Giving curriculum planners an edge: Using entrance surveys to design family medicine education

ObjectiveTo pilot a survey of family medicine residents entering residency, describing their exposure to family medicine and their perspectives related to their future intentions to practise family medicine, in order to inform curriculum planners; and to test the methodology, feasibility, and utility of delivering a longitudinal survey to multiple residency programs.DesignPilot study using surveys.SettingFive Canadian residency programs.ParticipantsA total of 454 first-year family medicine residents were surveyed.ResultsOverall, 70% of first-year residents surveyed responded (n = 317). Although only 5 residency programs participated, respondents included graduates from each of the medical schools in Canada, as well as international medical graduates. Among respondents, 92% felt positive or strongly positive about their choice to be family physicians. Most (73%) indicated they had strong or very strong exposure to family medicine in medical school, yet more than 40% had no or minimal exposure to key clinical domains of family medicine like palliative care, home care, and care of underserved groups. Similar responses were found about residents’ lack of intention to practise in these domains.ConclusionExposure to clinical domains in family medicine could influence future practice intentions. Surveys at entrance to residency can help medical school and family medicine residency planners consider important learning experiences to include in training.     

Teaching an integrated approach to complementary, alternative, and mainstream therapies for children: a curriculum evaluation.

BACKGROUND: Increasing numbers of patients seek information about complementary and alternative medicine (CAM) from their primary physicians. We sought to evaluate our 4-year old curriculum integrating mainstream and CAM care for common outpatient pediatric problems within a family medicine residency. DESIGN: Cross-sectional survey. METHODS: Subjects included current (1998) third-year residents and recent graduates from our program and nearby University of Washington-affiliated family medicine residency programs. The survey included items on training experiences, knowledge, attitudes and behavior regarding CAM. RESULTS: Among the 18 respondents from our program and 21 from comparison programs, the average age was 32 years and one-third were male. Over 80% of respondents felt that residencies should provide training in CAM. Substantial numbers of respondents from all programs recommended CAM therapies to patients in the past year. All respondents had recommended special diets and nutritional supplements; more than 50% recommended herbal remedies, acupuncture, meditation or progressive relaxation, massage or home remedies. Respondents from all groups had similar attitudes and knowledge about integrative medicine; those from the intervention program were more likely than comparison respondents to agree that their residency training had prepared them to answer patients' questions about CAM (50% vs. 19%, p = 0.04). CONCLUSIONS: Primary care residents increasingly seek training to answer patients' questions and are already recommending a variety of CAM therapies. Primary care residencies need to develop and evaluate responsible, evidence-based curricula integrating mainstream and CAM therapies.     

Observation Medicine in Emergency Medicine Residency Programs

OBJECTIVE: To evaluate observation unit (OU) prevalence, emergency medicine (EM) resident exposure in observation medicine (OM), EM faculty/residency director (RD) OM training, and RD attitudes toward OM. METHODS: Information was obtained from residency programs by telephone during a four-month period. RESULTS: Survey respondents indicated that 36.1% have OUs and 44.9% plan to have an OU. Observation medicine resources include textbooks 32.0%, articles 45.9%, lectures 36.9%, fellowships 2.5%, and research 26.2%. Observation medicine patient care occurs: 1) during residency: 25.4% of RDs, 11.3% of entire faculty; 2) as an attending: 45.1% of RDs. CONCLUSIONS: Nearly two-thirds of EM programs have or are planning an OU. Resources are lagging behind. This survey describes current OM education strategies to teach OM.     

Transfusion medicine knowledge in Postgraduate Year 1 residents

BACKGROUND: Transfusion medicine is a complex important subspecialty of pathology. A transfusion carries measurable risks and benefits. Although fellowship training exists in transfusion medicine, the majority of transfusion decisions are made by clinicians without formal training. STUDY DESIGN AND METHODS: A total of 116 recently graduated medical students entering 10 residency programs at a single medical center over 2 years were evaluated using a standardized patient encounter to determine baseline knowledge. Transfusion medicine knowledge was assessed during the encounter by obtaining verbal consent for red blood cell transfusion, answering patient questions, and completing a written quiz. Final performance was scored using a peer‐reviewed data collection sheet. RESULTS: Scores ranged from 24.0% to 67.1%. Postgraduate Year 1 (PGY‐1) residents graduating from allopathic medical schools had higher scores than those from osteopathic schools (mean, 41.3% vs. 37.5%; p = 0.036). There was no significant difference between PGY‐1 residents entering primary care versus surgical specialties (38.2% and 41.6%; p = 0.10). Although not significant, PGY‐1 residents with previous transfusion medicine education demonstrated a trend toward better performance than those without prior education (47.0% vs. 43.0%; p = 0.057). A total of 17.2% of PGY‐1's could define transfusion‐related acute lung injury, 6.0% knew the transfusion transmission rate of human immunodeficiency virus, 5.2% knew the transfusion transmission rate of hepatitis C virus, and 0% knew the indication for blood product irradiation. CONCLUSIONS: Marked knowledge deficits in transfusion medicine were noted. If the results of this study could be reproduced at other training institutions, medical schools may be willing to donate more resources into transfusion medicine education.     

Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents

OBJECTIVE: We aimed to determine internal medicine residents' perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal. DESIGN: Cross-sectional postal survey. SETTING: Canadian internal medicine training programs. PARTICIPANTS: Internal medicine residents attending Canadian English-speaking medical schools. INTERVENTIONS: A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools. MEASUREMENTS AND MAIN RESULTS: Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r(2) = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence. CONCLUSIONS: The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.     

Residents as teachers: Survey of Canadian family medicine residents

Objective

To examine Canadian family medicine residents’ perspectives surrounding teaching opportunities and mentorship in teaching.

Design

A 16-question online survey.

Setting

Canadian family medicine residency programs.

Participants

Between May and June 2011, all first- and second-year family medicine residents registered in 1 of the 17 Canadian residency programs as of September 2010 were invited to participate. A total of 568 of 2266 residents responded.

Main outcome measures

Demographic characteristics, teaching opportunities during residency, and resident perceptions about teaching.

Results

A total of 77.7% of family medicine residents indicated that they were either interested or highly interested in teaching as part of their future careers, and 78.9% of family medicine residents had had opportunities to teach in various settings. However, only 60.1% of respondents were aware of programs within residency intended to support residents as teachers, and 33.0% of residents had been observed during teaching encounters.

Conclusion

It appears that most Canadian family medicine residents have the opportunity to teach during their residency training. Many are interested in integrating teaching as part of their future career goals. Family medicine residencies should strongly consider programs to support and further develop resident teaching skills.     

Resident and fellow training in transfusion medicine

This article focuses on the design of transfusion medicine residency and fellowship training programs in the context of the Accreditation Commission for Graduate Medical Education (ACGME) competencies. Transfusion-specific examples of the six ACGME competencies are discussed, a transfusion medicine curriculum with designated training stages for specific curriculum elements is proposed, and examples of training activities are given. The authors also discuss transfusion service rotation design and how to build in graduated responsibility as training proceeds. Finally, methods for assessing the competency of transfusion medicine trainees and the effectiveness of the training program and teaching faculty are described. It is hoped that this article will provide a blueprint for how to design and implement a successful transfusion medicine residency and fellowship training program.     

A survey of Canadians enrolled in American Emergency Medicine residencies

Despite the existence of Emergency Medicine (EM) residency programs in Canada, Canadian physicians continue to pursue EM training in the United States. To determine the factors that may influence these Canadian physicians to return to practice in Canada, a survey was sent to all Canadians enrolled in U.S. EM training programs. Seventeen of 22 (77%) post-graduate trainees responded. Residents said they had chosen U.S. training mainly because of the low number of residents in Canadian EM specialty programs, and they also had the perception that U.S. EM training was superior. Lower salaries, restrictions on location of practice, and an inability to obtain Royal College certification were the factors most likely to prevent a return to Canada. Six of the 17 respondents (35%) said they were definitely or probably returning to Canada. Given the limited number of Canadian training positions and the Canadian Emergency Physician workforce shortfall, the U.S. training route appears to be underutilized.     

Substance abuse policies in rehabilitation medicine departments

A 27-item substance abuse questionnaire covering attitudes, beliefs, and policies was sent to the directors or other representatives of the 68 physical medicine and rehabilitation training programs in the United States. Anonymity of the respondents was guaranteed. Respondents representing 52 programs (76%) from 20 states participated. Almost all respondents were physicians; most were rehabilitation unit directors, directors of residency training, or department chairpersons. The average size of the rehabilitation units was 46 beds. Four important findings are emphasized. First, 73% of respondents were concerned about alcohol or drug (A/D) problems in their patients, but only 52% supported routine A/D screening for all patients. Importantly, only 25% routinely screened all patients. Second, 90% supported guidelines prohibiting A/D use in the rehabilitation unit, but only 65% had a prohibition policy and only 45% had written guidelines. More than 50% of the respondents stated that there were appropriate reasons for ordering alcohol for an inpatient. Third, 92% supported immediate intervention for inpatients found to have A/D problems, but only 55% routinely provided access to drug counselors. Fourth, 75% were in favor of drug abuse education for patients and staff, but only 29% provided education to patients and 22% to staff. The results suggest that the problems of A/D abuse in the physically disabled have yet to be adequately recognized and addressed by workers in rehabilitation medicine.     

