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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.

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.

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.

Background

Physician workforce projections by the Institute of Medicine require enhanced training in geriatrics for all primary care and subspecialty physicians. Defining essential geriatrics competencies for internal medicine and family medicine residents would improve training for primary care and subspecialty physicians. The objectives of this study were to (1) define essential geriatrics competencies common to internal medicine and family medicine residents that build on established national geriatrics competencies for medical students, are feasible within current residency programs, are assessable, and address the Accreditation Council for Graduate Medical Education competencies; and (2) involve key stakeholder organizations in their development and implementation.

Methods

Initial candidate competencies were defined through small group meetings and a survey of more than 100 experts, followed by detailed item review by 26 program directors and residency clinical educators from key professional organizations. Throughout, an 8-member working group made revisions to maintain consistency and compatibility among the competencies. Support and participation by key stakeholder organizations were secured throughout the project.

Results

The process identified 26 competencies in 7 domains: Medication Management; Cognitive, Affective, and Behavioral Health; Complex or Chronic Illness(es) in Older Adults; Palliative and End-of-Life Care; Hospital Patient Safety; Transitions of Care; and Ambulatory Care. The competencies map directly onto the medical student geriatric competencies and the 6 Accreditation Council for Graduate Medical Education Competencies.

Conclusions

Through a consensus-building process that included leadership and members of key stakeholder organizations, a concise set of essential geriatrics competencies for internal medicine and family medicine residencies has been developed. These competencies are well aligned with concerns for residency training raised in a recent Medicare Payment Advisory Commission report to Congress. Work is underway through stakeholder organizations to disseminate and assess the competencies among internal medicine and family medicine residency programs.

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.

A review of the literature and the experience of a residency program in internal medicine indicate that house officers have special problems during training. Some are shared by all residents, whereas others are unique to certain groups. These problems are caused by historical and cultural factors that have led to the current structure of many residency programs and often interfere with the parallel development of professional, personal and family growth. Program directors and chiefs of service need to be flexible and humane and should negotiate clear expectations with house staff to allow efficient functioning of the residency program and insightful personal growth.

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.

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.

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.

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.

INTRODUCTION

Governing bodies for medical education recommend that spirituality and medicine be incorporated into training.

AIM

To pilot a workshop on spirituality and medicine on a convenience sample of preclinical medical students and internal medicine residents and determine whether content was relevant to learners at different levels, whether preliminary evaluation was promising, and to generate hypotheses for future research.

SETTING

Private medical school and university primary care internal medicine residency program, both in the Northeast.

CURRICULUM DESCRIPTION

The authors designed and implemented a required 2-hour workshop for all second-year medical students and a separate required 1.5-hour workshop for all primary care internal medicine house staff. The workshops used multiple educational strategies including lecture, discussion, and role-play to address educational objectives.

PROGRAM EVALUATION

Learners completed optional, anonymous pre and postworkshop surveys with six 5-point Likert-rated statements and space to cite the most useful part of the curriculum and their remaining questions. One hundred and thirty-seven learners participated and 100 completed both surveys. Medical students and residents had increased (all P≤.002): agreement regarding the appropriateness of inquiring about spiritual and religious beliefs in the medical encounter, their perceived competence in taking a spiritual history, and their perceived knowledge of available pastoral care resources. Medical students, but not residents, had an increase in their perceived comfort in working with hospital chaplains.

DISCUSSION

A brief pilot workshop on spirituality and medicine had a modest effect in improving attitudes and perceived competence of both medical students and residents.

Context:

Various consensus and position statements recommend a multifaceted approach when diagnosing a possible concussion. The effectiveness of these materials depends largely on their content being disseminated to educators and to those in the clinical setting.

Objective:

To identify the concussion management methods and guidelines currently taught in the athletic training classroom and clinical settings and to track the dissemination of the Vienna guidelines throughout the educational curriculum.

Design:

A 17-question Internet survey.

Setting:

A Web link was e-mailed to the program directors and certified athletic trainers holding educational positions in athletic training at 300 accredited programs in the United States.

Patients or Other Participants:

513 program directors and athletic trainers.

Main Outcome Measure(s):

Survey questions addressed education level, years of certification, employment setting, concussion assessment and return-to-play guidelines used in the clinical setting and the classroom, and clinical and teaching preferences for existing position statements and concussion grading systems. The Vienna guidelines' “simple” and “complex” definitions of concussions were provided with the return-to-play stepwise approach.

