rotation in outpatient HIV care, and 50.5% of programs have curricula in place to teach about outpatient HIV care. Only 18.8% of program directors believed their graduates had the skills to be primary providers for patients with HIV, and 70.6% reported that residents interested in providing care for patients with HIV pursued ID fellowships. The strongest reasons cited for limited HIV training during residency were beliefs that patients with HIV prefer to be seen and receive better care in ID clinics compared to general medicine clinics.
Conclusions
With a looming HIV workforce shortage, we believe that internal medicine programs should create educational experiences that will provide their residents with the skills and knowledge necessary to meet the healthcare needs of this population.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1398-6) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1398-6
PMCID: PMC2917660  PMID: 20505999
HIV/AIDS; primary care; medical education; residency education; workforce
9.  Burnout and Distress Among Internal Medicine Program Directors: Results of A National Survey 
Journal of General Internal Medicine  2013;28(8):1056-1063.
BACKGROUND
Physician burnout and distress has been described in national studies of practicing physicians, internal medicine (IM) residents, IM clerkship directors, and medical school deans. However, no comparable national data exist for IM residency program directors.
OBJECTIVE
To assess burnout and distress among IM residency program directors, and to evaluate relationships of distress with personal and program characteristics and perceptions regarding implementation and consequences of Accreditation Council for Graduate Medical Education (ACGME) regulations.
DESIGN AND PARTICIPANTS
The 2010 Association of Program Directors in Internal Medicine (APDIM) Annual Survey, developed by the APDIM Survey Committee, was sent in August 2010 to the 377 program directors with APDIM membership, representing 99.0 % of the 381 United States categorical IM residency programs.
MAIN MEASURES
The 2010 APDIM Annual Survey included validated items on well-being and distress, including questions addressing quality of life, satisfaction with work-life balance, and burnout. Questions addressing personal and program characteristics and perceptions regarding implementation and consequences of ACGME regulations were also included.
KEY RESULTS
Of 377 eligible program directors, 282 (74.8 %) completed surveys. Among respondents, 12.4 % and 28.8 % rated their quality of life and satisfaction with work-life balance negatively, respectively. Also, 27.0 % reported emotional exhaustion, 10.4 % reported depersonalization, and 28.7 % reported overall burnout. These rates were lower than those reported previously in national studies of medical students, IM residents, practicing physicians, IM clerkship directors, and medical school deans. Aspects of distress were more common among younger program directors, women, and those reporting greater weekly work hours. Work–home conflicts were common and associated with all domains of distress, especially if not resolved in a manner effectively balancing work and home responsibilities. Associations with program characteristics such as program size and American Board of Internal Medicine (ABIM) pass rates were not found apart from higher rates of depersonalization among directors of community-based programs (23.5 % vs. 8.6 %, p = 0.01). We did not observe any consistent associations between distress and perceptions of implementation and consequences of program regulations.
CONCLUSIONS
The well-being of IM program directors across domains, including quality of life, satisfaction with work-life balance, and burnout, appears generally superior to that of medical trainees, practicing physicians, and other medical educators nationally. Additionally, it is reassuring that program directors' perceptions of their ability to respond to current regulatory requirements are not adversely associated with distress. However, the increased distress levels among younger program directors, women, and those at community-based training programs reported in this study are important concerns worthy of further study.
doi:10.1007/s11606-013-2349-9
PMCID: PMC3710382  PMID: 23595924
graduate medical education; residency; burnout; well-being
10.  Educating physicians about women's health. Survey of Canadian family medicine residency programs. 
Canadian Family Physician  1994;40:900-905.
