Internal medicine residency training in Turkey

Medical school entrance depends on passing a central examination that is given annually by the National Selection and Placement Center. Undergraduate medical education takes 6 years. About 5000 students graduate from medical faculties annually. The central exam necessary for residency training is given by the National Selection and Placement Center. A Specialist Training Regulation regulates residency training. Internal medicine residency training takes 4 years and includes inpatient and outpatient care in wards and rotations. Residents prepare a dissertation that is used in the evaluation of residency competency. At the end of the residency period, residents who have been successful in previous evaluations take an oral exam followed by a written exam, which lead to their certification in internal medicine. Residents' scientific knowledge and skills are assessed by a jury consisting of five people, four from the same department and one from the equivalent department in another training institution. The title of specialist is granted after a certification exam given by training institutions and approved by the Ministry of Health. Internists are mainly employed in state hospitals, which are under the Ministry of Health. Subspecialty areas in internal medicine include gastroenterology, geriatrics, endocrinology, nephrology, hematology, rheumatology, immunology, allergology, and oncology. The training period for a subspecialty is 2 years. A substantial effort is being made all over the country to improve regulations and health care service delivery. These changes will also affect the residency training and manpower planning and employment of internists.     

National Study of Internal Medicine Manpower: XVII. Changes in the characteristics of internal medicine residents and their training programs, 1988-1989

The National Study of Internal Medicine Manpower (NaSimm) has been surveying program directors of internal medicine about their programs and residents for 13 years. The 1988-1989 survey results, when compared with the results for 1987-1988, show an increase in both the number of residency positions offered in internal medicine and the number of residents in internal medicine programs. Although the proportion of graduates from U.S. medical schools who choose internal medicine is not changing (34%), the proportion of U.S. medical school graduates who continue training in internal medicine after their first year is decreasing. The composition of the residents in internal medicine by medical school graduated is also changing. Almost 25% of the first-year residents (R1s) in internal medicine are now graduates of foreign medical schools (FMGs) compared with 14% in 1976. The proportion of first-year female residents in internal medicine has increased to 30%, whereas the proportion of both first-year blacks and Hispanics has remained constant at 5% each. In nearly 25% (109 of 440) of the residency programs, more than 50% of the R1s are FMGs. Hispanics, Asians, and blacks were found to be over-represented in the programs training larger proportions of FMGs. This over-representation is attributable, in part, to the fact that Hispanics and Asians may be FMGs. Training issues of concern to program directors continue to be the provision of ambulatory and primary care experiences and the scheduling of nights on call. The survey results show that many residency program directors have reported a reduction in the number of nights on call and an increase in the amount of time residents spend in ambulatory training.     

Complexity in Graduate Medical Education: A Collaborative Education Agenda for Internal Medicine and Geriatric Medicine

Internal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.     

National Study of Internal Medicine Manpower: XIX. Trends in internal medicine residency training programs.

The National Study of Internal Medicine Manpower (NaSIMM) reports on the results of its 1989-1990 census of residency programs. The results are integrated into an organizational model identifying inputs, process, outputs, and environment of medical training programs. The number of residents entering internal medicine continues to grow at a relatively rapid pace. This growth is largely accounted for by foreign citizens who are graduates of foreign medical schools (AFMGs). Residents are spending an increasing proportion of their time in ambulatory care settings, but, thus far, this ambulatory care training has occurred primarily in hospital clinics and emergency rooms. The proportion of a program's residents entering general internal medicine was found in a multiple regression analysis to be negatively associated with the number of subspecialty programs located in the training hospital, the percent of AFMG residents in the program, and the presence of a preliminary track in the program.     