Effect of Changes in Graduate Medical Education Funding on Emergency Medicine Residency Programs

OBJECTIVE: To determine whether changes in graduate medical education (GME) funding have had an impact on emergency medicine (EM) residency training programs. METHODS: A 34-question survey was mailed to the program directors (PDs) of all 115 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs in the United States in the fall of 1998, requesting information concerning the impact of changes in GME funding on various aspects of the EM training. The results were then compared with a similar unpublished survey conducted in the fall of 1996. RESULTS: One hundred one completed surveys were returned (88% response rate). Seventy-one (70%) of the responding EM residency programs were PGY-I through PGY-III, compared with 55 (61%) of the responding programs in 1996. The number of PGY-II through PGY-IV programs decreased from 25 (28%) of responding programs in 1996 to 17 (16%). The number of PGY-I through PGY-IV programs increased slightly (13 vs 10); the number of EM residency positions remained relatively stable. Fifteen programs projected an increase in their number of training positions in the next two years, while only three predicted a decrease. Of the respondents, 56 programs reported reductions in non-EM residency positions and 35 programs reported elimination of fellowship positions at their institutions. Only four of these were EM fellowships. Forty-six respondents reported a reduction in the number of non-EM residents rotating through their EDs, and of these, 11 programs reported this had a moderate to significant effect on their ability to adequately staff the ED with resident physicians. Sixteen programs limited resident recruitment to only those eligible for the full three years of GME funding. Eighty-seven EM programs reported no change in faculty size due to funding issues. Sixty-two programs reported no change in the total number of hours of faculty coverage in the ED, while 34 programs reported an increase. Three EM programs reported recommendations being made to close their residency programs in the near future. CONCLUSIONS: Changes in GME funding have not caused a decrease in the number of existing EM residency and fellowship training positions, but may have had an impact in other areas, including: an increase in the number of EM programs structured in a PGY-I through PGY-III format (with a corresponding decrease in the number of PGY-II through PGY-IV programs); a decrease in the number of non-EM residents rotating through the ED; restriction of resident applicants who are ineligible for full GME funding from consideration by some EM training programs; and an increase in the total number of faculty clinical hours without an increase in faculty size.     

The American Society for Clinical Pathology resident in-service examination: does resident performance provide insight into the effectiveness of clinical pathology education?

The resident in-service examination in pathology is an in-training exercise that is taken by virtually all pathology residents in the United States as well as by some participants in Canada, Ireland, and Lebanon. Although all of the anatomic pathology topics in the examination, with only one exception-forensic pathology, show significant improvement in scores over the 4 years of residency training, three areas of clinical pathology training (laboratory administration, clinical chemistry, and microbiology) show significantly lower improvement in performance over the years of residency training. By contrast, transfusion medicine, hematopathology and the special topics section of the examination all demonstrate improved performance by residents over time. While the reason behind these differences must remain speculative at this time, these findings suggest that measures to improve effectiveness in clinical pathology training might be suggested by examining the differences between residency training practices between higher and lower performing areas of clinical pathology.     

Animal procedure laboratory surveys: Use of the animal laboratory to improve physician confidence and ability

Animal laboratories have been used for many years to teach procedures. Our department has a weekly swine laboratory devoted to training residents, interns and students in resuscitative procedures. Physicians who participated in our swine procedure laboratory over the past three years were queried as to their prelaboratory and postlaboratory comfort levels with six different resuscitative procedures, and 57 (76%) physicians responded. Statistical analysis of the data showed significant improvement in comfort levels for all six procedures. Every responder felt the swine laboratory helped or will help them perform the procedures on humans. We also surveyed all U.S. emergency medicine residency program directors from established programs regarding the status of their animal procedure laboratories, and 67 of the 68 (98%) directors responded. Of these responders, 62% offer an animal procedure laboratory. Overall, 97% of the residency directors rated the laboratory successful, and 97% of the residents rated the laboratory successful. Therefore, we conclude that an ongoing emergency medicine animal procedure laboratory is a valuable tool for improving physician-in-training ability and confidence.     

