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1.  Functional Neuroimaging Correlates of Burnout among Internal Medicine Residents and Faculty Members 
Burnout is prevalent in residency training and practice and is linked to medical error and suboptimal patient care. However, little is known about how burnout affects clinical reasoning, which is essential to safe and effective care. The aim of this study was to examine how burnout modulates brain activity during clinical reasoning in physicians. Using functional Magnetic Resonance Imaging (fMRI), brain activity was assessed in internal medicine residents (n = 10) and board-certified internists (faculty, n = 17) from the Uniformed Services University (USUHS) while they answered and reflected upon United States Medical Licensing Examination and American Board of Internal Medicine multiple-choice questions. Participants also completed a validated two-item burnout scale, which includes an item assessing emotional exhaustion and an item assessing depersonalization. Whole brain covariate analysis was used to examine blood-oxygen-level-dependent (BOLD) signal during answering and reflecting upon clinical problems with respect to burnout scores. Higher depersonalization scores were associated with less BOLD signal in the right dorsolateral prefrontal cortex and middle frontal gyrus during reflecting on clinical problems and less BOLD signal in the bilateral precuneus while answering clinical problems in residents. Higher emotional exhaustion scores were associated with more right posterior cingulate cortex and middle frontal gyrus BOLD signal in residents. Examination of faculty revealed no significant influence of burnout on brain activity. Residents appear to be more susceptible to burnout effects on clinical reasoning, which may indicate that residents may need both cognitive and emotional support to improve quality of life and to optimize performance and learning. These results inform our understanding of mental stress, cognitive control as well as cognitive load theory.
doi:10.3389/fpsyt.2013.00131
PMCID: PMC3796712  PMID: 24133462
expertise; burnout; clinical reasoning; cognitive load; fMRI
2.  Expectations for Oral Case Presentations for Clinical Clerks: Opinions of Internal Medicine Clerkship Directors 
BACKGROUND
Little is known about the expectations of undergraduate internal medicine educators for oral case presentations (OCPs).
OBJECTIVE
We surveyed undergraduate internal medicine educational leaders to determine the degree to which they share the same expectations for oral case presentations.
SUBJECTS
Participants were institutional members of the Clerkship Directors of Internal Medicine (CDIM).
DESIGN
We included 20 questions relating to the OCP within the CDIM annual survey of its institutional members. We asked about the relative importance of specific attributes in a third-year medical student OCP of a new patient as well as its expected length. Percentage of respondents rating attributes as “very important” were compared using chi-squared analysis.
RESULTS
Survey response rate was 82/110 (75%). Some attributes were more often considered very important than others ( < .001). Eight items, including aspects of the history of present illness, organization, a directed physical exam, and a prioritized assessment and plan focused on the most important problems, were rated as very important by >50% of respondents. Respondents expected the OCP to last a median of 7 minutes.
CONCLUSIONS
Undergraduate internal medicine education leaders from a geographically diverse group of North American medical schools share common expectations for OCPs which can guide instruction and evaluation of this skill.
doi:10.1007/s11606-008-0900-x
PMCID: PMC2642568  PMID: 19139965
education leaders; oral case presentations; clinical clerks
4.  Internal Medicine Clerkship Directors’ Perceptions About Student Interest in Internal Medicine Careers 
Journal of General Internal Medicine  2008;23(7):1101-1104.
Background
Experienced medical student educators may have insight into the reasons for declining interest in internal medicine (IM) careers, particularly general IM.
Objective
To identify factors that, according to IM clerkship directors, influence students’ decisions for specialty training in IM.
Design
Cross-sectional national survey.
Participants
One hundred ten institutional members of Clerkship Directors in IM.
Measurements
Frequency counts and percentages were reported for descriptive features of clerkships, residency match results, and clerkship directors’ perceptions of factors influencing IM career choice at participating schools. Perceptions were rated on a five-point scale (1 = very much pushes students away from IM careers; 5 = very much attracts students toward IM careers).