Results:

The National Athletic Trainers' Association position statement was the most widely used method of assessing, managing (61%), and making return-to-play decisions (47%) among participants. More than half of participants (66%) had never heard of the Vienna guidelines. After reading the Vienna guidelines' definitions and return-to-play criteria, nearly three-fourths of participants agreed with them. In addition, 68% said that they would use them, and 84% reported that they would teach them to students.

Conclusions:

The majority of program directors and certified athletic trainers used a multidimensional approach to assess and manage a concussion. The National Athletic Trainers' Association position statement and Vienna guidelines were underused in both the classroom and clinical settings.

Background

In the United States, the Accreditation Council of graduate medical education (ACGME) requires all accredited Internal medicine residency training programs to facilitate resident scholarly activities. However, clinical experience and medical education still remain the main focus of graduate medical education in many Internal Medicine (IM) residency-training programs. Left to design the structure, process and outcome evaluation of the ACGME research requirement, residency-training programs are faced with numerous barriers. Many residency programs report having been cited by the ACGME residency review committee in IM for lack of scholarly activity by residents.

Methods

We would like to share our experience at Lincoln Hospital, an affiliate of Weill Medical College Cornell University New York, in designing and implementing a successful structured research curriculum based on ACGME competencies taught during a dedicated "research rotation".

Results

Since the inception of the research rotation in 2004, participation of our residents among scholarly activities has substantially increased. Our residents increasingly believe and appreciate that research is an integral component of residency training and essential for practice of medicine.

Conclusion

Internal medicine residents' outlook in research can be significantly improved using a research curriculum offered through a structured and dedicated research rotation. This is exemplified by the improvement noted in resident satisfaction, their participation in scholarly activities and resident research outcomes since the inception of the research rotation in our internal medicine training program.

To characterize evidence-based medicine (EBM) curricula in internal medicine residency programs, a written survey was mailed to 417 program directors of U.S. internal medicine residency programs. For programs offering a freestanding (dedicated curricular time) EBM curriculum, the survey inquired about its objectives, format, curricular time, attendance, faculty development, resources, and evaluation. All directors responded to questions regarding integrating EBM teaching into established educational venues. Of 417 program directors, 269 (65%) responded. Of these 269 programs, 99 (37%) offered a freestanding EBM curriculum. Among these, the most common objectives were performing critical appraisal (78%), searching for evidence (53%), posing a focused question (44%), and applying the evidence in decision making (35%). Although 97% of the programs provided medline, only 33% provided Best Evidence or the Cochrane Library. Evaluation was performed in 37% of the freestanding curricula. Considering all respondents, most programs reported efforts to integrate EBM teaching into established venues, including attending rounds (84%), resident report (82%), continuity clinic (76%), bedside rounds (68%), and emergency department (35%). However, only 51% to 64% of the programs provided on-site electronic information and 31% to 45% provided site-specific faculty development. One third of the training programs reported offering freestanding EBM curricula, which commonly targeted important EBM skills, utilized the residents' experiences, and employed an interactive format. Less than one half of the curricula, however, included curriculum evaluation, and many failed to provide important medical information sources. Most programs reported efforts to integrate EBM teaching, but many of these attempts lacked important structural elements.

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.

Introduction

Imperfect sign-out of patient information between providers has been shown to contribute to medical error, but there are no standardized curricula to teach sign-out skills. At our institution, we identified several deficiencies in skills and a lack of any existing training.

Aim

To develop a sign-out curriculum for medical house staff. Setting: Internal medicine residency program.

Program description

We developed a 1-h curriculum and implemented it in August of 2006 at three hospital sites. Teaching strategies included facilitated discussion, modeling, and observed individual practice with feedback. We emphasized interactive communication, a structured sign-out format summarized by an easy-to-remember mnemonic (“SIGNOUT”), consistent inclusion of key content items such as anticipatory guidance, and use of concrete language.

Program evaluation

We received 34 evaluations. The mean score for the course was 4.44 ± 0.61 on a 1–5 scale. Perceived usefulness of the structured oral communication format was 4.46 ± 0.78. Participants rated their comfort with providing oral sign-out significantly higher after the session than before (3.27 ± 1.0 before vs. 3.94 ± 0.90 after; p < .001).

Discussion

We developed an oral sign-out curriculum that was brief, structured, and well received by participants. Further study is necessary to determine the long-term impact of the curriculum.