Health care system chaos should spur innovation: summary of a report of the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The Society believes that the chaos and dysfunction that characterize today's medical care and the challenges facing general internal medicine should spur innovation. The task force proposed the following recommendations. Remaining true to its core values and competencies, general internal medicine should stay both broad and deep, ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care given by their teams, embrace changes in information systems, and aim to provide most of the care required by their patients. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency and provide comprehensive, ongoing care. General internal medicine residency training should provide both broad and deep medical knowledge as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification in generalist fields. Research should expand to include practice and operations management, developing more effective shared decision making and transparent medical records and promoting the close personal connection that both doctors and patients want. The task force believes that these changes will benefit patients and the public and reenergize general internal medicine.     

Medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group Survey on Factors Influencing Career Choice in Internal Medicine

OBJECTIVE: To determine the factors that attract students toward and push students away from a career in internal medicine. DESIGN: National survey of senior U.S. medical students using a stratified random cluster sampling of medical schools. PARTICIPANTS: The survey included 1650 U.S. senior students from 16 medical schools, of whom 1244 (76%) responded. MEASUREMENTS AND MAIN RESULTS: A survey instrument was developed and pilot tested at 17 medical schools. Twenty-four percent of the respondents to the final survey chose a career in general internal medicine (9%) or subspecialty internal medicine (15%). A career in internal medicine had been "seriously considered" by 608 respondents (50%) who finally chose a career other than internal medicine (the "switchers"). Compared with other specialties, internal medicine was perceived as being more stressful to residents, more demanding of time and workload as a career and a residency, and as an easier residency to enter. Internal medicine was also seen as providing less satisfaction for residents, having lower income potential, and allowing less leisure time. For the 608 switchers, the most important influences leading to their decision to switch were the type of patient seen in internal medicine (for example, chronically ill, alcohol and drug abusing patients) as well as dissatisfaction and stress among internal medicine residents. Factor analysis showed that three factors, "intellectual challenge of internal medicine," "primary care interests," and "the medicine clerkship" attracted students toward internal medicine, whereas three others, "taking care of chronically ill patients," "level of satisfaction among internists and medical residents," and "workload and stress" pushed students away from internal medicine. Factors pushing students away from internal medicine were significantly more negative with regard to a career in general as opposed to subspecialty internal medicine (P less than 0.001). CONCLUSION: Medical students have serious reservations about internal medicine as a career choice. Perceptions about the medical residency, the patients they expect to see, and the dissatisfaction among residents and internists are foremost in their thinking. Changes to improve the attractiveness of internal medicine should address these adverse perceptions while building on the positive influences identified by the respondents.     

National Study of Internal Medicine Manpower: XI. Internal medicine residency and fellowship training in the 1980s

The number of residents beginning training in internal medicine continued to increase slightly in 1985-86. However, the total number of residents in internal residency training decreased slightly from the previous year due to a decrease in the number of second- and third-year residents. The proportion of first-year residents who were foreign-trained physicians decreased from 21% to 20%, and the proportion of residents who finished training and went on to subspecialty training in 1985 decreased substantially to 56%. The number of physicians entering residency and fellowship training in internal medicine considerably exceeds the number projected by the Graduate Medical Education National Advisory Committee. In this article, we discuss implications of these trends for medical education and practice.     

National Study of Internal Medicine Manpower: X. Internal medicine residency and fellowship training: 1985 update

The number of medical school graduates entering internal medicine residency training was at an all-time high in 1984-85. Although the number of first-year residents who were foreign-trained physicians did not differ greatly from the 1983-84 census, the number of first-year residents who were U.S. medical school graduates was much higher than the previous year largely because the number of graduates from U.S. medical schools increased substantially in 1984. The number of internal medicine fellowship programs and the number of fellows in 1984-85 were also at an all-time high. Foreign-trained physicians represent 22% of those in residency training and 20% of those in fellowship training. Of every 100 who completed residency training, 61 went on to a first year of subspecialty fellowship training, a number up slightly from the previous year. The increasing numbers of residents and fellows being trained in internal medicine, combined with the preference for subspecialization and the substantial proportion of foreign-trained physicians being trained, are discussed against the background of pending legislation to reduce federal assistance for graduate medical education.     