OBJECTIVE: To identify which women's health issues are taught in the 2-year core curriculum of Canadian family medicine residency programs and whether educators think their current teaching of women's health is adequate. DESIGN: Mailed survey using a questionnaire. PARTICIPANTS: All program and unit directors of the 16 Canadian family medicine residency training programs were surveyed. Replies were received from 63% (10 of 16) of program directors and 79% (55 of 70) of unit directors. MAIN OUTCOME MEASURES: Percentage of programs teaching specific women's health topics from a list of 21 possible topics; percentage offering educational opportunities with sexual assault teams and women's shelters; participants' assessment of the adequacy of current teaching in each training program; plans to increase women's health education. RESULTS: Topics such as violence against women and medical conditions more common among women were taught in more than 80% of programs, but poverty and the health care concerns of Native and immigrant women were included in fewer than 40% of programs. Half of the program directors indicated that residents were given educational opportunities with sexual assault teams or women's shelters. Unit directors gave a lower estimate. Most (90%) program directors thought their current teaching of women's health issues was inadequate and had plans to increase it, as did 64% of unit directors. CONCLUSION: Violence against women and the traditional medical topics of osteoporosis, weight disorders, and reproductive and breast cancer are frequently taught in family medicine training programs. However, the social and cultural aspects of health are addressed less often. It is encouraging that many family medicine programs plan to increase their teaching of women's health.
PMCID: PMC2380186  PMID: 8038635
11.  Getting Out of Silos: An Innovative Transitional Care Curriculum for Internal Medicine Residents Through Experiential Interdisciplinary Learning 
Background
Care transitions are common and highly vulnerable times during illness. Physicians need better training to improve care transitions. Existing transitional care curricula infrequently involve settings outside of the hospital or other health care disciplines.
Intervention
We created a curriculum to teach internal medicine residents how to provide better transitional care at hospital discharge through experiential, interdisciplinary learning in different care settings outside of the acute hospital, and we engaged other health care disciplines frequently involved in care transitions.
Setting/Participants
Nineteen postgraduate year-1 internal medicine trainees at an academic medical center in an urban location completed experiences in a postacute care facility, home health care, and outpatient clinics.
Program Description
The 2-week required curriculum involved teachers from geriatric medicine; physical, occupational, and speech therapy; and home health care, with both didactic and experiential components and self-reflective exercises.
Program Evaluation
The curriculum was highly rated (6.86 on a 9-point scale) and was associated with a significant increase in the rating of the overall quality of transitional care education (from 4.09 on a 5-point scale in 2011 to 4.53 in 2012) on the annual residency program survey. Learners reported improved knowledge in key curricular areas and that they would change practice as a result of the curriculum.
Conclusions
Our transitional care curriculum for internal medicine residents provides exposure to care settings and health care disciplines that patients frequently encounter. The curriculum has shown positive, short-term effects on learners' perceived knowledge and behavior.
doi:10.4300/JGME-D-12-00316.1
PMCID: PMC3886474  PMID: 24455024
12.  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
13.  Building Faculty Community: Fellowship in Graduate Medical Education Administration 
Introduction
The Department of Graduate Medical Education at Stanford Hospital and Clinics has developed a professional training program for program directors. This paper outlines the goals, structure, and expected outcomes for the one-year Fellowship in Graduate Medical Education Administration program.
Background
The skills necessary for leading a successful Accreditation Council for Graduate Medical Education (ACGME) training program require an increased level of curricular and administrative expertise. To meet the ACGME Outcome Project goals, program directors must demonstrate not only sophisticated understanding of curricular design but also competency-based performance assessment, resource management, and employment law. Few faculty-development efforts adequately address the complexities of educational administration. As part of an institutional-needs assessment, 41% of Stanford program directors indicated that they wanted more training from the Department of Graduate Medical Education.
Intervention
To address this need, the Fellowship in Graduate Medical Education Administration program will provide a curriculum that includes (1) readings and discussions in 9 topic areas, (2) regular mentoring by the director of Graduate Medical Education (GME), (3) completion of a service project that helps improve GME across the institution, and (4) completion of an individual scholarly project that focuses on education.
Results
The first fellow was accepted during the 2008–2009 academic year. Outcomes for the project include presentation of a project at a national meeting, internal workshops geared towards disseminating learning to peer program directors, and the completion of a GME service project. The paper also discusses lessons learned for improving the program.
doi:10.4300/01.01.0024
PMCID: PMC2931184  PMID: 21975722
14.  Alternative Approaches to Ambulatory Training: Internal Medicine Residents’ and Program Directors’ Perspectives 
ABSTRACT
BACKGROUND
Internal medicine ambulatory training redesign, including recommendations to increase ambulatory training, is a focus of national discussion. Residents’ and program directors’ perceptions about ambulatory training models are unknown.
