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1.  A Clinical Process Change and Educational Intervention to Reduce the Use of Unnecessary Preoperative Tests 
Internal medicine residents receive limited training on how to be good stewards of health care dollars while preserving high-quality care.
We implemented a clinical process change and an educational intervention focused on the appropriate use of preoperative diagnostic testing by residents at a Veterans Administration (VA) medical center.
The clinical process change consisted of reducing routine ordering of preoperative tests in the absence of specific indications. Residents received a short didactic session, which included algorithms for determining the appropriate use of perioperative diagnostic testing. One outcome was the average cost savings on preoperative testing for a continuous cohort of patients referred for elective knee or hip surgery. Resident knowledge and confidence prior to and after the intervention was measured by pre- and posttest.
The mean cost of preoperative testing decreased from $74 to $28 per patient after the dual intervention (P < .001). The bulk of cost savings came from elimination of unnecessary blood and urine tests, as well as reduced numbers of electrocardiograms and chest radiographs. Among residents who completed the pretest and posttest, the mean score on the pretest was 54%, compared with 80% on the posttest (P  =  .027). Following the educational intervention, 70% of residents stated they felt “very comfortable” ordering appropriate preoperative testing (P  =  .006).
This initiative required few resources, and it simultaneously improved the educational experience for residents and reduced costs. Other institutions may be able to adopt or adapt this intervention to reduce unnecessary diagnostic expenditures.
PMCID: PMC4477571  PMID: 26140127
2.  Early Feedback on the Use of the Internal Medicine Reporting Milestones in Assessment of Resident Performance 
The educational milestones were designed as a criterion-based framework for assessing resident progression on the 6 Accreditation Council for Graduate Medical Education competencies.
We obtained feedback on, and assessed the construct validity and perceived feasibility and utility of, draft Internal Medicine Milestones for Patient Care and Systems-Based Practice.
All participants in our mixed-methods study were members of competency committees in internal medicine residency programs. An initial survey assessed participant and program demographics; focus groups obtained feedback on the draft milestones and explored their perceived utility in resident assessment, and an exit survey elicited input on the value of the draft milestones in resident assessment. Surveys were tabulated using descriptive statistics. Conventional content analysis method was used to assess the focus group data.
Thirty-four participants from 17 programs completed surveys and participated in 1 of 6 focus groups. Overall, the milestones were perceived as useful in formative and summative assessment of residents. Participants raised concerns about the length and complexity of some draft milestones and suggested specific changes. The focus groups also identified a need for faculty development. In the exit survey, most participants agreed that the Patient Care and Systems-Based Practice Milestones would help competency committees assess trainee progress toward independent practice.
Draft reporting milestones for 2 competencies demonstrated significant construct validity in both the content and response process and the perceived utility for the assessment of resident performance. To ensure success, additional feedback from the internal medicine community and faculty development will be necessary.
PMCID: PMC3771173  PMID: 24404307
3.  Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training 
The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice.
In November 2007, the American Board of Internal Medicine (ABIM) and the ACGME initiated the development of milestones for internal medicine residency training. ABIM and ACGME convened a 33-member milestones task force made up of program directors, experts in evaluation and quality, and representatives of internal medicine stakeholder organizations. This article reports on the development process and the resulting list of proposed milestones for each ACGME competency.
The task force adopted the Dreyfus model of skill acquisition as a framework the internal medicine milestones, and calibrated the milestones with the expectation that residents achieve, at a minimum, the “competency” level in the 5-step progression by the completion of residency. The task force also developed general recommendations for strategies to evaluate the milestones.
The milestones resulting from this effort will promote competency-based resident education in internal medicine, and will allow program directors to track the progress of residents and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking, and assist remediation by facilitating identification of specific deficits. Finally, by making explicit the profession's expectations for graduates and providing a degree of national standardization in evaluation, the milestones may improve public accountability for residency training.
PMCID: PMC2931179  PMID: 21975701
4.  Resident Identification of Learning Objectives after Performing Self-assessment based upon the ACGME Core Competencies 
Journal of General Internal Medicine  2008;23(7):1024-1027.
Self-assessment is increasingly being incorporated into competency evaluation in residency training. Little research has investigated the characteristics of residents’ learning objectives and action plans after self-assessment.
To explore the frequency and specificity of residents’ learning objectives and action plans after completing either a highly or minimally structured self-assessment.
Internal Medicine residents (N = 90) were randomized to complete a highly or minimally structured self-assessment instrument based on the Accreditation Council for Graduate Medical Education Core Competencies. All residents then identified learning objectives and action plans.
Learning objectives and action plans were analyzed for content. Differences in specificity and content related to form, gender, and training level were assessed.
Seventy-six residents (84% response rate) identified 178 learning objectives. Objectives were general (79%), most often focused on medical knowledge (40%), and were not related to the type of form completed (p > 0.01). “Reading more” was the most common action plan.
Residents commonly identify general learning objectives focusing on medical knowledge regardless of the structure of the self-assessment form. Tools and processes that further facilitate self-assessment should be identified.
PMCID: PMC2517926  PMID: 18612737
self-assessment; reflective practice; graduate medical education

Results 1-4 (4)