National Study of Internal Medicine Manpower: XV. A decade of change in residency training in internal medicine

We report on trends in the characteristics of residency training programs in internal medicine from 1976 to 1988 and make some comparisons with other specialties. Internal medicine is faring less well in the residency match compared with other specialties than it did 10 years ago. It has also increased the number of residency positions offered more than other major specialties. A sizable proportion of first-year residency positions in internal medicine are not filled through the Match. Foreign medical graduates account for almost 50% of the first-year resident (R1) positions filled outside the Match. Programs most dependent on foreign medical graduates are in hospitals with limited medical school affiliation, smaller size, operated by churches or the Veterans Administration, and located in eastern states and large metropolitan areas. Despite concerns about quality and oversupply, almost 50% of the program directors expected to increase the size of their programs in 1988-1990. Residents are not being scheduled for fewer hours per week than they were 12 years ago but they are being scheduled for fewer nights. No trends were noted toward increased ambulatory care training sites away from the hospital campus.     

Alumni perspectives comparing a general internal medicine program and a traditional medicine program

Objective:To evaluate a primary care internal medicine curriculum, the authors surveyed four years (1983–1986) of graduates of the primary care and traditional internal medicine residency programs at their institution concerning the graduates’ preparation. Design:Mailed survey of alumni of a residency training program. Setting:Teaching hospital alumni. Subjects/methods:Of 91 alumni of an internal medicine training program for whom addresses had been found, 82 (90%) of the residents (20 primary care and 62 traditional) rated on a five-point Likert scale 82 items for both adequacy of preparation for practice and importance of training. These items were divided into five groups: traditional medical disciplines (e.g., cardiology), allied disciplines (e.g., orthopedics), areas related to medical practice (e.g., patient education), basic skills and knowledge (e.g., history and physical), and technical procedures. Main results:Primary care residents were more likely to see themselves as primary care physicians versus subspecialists (84% versus 45%). The primary care graduates felt significantly better prepared in the allied disciplines and in areas related to medical practice (p<0.01). There was no significant difference overall in perceptions of preparation in the traditional medical disciplines, basic skills and knowledge, and procedures. The same results were obtained when the authors looked only at graduates from the two programs who spent more than 50% of their time as primary care physicians versus subspecialists. There was no significant difference between the two groups in the perceived importances of these areas to current practice. Conclusions:These results suggest that the primary care curriculum has prepared residents in areas particularly relevant to primary care practice. Additionally, these individuals feel as well prepared as do their colleagues in the traditional medical disciplines, basic skills and knowledge, and procedural skills. Received from the Division of General Internal Medicine, Brown University Program in Medicine, and the Rhode Island Hospital, Providence, Rhode Island. Dr. Kiel is a Henry J. Kaiser Family Foundation Faculty Scholar in general internal medicine. Address correspondence and reprint requests to General Internal Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.     

Variation in Internal Medicine Residency Clinic Practices: Assessing Practice Environments and Quality of Care

Background  Few studies have systematically and rigorously examined the quality of care provided in educational practice sites. Objective  The objectives of this study were to (1) describe the patient population cared for by trainees in internal medicine residency clinics; (2) assess the quality of preventive cardiology care provided to these patients; (3) characterize the practice-based systems that currently exist in internal medicine residency clinics; and (4) examine the relationships between quality, practice-based systems, and features of the program: size, type of program, and presence of an electronic medical record. Design  This is a cross-sectional observational study. Setting  This study was conducted in 15 Internal Medicine residency programs (23 sites) throughout the USA. Participants  The participants included site champions at residency programs and 709 residents. Measurements  Abstracted charts provided data about patient demographics, coronary heart disease risk factors, processes of care, and clinical outcomes. Patients completed surveys regarding satisfaction. Site teams completed a practice systems survey. Results  Chart abstraction of 4,783 patients showed substantial variability across sites. On average, patients had between 3 and 4 of the 9 potential risk factors for coronary heart disease, and approximately 21% had at least 1 important barrier of care. Patients received an average of 57% (range, 30–77%) of the appropriate interventions. Reported satisfaction with care was high. Sites with an electronic medical record showed better overall information management (81% vs 27%) and better modes of communication (79% vs 43%). Conclusions  This study has provided insight into the current state of practice in residency sites including aspects of the practice environment and quality of preventive cardiology care delivered. Substantial heterogeneity among the training sites exists. Continuous measurement of the quality of care provided and a better understanding of the training environment in which this care is delivered are important goals for delivering high quality patient care.     