OBJECTIVE
To describe internal medicine residents’ and program directors’ perceptions regarding ambulatory training duration, alternative ambulatory training models, and factors important for ambulatory education.
DESIGN
National cohort study.
PARTICIPANTS
Internal medicine residents (N = 14,941) and program directors (N = 222) who completed the 2007 Internal Medicine In-Training Examination (IM-ITE) Residents Questionnaire or Program Directors Survey, representing 389 US residency programs.
RESULTS
A total of 58.4% of program directors and 43.7% of residents preferred one-third or more training time in outpatient settings. Resident preferences for one-third or more outpatient training increased with higher levels of training (48.3% PGY3), female sex (52.7%), primary care program enrollment (64.8%), and anticipated outpatient-focused career, such as geriatrics. Most program directors (77.3%) and residents (58.4%) preferred training models containing weekly clinic. Although residents and program directors reported problems with competing inpatient-outpatient responsibilities (74.9% and 88.1%, respectively) and felt that absence of conflict with inpatient responsibilities is important for good outpatient training (69.4% and 74.2%, respectively), only 41.6% of residents and 22.7% of program directors supported models eliminating ambulatory sessions during inpatient rotations.
CONCLUSIONS
Residents’ and program directors’ preferences for outpatient training differ from recommendations for increased ambulatory training. Discordance was observed between reported problems with conflicting inpatient-outpatient responsibilities and preferences for models maintaining longitudinal clinic during inpatient rotations. Further study regarding benefits and barriers of ambulatory redesign is needed.
doi:10.1007/s11606-009-1015-8
PMCID: PMC2710468  PMID: 19475458
medical education-graduate; ambulatory care; curriculum/program evaluation; medical student and residency education
15.  Internal medicine residency training for unhealthy alcohol and other drug use: recommendations for curriculum design 
BMC Medical Education  2010;10:22.
Background
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.
Discussion
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.
Summary
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.
doi:10.1186/1472-6920-10-22
PMCID: PMC2848062  PMID: 20230607
16.  Residents' exposure to aboriginal health issues. Survey of family medicine programs in Canada. 
Canadian Family Physician  1999;45:325-330.
OBJECTIVE: To determine whether Canadian family medicine residency programs currently have objectives, staff, and clinical experiences for adequately exposing residents to aboriginal health issues. DESIGN: A one-page questionnaire was developed to survey the details of teaching about and exposure to aboriginal health issues. SETTING: Family medicine programs in Canada. PARTICIPANTS: All Canadian family medicine program directors in the 18 programs (16 at universities and two satellite programs) were surveyed between October 1997 and March 1998. MAIN OUTCOME MEASURES: Whether programs had teaching objectives for exposing residents to aboriginal health issues, whether they had resource people available, what elective and core experiences in aboriginal health were offered, and what types of experiences were available. RESULTS: Response rate was 100%. No programs had formal, written curriculum objectives for residency training in aboriginal health issues, although some were considering them. Some programs, however, had objectives for specific weekend or day sessions. No programs had a strategy for encouraging enrollment of residents of aboriginal origin. Eleven programs had at least one resource person with experience in aboriginal health issues, and 12 had access to community-based aboriginal groups. Core experiences were all weekend seminars or retreats. Elective experiences in aboriginal health were available in 16 programs, and 11 programs were active on reserves. CONCLUSIONS: Many Canadian family medicine programs give residents some exposure to aboriginal health issues, but most need more expertise and direction on these issues. Some programs have unique approaches to teaching aboriginal health care that could be shared. Formalized objectives derived in collaboration with other family medicine programs and aboriginal groups could substantially improve the quality of education in aboriginal health care in Canada.
PMCID: PMC2328292  PMID: 10065306
17.  Rural family medicine training in Canada. 
Canadian Family Physician  1995;41:993-1000.
