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1.  Demographic and Work-Life Study of Chief Residents: A Survey of the Program Directors in Internal Medicine Residency Programs in the United States 
Chief residents play a crucial role in internal medicine residency programs in administration, academics, team building, and coordination between residents and faculty. The work-life and demographic characteristics of chief residents has not been documented.
To delineate the demographics and day-to-day activities of chief residents.
Design, Setting, and Participants
The Survey Committee of the Association of Program Directors in Internal Medicine (APDIM) developed a Web-based questionnaire. A link was sent in November 2006 by e-mail to 381 member programs (98%). Data collection ended in April 2007.
Data collected include the number of chief residents per residency, the ratio of chief residents per resident, demographics, and information on salary/benefits, training and mentoring, and work life.
The response rate was 62% (N  =  236). There was a mean of 2.5 chief residents per program, and on average there was 1 chief resident for 17.3 residents. Of the chief residents, 40% were women, 38% international medical graduates, and 11% minorities. Community-based programs had a higher percentage of postgraduate year 3 (PGY-3)–level chief residents compared to university-based programs (22% versus 8%; P  =  .02). Mean annual salary was $60 000, and the added value of benefits was $21 000. Chief residents frequently supplement their salaries through moonlighting. The majority of formal training occurs by attending APDIM meetings. Forty-one percent of programs assign academic rank to chief residents.
Most programs have at least 2 chief residents and expect them to perform administrative functions, such as organizing conferences. Most programs evaluate chief residents regularly in administration, teaching, and clinical skills.
PMCID: PMC2931204  PMID: 21975723
2.  Clinician-Educators and General Internal Medicine Fellowships 
PMCID: PMC1496971  PMID: 9669576
3.  The State of Evaluation in Internal Medicine Residency 
Journal of General Internal Medicine  2008;23(7):1010-1015.
There are no nationwide data on the methods residency programs are using to assess trainee competence. The Accreditation Council for Graduate Medical Education (ACGME) has recommended tools that programs can use to evaluate their trainees. It is unknown if programs are adhering to these recommendations.
To describe evaluation methods used by our nation’s internal medicine residency programs and assess adherence to ACGME methodological recommendations for evaluation.
Nationwide survey.
All internal medicine programs registered with the Association of Program Directors of Internal Medicine (APDIM).
Descriptive statistics of programs and tools used to evaluate competence; compliance with ACGME recommended evaluative methods.
The response rate was 70%. Programs were using an average of 4.2–6.0 tools to evaluate their trainees with heavy reliance on rating forms. Direct observation and practice and data-based tools were used much less frequently. Most programs were using at least 1 of the Accreditation Council for Graduate Medical Education (ACGME)’s “most desirable” methods of evaluation for all 6 measures of trainee competence. These programs had higher support staff to resident ratios than programs using less desirable evaluative methods.
Residency programs are using a large number and variety of tools for evaluating the competence of their trainees. Most are complying with ACGME recommended methods of evaluation especially if the support staff to resident ratio is high.
PMCID: PMC2517950  PMID: 18612734
graduate medical education; residency; ACGME; competency
4.  Personal Growth During Internship: A Qualitative Analysis of Interns' Responses to Key Questions 
During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship.
Prospective qualitative study conducted over the course of internship.
Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs.
Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns' writings to identify triggers, facilitators, and barriers related to personal growth.
Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs.
Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns' core values especially in association with powerful triggers.
PMCID: PMC1924625  PMID: 16808737
graduate medical education; personal growth; qualitative research
5.  Perceived, Actual, and Desired Knowledge Regarding Medicare Billing and Reimbursement 
Economics and reimbursement have become a daily part of practicing physicians' lives. Yet, few internal medicine (IM) programs have offered formal curricula during residency about practice management or economics.
To determine perceived, desired, and actual knowledge of Medicare billing and reimbursement among residents compared with community-based General Internists.
Cross-sectional needs assessment survey of community and university-based second-year IM residents from 4 geographic regions of the United States.