Transforming Primary Care Training—Patient-Centered Medical Home Entrustable Professional Activities for Internal Medicine Residents

INTRODUCTION

The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.

AIM

We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?

PROGRAM DESCRIPTION

The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, ‘medical home builder’ tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).

RESULTS

The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.

DISCUSSION

The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.     

Evaluating and enhancing a women’s health curriculum in an internal medicine residency program

OBJECTIVE: Resident education in women's health is required but is often underemphasized. Our aim was to identify women's health topics with the most relevance to our graduates' practices and to determine how well they were prepared to address women's health issues. DESIGN: Postgraduate survey. SETTING: University-affiliated internal medicine residency program. PARTICIPANTS: Program graduates in general internal medicine practice. METHODS: A survey was drafted listing the 65 topics described in a published residency curriculum in women's health. Respondents indicated the extent to which each item was relevant to their practice and the adequacy of instruction received on a Likert-type scale of 1 (not relevant/inadequate) to 5 (highly relevant/adequate). RESULTS: The response rate was 86%. Many of the items were highly relevant to our graduates' practices. Learning needs were found in all areas as none of the topics were rated as "adequately" taught during residency. Many areas in the curriculum had low relevance scores. Few differences were seen in the perceived relevance of women's health problems or the adequacy of instruction received based on gender, practice type and setting, or amount of ambulatory training during residency. CONCLUSIONS: Use of this survey has allowed us to tailor and prioritize learning issues in women's health to meet the needs of our graduates. Increased time in ambulatory rotations alone may not be sufficient to prepare residents to provide comprehensive care in this field. Further study of the effectiveness of a dedicated curriculum in women's heath is needed.     

Family Medicine and Primary Care Internal Medicine Residents' Attitudes Toward Care of the Elderly

Family medicine and primary care internal medicine residents in a university training program were surveyed about their attitudes toward caring for the elderly. Respondents reported satisfaction with care of the elderly. They considered caring for elderly patients to be medically challenging and reported that they learned an appreciable amount of medicine from elderly patients. The residents were less positive about their impact on elderly patients' health and the quality of care they delivered. Rather than supporting the belief that residents have negative attitudes toward the elderly, the study suggests this group of residents has positive attitudes about caring for this population. Their more negative responses about caring for this population. Their more negative responses about the quality of care they deliver suggest they would be receptive to learning more about delivery of health care to the elderly.     

An Integrated Geriatric Training Experience for Internal Medicine Residents

This paper describes an integrated approach to geriatric medical education programming which utilizes the Geriatric Evaluation Unit (GEU) as a training ground for consultative geriatrics. In addition, it presents pilot data regarding the program's effectiveness in altering attitudinal biases of general internal medicine residents toward elderly patients and their health care needs. Preliminary results suggest that improvement in attitudes occurred following a one month consultative geriatrics rotation. Use of the consultative mode described is felt to allow better utilization of resources in teaching more primary care physicians proper concepts of delivery of care to geriatric patients than the subspecialty mode.     