OBJECTIVE: To examine the status of postgraduate family medicine training that occurs in rural family practice settings in Canada and to identify problems and how they are addressed. DESIGN: A retrospective questionnaire sent to all 18 Canadian family medicine training programs followed by a focus group discussion of results. SETTING: Canadian university family medicine training programs. PARTICIPANTS: Chairs or program directors of all 18 Canadian family medicine training programs and people attending a workshop at the Section of Teachers of Family Medicine annual meeting. MAIN OUTCOME MEASURES: Extent of training offered, educational models used, common problems for residents and teachers. RESULTS: Nine of 18 programs offer some family medicine training in a rural practice setting to some or all of their first-year family medicine residents, and 99 of 684 first-year family medicine residents did some training in a rural practice. All programs offer some training in a rural practice to some or all of the second-year residents, and 567 of 702 second-year residents did some training in a rural setting. In 12 of 18 programs, a rural family medicine block is compulsory. Education models for training for rural family practice vary widely. Isolation, accommodation, and supervision are common problems for rural family medicine residents. Isolation and faculty development are common problems for rural physician-teachers. Programs use various approaches to address these problems. CONCLUSIONS: The variety of postgraduate training models for rural family practice used in the 18 training programs reflects different regional health care needs and resources. There is no common rural family medicine curriculum. Networking through a rural physician-teachers group or a faculty of rural medicine could further the development of education for rural family practice.
PMCID: PMC2146570  PMID: 7780331
18.  Sports medicine training in Canadian paediatric residency programs: Are we doing enough? 
Paediatrics & Child Health  2007;12(4):295-299.
OBJECTIVE
To assess sports medicine teaching in Canadian paediatric residency programs and recent paediatric graduates’ comfort level with sports medicine.
DESIGN AND METHODS
Recent paediatric graduates were surveyed about the amount of sports medicine training they had received during residency, as well as their comfort level in diagnosing and managing common sports medicine problems. Paediatric residency program directors were surveyed about the sports medicine content in their programs.
RESULTS
Survey response rates for recent graduates and program directors were 52.6% and 81.3%, respectively. Of the recent graduates who responded, 84.7% had 5 h or less of formal sports medicine teaching during residency and 94.9% had no formal clinical rotation in sports medicine. The vast majority of respondents (84.2%) were less than comfortable with their musculoskeletal anatomy knowledge; only 15.8% were comfortable. There were no significant differences between general paediatricians and subspecialists in their reported comfort level with diagnosis (P=0.938) and management (P=0.967) of sports injuries. No program provided more than 5 h of formal teaching in sports medicine, and only one program has a core sports medicine rotation. None of the responding program directors felt that new paediatricians are even somewhat prepared to provide adequate medical care for athletes, and 61.5% felt that a curriculum in sports medicine was necessary.
CONCLUSIONS
Canadian paediatric residents had limited exposure to sports medicine, and many recent graduates were uncomfortable with their skills in sports medicine. Canadian paediatric residency programs should include a curriculum in sports medicine to adequately prepare future paediatricians to care for young athletes.
PMCID: PMC2528690  PMID: 19030373
Paediatric residency; Residency training; Sports medicine
19.  The Impact of Severe Acute Respiratory Syndrome on Medical House Staff 
OBJECTIVE
To explore the impact of severe acute respiratory syndrome (SARS) on a medical training program and to develop principles for professional training programs to consider in dealing with future, similar crises.
DESIGN
Qualitative interviews analyzed using grounded theory methodology.
SETTING
University-affiliated hospitals in Toronto, Canada during the SARS outbreak in 2003.
PARTICIPANTS
Medical house staff who were allocated to a general internal medicine clinical teaching unit, infectious diseases consultation service, or intensive care unit.
RESULTS
Seventeen medical residents participated in this study. Participants described their experiences during the outbreak and highlighted several themes including concerns about their personal safety and about the negative impact of the outbreak on patient care, house staff education, and their emotional well-being.