Background

Current training practices and teaching methods for critical care medicine education during internal medicine residency have not been well described. This study explored critical care medicine education practices and environments for internal medicine residents in the United States.

Methods

A web-based survey recruited Pulmonary and Critical Care Medicine fellowship program directors involved with internal medicine residency programs at academic institutions in the United States.

Results

Of 127 accredited Pulmonary and Critical Care Medicine programs in 2007, 63 (50%) responded. Demographics of the intensive care units varied widely in size (7–52 beds), monthly admissions (25–300 patients), and presence of a “night float” (22%) or an admissions “cap” (34%). All programs used bedside teaching, and the majority used informal sessions (91%) or didactic lectures (75%). More time was spent on resident teaching in larger (≥20 bed) medical intensive care units, on weekdays, in programs with a night-float system, and in programs that suspended residents' primary care clinic duties during their intensive care unit rotation.

Conclusions

Although similar teaching methods were used within a wide range of training environments, there is no standardized approach to critical care medicine education for internal medicine residents. Some survey responses indicated a correlation with additional teaching time.

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.

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.

Background

The location of postgraduate medical training is shifting from teaching hospitals in urban centres to community practice in rural and remote settings. We were interested in knowing whether learning, as measured by summative examinations, was comparable between graduates who trained in urban centres and those who trained in remote and rural settings.

Methods

Family medicine training programs in Ontario were selected as a model of postgraduate medical training. The results of the 2 summative examinations — the Medical Council of Canada Qualifying Examination (MCCQE) Part II and the College of Family Physicians of Canada (CFPC) certification examination — for graduates of the programs at Ontario‚s 5 medical schools were compared with the results for graduates of the programs in Sudbury and Thunder Bay from 1994 to 1997. The comparability of these 2 cohorts at entry into training was evaluated using the results of their MCCQE Part I, completed just before the family medicine training.

Results

Between 1994 and 1997, 1013 graduates of family medicine programs (922 at the medical schools and 91 at the remote sites) completed the CFPC certification examination; a subset of 663 completed both the MCCQE Part I and the MCCQE Part II. The MCCQE Part I results for graduates in the remote programs did not differ significantly from those for graduates entering the programs in the medical schools (mean score 531.3 [standard deviation (SD) 69.8] and 521.8 [SD 74.4] respectively, p = 0.33). The MCCQE Part II results did not differ significantly between the 2 groups either (mean score 555.1 [SD 71.7] and 545.0 [SD 76.4] respectively, p = 0.32). Similarly, there were no consistent, significant differences in the results of the CFPC certification examination between the 2 groups.

Interpretation

In this model of postgraduate medical training, learning was comparable between trainees in urban family medicine programs and those in rural, community-based programs. The reasons why this outcome might be unexpected and the limitations on the generalizability of these results are discussed.

SGIM endoreses seven principles related to current thinking about internal medicine training: 1) internal medicine requires a full three years of residency training before subspecialization; 2) internal medicine residency programs must dramatically increase support for training in the ambulatory setting and offer equivalent opportunities for training in both inpatient and outpatient medicine; 3) in settings where adequate support and time are devoted to ambulatory training, the third year of residency could offer an opportunity to develop further expertise or mastery in a specific type or setting of care; 4) further certification in specific specialties within internal medicine requires the completion of an approved fellowship program; 5) areas of mastery in internal medicine can be demonstrated through modified board certification and recertification examinations; 6) certification processes throughout internal medicine should focus increasingly on demonstration of clinical competence through adherence to validated standards of care within and across practice settings; and 7) regardless of the setting in which General Internists practice, we should unite to promote the critical role that this specialty serves in patient care.

Background

Teaching the content of clinical practice guidelines (CPGs) is important to both clinical care and graduate medical education. The objective of this study was to determine the characteristics of curricula for teaching the content of CPGs in family medicine and internal medicine residency programs in the United States.

Methods

We surveyed the directors of family medicine and internal medicine residency programs in the United States. The questionnaire included questions about the characteristics of the teaching of CPGs: goals and objectives, educational activities, evaluation, aspects of CPGs that the program teaches, the methods of making texts of CPGs available to residents, and the major barriers to teaching CPGs.