Results
Survey response rate was 83/110 (76%); 80 answered IM career-choice questions. Clerkship directors identified three educational items attracting students to IM careers: quality of IM faculty (mean score 4.3, SD = 0.56) and IM rotation (4.1, SD = 0.67), and experiences with IM residents (3.9, SD = 0.94). Items felt most strongly to push students away from IM careers were current practice environment for internists (mean score 2.1, SD = 0.94), income (2.1, SD = 1.08), medical school debt (2.3, SD = 0.89), and work hours in IM (2.4, SD = 1.05). Factor analysis indicated three factors explaining students’ career choices: value/prestige of IM, clerkship experience, and exposure to internists.
Conclusions
IM clerkship directors believe that IM clerkship experiences attract students toward IM, whereas the income and lifestyle for practicing internists dissuade them. These results suggest that interventions to enhance the practice environment for IM could increase student interest in the field.
doi:10.1007/s11606-008-0640-y
PMCID: PMC2517945  PMID: 18612752
career choice; education, medical, undergraduate; medical students, workforce
5.  Identifying Medical Students Likely to Exhibit Poor Professionalism and Knowledge During Internship 
Journal of General Internal Medicine  2007;22(12):1711-1717.
CONTEXT
Identifying medical students who will perform poorly during residency is difficult.
OBJECTIVE
Determine whether commonly available data predicts low performance ratings during internship by residency program directors.
DESIGN
Prospective cohort involving medical school data from graduates of the Uniformed Services University (USU), surveys about experiences at USU, and ratings of their performance during internship by their program directors.
SETTING
Uniformed Services University.
PARTICIPANTS
One thousand sixty-nine graduates between 1993 and 2002.
MAIN OUTCOME MEASURE(S)
Residency program directors completed an 18-item survey assessing intern performance. Factor analysis of these items collapsed to 2 domains: knowledge and professionalism. These domains were scored and performance dichotomized at the 10th percentile.
RESULTS
Many variables showed a univariate relationship with ratings in the bottom 10% of both domains. Multivariable logistic regression modeling revealed that grades earned during the third year predicted low ratings in both knowledge (odds ratio [OR] = 4.9; 95%CI = 2.7–9.2) and professionalism (OR = 7.3; 95%CI = 4.1–13.0). USMLE step 1 scores (OR = 1.03; 95%CI = 1.01–1.05) predicted knowledge but not professionalism. The remaining variables were not independently predictive of performance ratings. The predictive ability for the knowledge and professionalism models was modest (respective area under ROC curves = 0.735 and 0.725).
CONCLUSIONS
A strong association exists between the third year GPA and internship ratings by program directors in professionalism and knowledge. In combination with third year grades, either the USMLE step 1 or step 2 scores predict poor knowledge ratings. Despite a wealth of available markers and a large data set, predicting poor performance during internship remains difficult.
doi:10.1007/s11606-007-0405-z
PMCID: PMC2219838  PMID: 17952512
predicting; intern; professionalism; knowledge; medical education
6.  Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training? 
Background
Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Purposes
Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.
Methods
We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990–1999 for IM residency program graduates from a training program.
Results
Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4–3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.
Conclusions
Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM’s action to remove resident procedural competence from the monthly ABIM-MEF ratings.
doi:10.1007/s11606-006-0068-1
PMCID: PMC1824756  PMID: 17356968
procedural skills; Internal Medicine residency training program; ABIM evaluation
7.  Are Commonly Used Resident Measurements Associated with Procedural Skills in Internal Medicine Residency Training? 
Background
Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training.
Purposes
Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores.
Methods
We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990–1999 for IM residency program graduates from a training program.
Results
Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4–3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications.
Conclusions
Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM’s action to remove resident procedural competence from the monthly ABIM-MEF ratings.
doi:10.1007/s11606-006-0068-1
PMCID: PMC1824756  PMID: 17356968
procedural skills; Internal Medicine residency training program; ABIM evaluation

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