One hundred and thirty-three second-year IM residents completed the questionnaire. Residents rated their level of knowledge about Medicare as a 2.0 (SD = 0.9) on a Likert scale (1 = “very low,” 5 = “very high”). Residents agreed that Medicare reimbursement should be taught in residency with a score of 4.0 (SD = 1.1; 1 = “strongly disagree,” 5 = “strongly agree” SD = 1.1). On the knowledge assessment portion of the questionnaire, residents scored significantly lower than a group of general IM physicians who completed the same questions (percent correct = 41.8% vs 59.0%, P<.001). Residents' scores correlated with their self-assessed level of knowledge (P = .007).
Our study demonstrates that second year IM residents feel they have a low level of knowledge regarding outpatient Medicare billing, and have a lower test score than practicing Internists to back up their feelings. The residents also strongly agree that they do not receive enough education about Medicare reimbursement, and believe it should be a requirement in residency training.
PMCID: PMC1484800  PMID: 16704389
internship and residency; curriculum; medicare; needs assessment
6.  A Time to be Promoted 
The study's objectives were to determine (1) the rate at which department of medicine faculty in the United States are promoted, (2) if clinician-educators (CEs) are promoted to Associate Professor at the same rate as clinician-investigators (CIs), and (3) the variables that predict promotion.
The Prospective Study of Promotion in Academia was a part-retrospective, part-prospective (from 2000 to 2003) cohort study. Six-hundred and four Internal Medicine junior faculty across the United States who had been registered as new appointees with the Association of American Medical Colleges in 1995 were invited to participate. Twenty-one percent of these had already left their institution when the study began. One hundred and eighty-three Internal Medicine faculty from 87 institutions in 35 states enrolled. The main outcome measure was the time from appointment as Assistant Professor to promotion to Associate Professor.
Follow-up was complete for all 183 faculty. Among the faculty that achieved promotion, the estimated median time to promotion was 6.0 years (95% Conf. Int.=5.8 to 6.2). The unadjusted sixth-year promotion rate for CEs was 16%, while for CIs it was 26% (P=.002). Independent negative predictors of promotion included low amount of research time (Hazard Ratio [HR] =0.3, 95% Conf. Int.=0.2 to 0.5), having a manuscript review service (HR=0.4, 95% Conf. Int.=0.2 to 0.7), never meeting with Chairman/Chief about promotion (HR=0.4, 95% Conf. Int.=0.2 to 0.7), low job satisfaction (HR=0.5, 95% Conf. Int.=0.3 to 0.9), and working in the Northeast (HR=0.6, 95% Conf. Int.=0.4 to 1.1). Positive predictors included making between $130 and $149,000 per year (HR=1.9, 95% Conf. Int.=1.1 to 3.4), working more than 60 h/wk (HR=1.9, 95% Conf. Int.=1.1 to 3.0), having a career mentor available (HR=1.8, 95% Conf. Int.=1.1 to 2.9), and having access to a grant office (HR=1.6, 95% Conf. Int.=1.0 to 2.6).
CEs and CIs appear to be promoted at different rates. The characteristics that are independently associated with earlier promotion may be helpful for institutions and individual faculty that are committed to achieving promotion efficiently.
PMCID: PMC1484667  PMID: 16336619
promotion; motivation; academic medicine
7.  Incidence of Venous Thromboembolic Events Among Nursing Home Residents 
Chronic care facility stay has been shown to be an independent risk factor for venous thromboembolism. Review of the literature, however, reveals a paucity of data addressing the issue of venous thromboembolism in nursing home residents. The purpose of this study was to determine the incidence of venous thromboembolic events among nursing home residents. A retrospective cohort study was derived from data compiled in the State of Kansas Minimum Data Set (MDS) for nursing home residents from July 1, 1997 to July 1, 1998. A total of 18,661 residents (median age, 85 years, 74% female, 95% white) satisfied the study criteria. The outcome measures of the primary endpoint—development of a venous thromboembolic event (VTE)—were obtained from the MDS quarterly health assessments and the Medicare ICD-9 codes. We determined the incidence of VTE among nursing home residents as 1.30 events per 100 person-years of observation.