Results

Of 434 programs responding (out of 839, 52%), 14% percent reported having written goals and objectives related to teaching CPGs. The most frequently taught aspect was the content of specific CPGs (76%). The top two educational strategies used were didactic sessions (76%) and journal clubs (64%). Auditing for adherence by residents was the primary evaluation strategy (44%), although 36% of program directors conducted no evaluation. Programs made texts of CPGs available to residents most commonly in the form of paper copies (54%) while the most important barrier was time constraints on faculty (56%).

Conclusion

Residency programs teach different aspects of CPGs to varying degrees, and the majority uses educational strategies not supported by research evidence.

OBJECTIVE: To survey all family medicine programs in Canada to determine how many positions for third-year training were available. DESIGN: The survey instrument contained questions to determine how many second-year positions and how many third-year positions each program had. Descriptions of third-year positions were requested. One survey question asked about the percentage of people with third-year training who initially went into rural or small-town practice. Last, each program director was asked for an opinion on how many third-year positions should be available for further training. SETTING: The survey was administered to the program directors of all 16 family medicine programs in Canada. PARTICIPANTS: Program directors of departments of family medicine. RESULTS: The survey indicated that the number of third-year positions was 18% of the number of second-year positions currently available (an increase over the 10% determined in Busing's study in 1989). The largest proportion of third-year training was in emergency medicine, and approximately 30% of third-year positions were primarily reserved for physicians intending to go into rural practice. Academic family physicians and residents are in fairly close agreement that third-year positions should represent 40% of second-year positions. CONCLUSION: A survey of Canadian family medicine programs during the 1996-1997 academic years indicated that third-year positions available for family medicine residents have almost doubled since Busing's original survey in 1989.

Objective: To determine the general status of sports medicine training in internal medicine residency programmes in the United States.

Methods: A cross sectional survey of the programme directors and chief residents of each of the 407 accredited internal medicine programmes listed in the 1999–2000 Graduate Medical Education Directory.

Results: The questionnaire was returned by 231 of 404 (57%) programme directors and 233 of 404 (58%) chief residents. A chief and director of the same programme (paired responses) replied from 144 of 404 (36%) programmes surveyed. A formal sports medicine curriculum was reported by 22.1% of programme directors. Programmes with a formal curriculum were 2.9 times more likely to offer any of the sports medicine educational experiences (p<0.0001; Cochran-Mantel-Haenszel). Programmes with block rotations were more likely to include all of the educational experiences surveyed than those without (p<0.002 for each; χ2 test). A total of 162 programmes included sports medicine as part of other rotations. Most programmes only included sports medicine as part of other rotations: 44.6% (103/231) of all programmes and 63.6% (103/162) of programmes with sports medicine as part of other rotations. Some 29.9% (69/231) of directors reported having an elective, and 3.9% (9/231) reported a required rotation. Almost a quarter (21.7%; 50/231) of directors reported that their residents received no clinical experience in sports medicine.

Conclusions: Little attention is given to the subject of sports medicine when internal medicine residency curricula are developed in the United States. Thus only a small percentage of American internal medicine residency programmes provide significant training in sports medicine.

Introduction

The increased demand for clinician-educators in academic medicine necessitates additional training in educational skills to prepare potential candidates for these positions. Although many teaching skills training programs for residents exist, there is a lack of reports in the literature evaluating similar programs during fellowship training.

Aim

To describe the implementation and evaluation of a unique program aimed at enhancing educational knowledge and teaching skills for subspecialty medicine fellows and chief residents.

Setting

Fellows as Clinician-Educators (FACE) program is a 1-year program open to fellows (and chief residents) in the Department of Internal Medicine at the University of Iowa.

Program Description

The course involves interactive monthly meetings held throughout the academic year and has provided training to 48 participants across 11 different subspecialty fellowships between 2004 and 2009.

Program Evaluation

FACE participants completed a 3-station Objective Structured Teaching Examination using standardized learners, which assessed participants' skills in giving feedback, outpatient precepting, and giving a mini-lecture. Based on reviews of station performance by 2 independent raters, fellows demonstrated statistically significant improvement on overall scores for 2 of the 3 cases. Participants self-assessed their knowledge and teaching skills prior to starting and after completing the program. Analyses of participants' retrospective preassessments and postassessments showed improved perceptions of competence after training.

Conclusion

The FACE program is a well-received intervention that objectively demonstrates improvement in participants' teaching skills. It offers a model approach to meeting important training skills needs of subspecialty medicine fellows and chief residents in a resource-effective manner.