The medical chief residency and its relation to academic sections of general medicine

The role and function of chief medical residents in academic programs were reexamined in light of the advent of departmental units of general internal medicine. Of 87 chief medical residents responding to a questionnaire, 74 worked in departments with active general internal medicine sections. There was much interaction between chief medical residents and general internal medicine faculty: 36 percent of chief medical residents participated formally in general internal medicine section activities, 54 percent shared teaching responsibilities with general internal medicine faculty, and 45 percent of chief medical residents interacted with general internal medicine faculty in administrative activities. Despite this interaction, most basic administrative tasks were handled by chief medical residents alone. Forty-eight percent of chief medical residents thought the position had declined in prestige. Recent literature on the evolution of the chief residency in internal medicine and in other specialties is reviewed, and recommendations for capitalizing on the presence of general internal medicine faculty to make the position more rewarding are made.     

Hospitalist Career Decisions Among Internal Medicine Residents

BACKGROUND

Hospital medicine is a rapidly growing field of internal medicine. However, little is known about internal medicine residents’ decisions to pursue careers in hospital medicine (HM).

OBJECTIVE

To identify which internal medicine residents choose a career in HM, and describe changes in this career choice over the course of their residency education.

DESIGN

Observational cohort using data collected from the annual Internal Medicine In-Training Examination (IM-ITE) survey.

PARTICIPANTS

16,781 postgraduate year 3 (PGY-3) North American internal medicine residents who completed the annual IM-ITE survey in 2009–2011, 9,501 of whom completed the survey in all 3 years of residency.

MAIN MEASSURES

Self-reported career plans for individual residents during their postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2) and PGY-3.

KEY RESULTS

Of the 16,781 graduating PGY-3 residents, 1,552 (9.3 %) reported HM as their ultimate career choice. Of the 951 PGY-3 residents planning a HM career among the 9,501 residents responding in all 3 years, 128 (13.5 %) originally made this decision in PGY-1, 192 (20.2 %) in PGY-2, and 631 (66.4 %) in PGY-3. Only 87 (9.1 %) of these 951 residents maintained a career decision of HM during all three years of residency education.

CONCLUSIONS

Hospital medicine is a reported career choice for an important proportion of graduating internal medicine residents. However, the majority of residents do not finalize this decision until their final year.     

Academic Detailing to Teach Aging and Geriatrics

Geriatric education is a required component of internal medicine training. Work hour rules and hectic schedules have challenged residency training programs to develop and utilize innovative teaching methods. In this study, the authors examined the use of academic detailing as a teaching intervention in their residents’ clinic and on the general medicine inpatient wards to improve clinical knowledge and skills in geriatric care. The authors found that this teaching method enables efficient, directed education without disrupting patient care. We were able to show improvements in medical knowledge as well as self-efficacy across multiple geriatric topics.     

Effect of a Community‐Based Service Learning Experience in Geriatrics on Internal Medicine Residents and Community Participants

Community‐based service learning (CBSL) provides an opportunity to teach internal medicine residents the social context of aging and clinical concepts. The objectives of the current study were to demonstrate the feasibility of a CBSL program targeting internal medicine residents and to assess its effect on medical residents and community participants. internal medicine residents participated in a CBSL experience for half a day during ambulatory blocks from 2011 to 2014. Residents attended a senior housing unit or center, delivered a presentation about a geriatric health topic, toured the facility, and received information about local older adult resources. Residents evaluated the experience. Postgraduate Year 3 internal medicine residents (n = 71) delivered 64 sessions. Residents felt that the experience increased their ability to communicate effectively with older adults (mean 3.91 ± 0.73 on a Likert scale with 5 = strongly agree), increased their knowledge of resources (4.09 ± 1.01), expanded their knowledge of a health topic pertinent to aging (3.48 ± 1.09), and contributed to their capacity to evaluate and care for older adults (3.84 ± 0.67). Free‐text responses demonstrated that residents thought that this program would change their practice. Of 815 older adults surveyed from 36 discrete teaching sessions, 461 (56%) thought that the medical residents delivered health information clearly (4.55 ± 0.88) and that the health topics were relevant (4.26 ± 0.92). Free‐text responses showed that the program helped them understand their health concerns. This CBSL program is a feasible and effective tool for teaching internal medicine residents and older adults.