PMCID: PMC1494943  PMID: 14687280
incidence; nursing homes; venous thromboembolism
8.  Looking Forward to Promotion 
To determine what clinician-educators consider important for promotion, and what support they find helpful and useful for success.
Cross-sectional study.
Eighty academic medical centers in the United States.
One hundred eighty-three participants of the Prospective Study of Promotion in Academia comprising assistant professors in departments of medicine from 80 different medical schools in 35 states.
Differences between clinician-educators' and clinician-investigators' work activities, promotion preparedness, and faculty support needs.
One hundred seven (58%) of the faculty were clinician-educators (CEs), and 63 (34%) were clinician-investigators (CIs); the remaining 13 fit neither category. Participants had been in their faculty position for 4.7 years. Ninety-eight percent of CIs reported a publication expectation for promotion, and 75% of CEs also reported such an expectation. More CIs had career mentors available than CEs (68% vs 32%, P < .001). Seventy-nine percent of CIs indicated >10% protected scholarly work time, compared to only 35% of CEs (P < .001). Fifty-three percent of CIs as compared to 32% of CEs (P < .01) meet more often than yearly with their chief/chair for performance review, and more CIs have seen written promotion guidelines (72% vs 51%, P < .01). Clinician educators believed out of 11 job performance areas, research, written scholarship, and reputation were the 3 most important factors that would determine the success of their application for promotion. Both CEs and CIs sense that CIs are more likely get promoted (82% vs 79%).
Clinician educators are less familiar with promotion guidelines, meet less often with superiors for performance review, and have less protected time than CI colleagues. There is dissonance between CEs' beliefs and previously published data from promotion committee chairs in the importance given to specific aspects of job performance.
PMCID: PMC1494911  PMID: 12950478
academic medical centers; mentors; medical faculty; cohort studies; socioeconomic factors; peer review
9.  Promotion Criteria for Clinician-educators 
Department of medicine chairs have a critical role in the promotion of clinician-educators. Our primary objective was to determine how chairs viewed: 1) the importance of specific areas of clinician-educator performance in promotion decisions; and 2) the importance and quality of information on available measures of performance. A secondary objective was to compare the views of department chairs with those of promotion and tenure committee chairs.
In October 1997, a questionnaire was mailed to all department chairs in the United States and Canada asking them to rate the importance of 11 areas of clinician-educators' performance in evaluating them for promotion. We also asked them to rate 36 measures of performance. We compared their responses to a similar 1996 survey administered to promotion committee chairs.
One hundred fourteen of 139 department chairs (82%) responded to the survey. When considering a clinician-educator for promotion, department chairs view teaching skills and clinical skills as the most important areas of performance, as did the promotion committee chairs. Of the measures used to evaluate teaching performance, teaching awards were considered most important and rated as a high-quality measure. When evaluating a clinician-educator's clinical skills, peer and trainee evaluation were considered as the most important measures of performance, but these were rated low in quality. Patient satisfaction and objective outcome measures also were viewed as important measures that needed improvement. Promotion committee chairs placed more emphasis on productivity in publications and external grant support when compared to department chairs.
It is reassuring that both department chairs and promotion committee chairs value teaching skills and clinical skills as the most important areas of a clinician-educator's performance when evaluating for promotion. However, differences in opinion regarding the importance of several performance measures and the need for improved quality measures may represent barriers to the timely promotion of clinician-educators.
PMCID: PMC1494922  PMID: 12950479
promotion criteria; clinician-educators; academic advancement
10.  Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease 
To develop a meta-analysis to determine the effectiveness of rehabilitation in patients with chronic obstructive pulmonary disease (COPD).
medline, cinhal, and Cochrane Library searches for trials of rehabilitation for COPD patients. Abstracts presented at national meetings and the reference lists of pertinent articles were reviewed.
Studies were included if: trials were randomized; patients were symptomatic with forced expiratory volume in one second (FEV1) <70% or FEV1 divided by forced vital capacity (FEV1/FVC) <70% predicted; rehabilitation group received at least 4 weeks of rehabilitation; control group received no rehabilitation; and outcome measures included exercise capacity or shortness of breath. We identified 69 trials, of which 20 trials were included in the final analysis.