CONCLUSION
The ability of residents to cope with the stress of the SARS outbreak was enhanced by the communication of relevant information and by the leadership of their supervisors and infection control officers. It is hoped that training programs for health care professionals will be able to implement these tenets of crisis management as they develop strategies for dealing with future health threats.
doi:10.1111/j.1525-1497.2005.0099.x
PMCID: PMC1490116  PMID: 15963157
medical house staff; severe acute respiratory distress syndrome; training program; outbreak
20.  Emergency medicine ultrasonography 
Canadian Family Physician  2009;55(10):1010-1011.e4.
ABSTRACT
OBJECTIVE
To survey program directors of family medicine–emergency medicine (CCFP[EM]) training programs regarding current and future emergency medicine ultrasonography (EMUS) training.
DESIGN
A Web-based survey using a modified Dillman method. Two academic emergency physicians reviewed the validity and reliability of the survey.
SETTING
Canada.
PARTICIPANTS
Program directors of all 17 Canadian CCFP(EM) residency training programs in 2006.
MAIN OUTCOME MEASURES
Characteristics of EMUS training currently offered and program directors’ perceptions of needs for future EMUS training.
RESULTS
The survey, performed in 2006, had a response rate of 100% (17/17), although not all respondents answered all questions. At the time of the study, 82.4% of respondents’ programs used EMUS. Although all program directors recommended that residents attend introductory EMUS courses, only 71.4% (10/14) of programs offered such courses; 60.0% (9/15) of those were mandatory. In one-third of the programs, more than 75% of the attending staff used EMUS. A total of 76.5% of program directors thought that introductory courses in EMUS should be mandatory; 62.5% (10/16) believed that residents were able to acquire sufficient experience to use EMUS independently to make practice decisions before completion of their residency; and 88.2% believed that EMUS should be a part of the scope of practice for emergency medicine physicians. Only 58.8% believed that there should be questions about EMUS on the CCFP(EM) Certification examination. Open responses indicated that funding, resources, and standardization were issues that needed to be addressed.
CONCLUSION
Formal EMUS training for CCFP(EM) programs is being introduced in Canada. Quality assurance needs to be strengthened. Most program directors thought that an introductory course in EMUS should be mandatory. Fewer directors, however, believed EMUS should be on the CCFP(EM) Certification examination until further funding, resources, and standardization of EMUS programs were in place.
PMCID: PMC2761962  PMID: 19826164
21.  Teaching the Teachers 
OBJECTIVE
To determine the prevalence, topics, methods, and intensity of ongoing faculty development (FD) in teaching skills.
DESIGN
Mailed survey.
PARTICIPANTS
Two hundred and seventy-seven of the 386 (72%) U.S. teaching hospitals with internal medicine residency programs.
MEASUREMENTS
Prevalence and characteristics of ongoing FD.
RESULTS
One hundred and eight teaching hospitals (39%) reported ongoing FD. Hospitals with a primary medical school affiliation (university hospitals) were more likely to have ongoing FD than nonuniversity hospitals. For nonuniversity hospitals, funding from the Health Resources Services Administration and >50 house staff were associated with ongoing FD. For university hospitals, >100 department of medicine faculty was associated. Ongoing programs included a mean of 10.4 topics (standard deviation, 5.4). Most offered half-day workshops (80%), but 22% offered ≥1-month programs. Evaluations were predominantly limited to postcourse evaluations forms. Only 14% of the hospitals with ongoing FD (5% of all hospitals) had “advanced” programs, defined as offering ≥10 topics, lasting >2 days, and using ≥3 experiential teaching methods. These were significantly more likely to be university hospitals and to offer salary support and/or protected time to their FD instructors. Generalists and hospital-based faculty were more likely to receive training than subspecialist and community-based faulty. Factors facilitating participation in FD activities were supervisor attitudes, FD expertise, and institutional culture.
CONCLUSIONS
A minority of U.S. teaching hospitals offer ongoing faculty development in teaching skills. Continued progress will likely require increased institutional commitment, improved evaluations, and adequate resources, particularly FD instructors and funding.
doi:10.1111/j.1525-1497.2004.30334.x
PMCID: PMC1492160  PMID: 15009774
faculty development; teaching skills; survey
22.  Pharmacists teaching in family medicine residency programs 
Canadian Family Physician  2011;57(9):e341-e346.