Effect of rehabilitation was calculated as the standardized effect size (ES) using random effects estimation techniques.
The rehabilitation groups of 20 trials (979 patients) did significantly better than control groups on walking test (ES = 0.71; 95% confidence interval [95% CI], 0.43 to 0.99). The rehabilitation groups of 12 trials (723 patients) that used the Chronic Respiratory Disease Questionnaire had less shortness of breath than did the control groups (ES = 0.62; 95% CI, 0.35 to 0.89). Trials that used respiratory muscle training only showed no significant difference between rehabilitation and control groups, whereas trials that used at least lower-extremity training showed that rehabilitation groups did significantly better than control groups on walking test and shortness of breath. Trials that included severe COPD patients showed that rehabilitation groups did significantly better than control groups only when the rehabilitation programs were 6 months or longer. Trials that included mild/moderate COPD patients showed that rehabilitation groups did significantly better than control groups with both short- and long-term rehabilitation programs.
COPD patients who receive rehabilitation have a better exercise capacity and they experience less shortness of breath than patients who do not receive rehabilitation. COPD patients may benefit from rehabilitation programs that include at least lower-extremity training. Patients with mild/moderate COPD benefit from short- and long-term rehabilitation, whereas patients with severe COPD may benefit from rehabilitation programs of at least 6 months.
PMCID: PMC1494836  PMID: 12648254
rehabilitation; obstructive lung disease; shortness of breath; exercise; review
11.  Evidence-based Medicine Knowledge, Attitudes, and Skills of Community Faculty 
As medical schools turn to community physicians for ambulatory care teaching, assessing the preparation of these faculty in principles of evidence-based medicine (EBM) becomes important.
To determine the knowledge and attitudes of community faculty concerning EBM and their use of EBM in patient care and teaching.
Cross-sectional survey conducted from January to March of 2000.
A clinical campus of a state medical school; a midwestern city of a half-million people with demographics close to national means.
Comparisons of community faculty with full-time faculty in perceived importance and understanding of EBM (5-point scale), knowledge of EBM, and use of EBM in patient care and teaching.
Responses were obtained from 63% (177) of eligible community faculty and 71% (22) of full-time faculty. Community faculty considered EBM skills to be less important for daily practice than did full-time faculty (3.1 vs 4.0; P < .01). Primary care community faculty were less confident of their EBM knowledge than were subspecialty community or full-time faculty (2.9 vs 3.3 vs 3.6; P < .01). Objective measures of EBM knowledge showed primary care and subspecialty community faculty about equal and significantly below full-time faculty (P < .01). Thirty-three percent of community faculty versus 5% of full-time faculty do not incorporate EBM principles into their teaching (P < .01).
Community faculty are not as equipped or motivated to incorporate EBM into their clinical teaching as are full-time faculty. Faculty development programs for community faculty should feature how to use and teach basic EBM concepts.
PMCID: PMC1495085  PMID: 12213145
evidence-based medicine; continuing medical education; ambulatory care; medical education, graduate and undergraduate; community-based teachers
12.  Health Information in Material Safety Data Sheets for a Chemical Which Causes Asthma 
To assess the quality of health information on material safety data sheets (MSDS) for a workplace chemical that is well known to cause or exacerbate asthma (toluene diisocyanate, TDI).
We reviewed a random sample of 61 MSDSs for TDI products produced by 30 manufacturers.
Two physicians independently abstracted data from each MSDS onto a standardized audit form. One manufacturer provided no language about any respiratory effects of TDI exposure. Asthma was listed as a potential health effect by only 15 of the 30 manufacturers (50%). Listing asthma in the MSDS was associated with higher toluene diisocyanate concentrations in the product (P < .042). Allergic or sensitizing respiratory reactions were listed by 21 manufacturers (70%).
Many MSDSs for toluene diisocyanate do not communicate clearly that exposure can cause or exacerbate asthma. This suggests that physicians should not rely on the MSDS for information about health effects of this chemical.
PMCID: PMC1495175  PMID: 11251759
asthmas; MSDSs; chemical exposure

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