Abstract
Objective
To determine the percentage of family medicine residency programs that have pharmacists directly involved in teaching residents, the types and extent of teaching provided by pharmacists in family medicine residency programs, and the primary source of funding for the pharmacists.
Design
Web-based survey.
Setting
One hundred fifty-eight resident training sites within the 17 family medicine residency programs in Canada.
Participants
One hundred residency program directors who were responsible for overseeing the training sites within the residency programs were contacted to determine the percentage of training sites in which pharmacists were directly involved in teaching. Pharmacists who were identified by the residency directors were invited to participate in the Web-based survey.
Main outcome measures
The percentage of training sites for family medicine residency that have pharmacists directly involved in teaching residents. The types and the extent of teaching performed by the pharmacists who teach in the residency programs. The primary source of funding that supports the pharmacists’ salaries.
Results
More than a quarter (25.3%) of family medicine residency training sites include direct involvement of pharmacist teachers. Pharmacist teachers reported that they spend a substantial amount of their time teaching residents using a range of teaching modalities and topics, but have no formal pharmacotherapy curriculums. Nearly a quarter (22.6%) of the pharmacists reported that their salaries were primarily funded by the residency programs.
Conclusion
Pharmacists have a role in training family medicine residents. This is a good opportunity for family medicine residents to learn about issues related to pharmacotherapy; however, the role of pharmacists as educators might be optimized if standardized teaching methods, curriculums, and evaluation plans were in place.
PMCID: PMC3173442  PMID: 21918131
23.  Mastery Learning of Advanced Cardiac Life Support Skills by Internal Medicine Residents Using Simulation Technology and Deliberate Practice 
BACKGROUND
Internal medicine residents must be competent in advanced cardiac life support (ACLS) for board certification.
OBJECTIVE
To use a medical simulator to assess postgraduate year 2 (PGY-2) residents' baseline proficiency in ACLS scenarios and evaluate the impact of an educational intervention grounded in deliberate practice on skill development to mastery standards.
DESIGN
Pretest-posttest design without control group. After baseline evaluation, residents received 4, 2-hour ACLS education sessions using a medical simulator. Residents were then retested. Residents who did not achieve a research-derived minimum passing score (MPS) on each ACLS problem had more deliberate practice and were retested until the MPS was reached.
PARTICIPANTS
Forty-one PGY-2 internal medicine residents in a university-affiliated program.
MEASUREMENTS
Observational checklists based on American Heart Association (AHA) guidelines with interrater and internal consistency reliability estimates; deliberate practice time needed for residents to achieve minimum competency standards; demographics; United States Medical Licensing Examination Step 1 and Step 2 scores; and resident ratings of program quality and utility.
RESULTS
Performance improved significantly after simulator training. All residents met or exceeded the mastery competency standard. The amount of practice time needed to reach the MPS was a powerful (negative) predictor of posttest performance. The education program was rated highly.
CONCLUSIONS
A curriculum featuring deliberate practice dramatically increased the skills of residents in ACLS scenarios. Residents needed different amounts of training time to achieve minimum competency standards. Residents enjoy training, evaluation, and feedback in a simulated clinical environment. This mastery learning program and other competency-based efforts illustrate outcome-based medical education that is now prominent in accreditation reform of residency education.
doi:10.1111/j.1525-1497.2006.00341.x
PMCID: PMC1828088  PMID: 16637824
mastery learning; medical simulation; residency education
24.  A National Survey on the Current Status of General Internal Medicine Residency Education in Geriatric Medicine 
OBJECTIVES
The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs.
DESIGN, SETTING, PARTICIPANTS
An original survey was mailed to all the GIM residency directors in the United States (N = 390).
RESULTS
A 53% response rate was achieved (n = 206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education.
CONCLUSIONS
A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.
doi:10.1046/j.1525-1497.2003.20906.x
PMCID: PMC1494913  PMID: 12950475
geriatric medicine education; general internal medicine; graduate medical education
25.  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

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