An online immunohematology educational resource for post-graduate hematology trainees: LearnSerology.ca

BackgroundCanadian hematology residents are required to demonstrate competencies in transfusion medicine by the end of their 2-year training. Prior evaluation of final year trainees revealed significant variation in knowledge. To address the lack of standardization in serology teaching, an online educational immunohematology resource was created and evaluated.Study design and methodsAll Canadian post-graduate trainees completing a residency program in adult hematology during the 2018/2019 academic year were invited to participate. Only trainees from one university were exposed to the program curriculum. A validated exam was administered to trainees at both exposed and unexposed sites at the start of the academic year as a pre-test and in the following year as a post-test. The effectiveness of the program was assessed by both comparing the degree of improvement from pre- to post-test, and by comparing performance on the post-test.Results57 trainees from 13 universities completed the pre-test, and 45 trainees from 14 universities completed the post-test. A strong trend towards better performance in the exposed vs non-exposed trainees on the post-test was observed, and the difference was more pronounced, and statistically significant, when analysis was limited to two questions relating to interpretation of an antibody investigation panel.DiscussionLearnSerology.ca is effective and may be potentially superior to traditional immunohematology teaching. The interactive capability of the platform can improve skills related to the resolution of red cell antibody panels.     

Family physicians' attitudes toward education in research skills during residency: findings from a national mailed survey

OBJECTIVE

To determine the attitudes of practising Canadian family physicians toward education in research skills during residency, to identify what determines these attitudes, and to investigate the effect of education in research skills on future research activity.

DESIGN

Mailed survey.

SETTING

Primary care.

PARTICIPANTS

Stratified random sample of 247 practising physicians who were members of the College of Family Physicians of Canada.

MAIN OUTCOME MEASURES

Physicians’ attitudes toward education in research skills during residency, their perceptions of the value of research in primary care, and their current involvement in research activities.

RESULTS

Overall response rate was 56%. Nearly all respondents agreed that critical appraisal skills are essential to the practice of modern family medicine. Most agreed that it is very important that the evidence base for primary care medicine be developed by family physicians, yet only one-third agreed that research skills ought to receive more emphasis during residency training, and fewer than one-quarter agreed that practising family physicians should have strong research skills. Fewer than half the respondents agreed that a core goal of family medicine residency training should be to promote and develop an active interest in research. While three-quarters agreed that research projects during residency can be formative learning experiences, only about 40% indicated that research projects should be required, and only about 20% considered their own resident research projects to have been highly influential learning experiences. Respondents whose residency programs had research in the curriculum were significantly more likely to have found their research projects to be highly influential learning experiences (P <.05), and those who had successfully completed research projects were less likely to believe that they lacked the necessary skills and expertise to conduct their own research studies. Those who had successfully completed resident research projects participated in postresidency research activity at a significantly higher rate than those who did not complete projects (P <.01).

CONCLUSION

Despite a conviction that research is important in primary care, only a few practising family physicians in our sample believed that strong research skills are important or that education in research skills should receive more emphasis during residency training. Resident research projects are not invariably influential learning experiences, although some evidence indicates that successful completion of a project makes future participation in research more likely.     

Physician Experiences With High Value Care in Internal Medicine Residency: Mixed-Methods Study of 2003–2013 Residency Graduates

Phenomenon: High healthcare costs and relatively poor health outcomes in the United States have led to calls to improve the teaching of high value care (defined as care that balances potential benefits of interventions with their harms including costs) to physicians-in-training. Numerous interventions to increase high value care in graduate medical education were implemented at the national and local levels over the past decade. However, there has been little evaluation of their impact on physician experiences during training and perceived preparedness for practice. We aimed to assess trends in U.S. physician experiences with high value care during residency over the past decade. Approach: This mixed-methods study used a cross-sectional survey mailed July 2014 to January 2015 to 902 internists who completed residency in 2003–2013, randomly selected from the American Medical Association Masterfile. Quantitative analyses of survey responses and content analysis of free-text comments submitted by respondents were performed. Findings: A total of 456 physicians (50.6%) responded. Fewer than one fourth reported being exposed to teaching about high value care at least frequently (23.6%, 106/450). Only 43.8% of respondents (193/446) felt prepared to use overtreatment guidelines in conversations with patients, whereas 85.8% (379/447) felt prepared to participate in shared decision making with patients at the conclusion of their training, and 84.4% (380/450) reported practicing generic prescribing. Physicians who completed residency more recently were more likely to report practicing generic prescribing and feeling well prepared to use overtreatment guidelines in conversations with patients (p < .01 for both). Insights: In a national survey, recent U.S. internal medicine residency graduates were more likely to experience high value care during training, which may reflect increased national and local efforts in this area. However, being exposed to high value care as a trainee may not translate into specific tools for practice. In fact, many U.S. internists reported inadequate exposure to prepare them for patient discussions about costs and the use of overtreatment guidelines in practice.     

The Status of Bedside Ultrasonography Training in Emergency Medicine Residency Programs

Bedside ultrasonography (BU) is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. In the past decade, several organizations in EM have issued position statements on the use of this technology. Program training content is currently driven by the recently published "Model of the Clinical Practice of Emergency Medicine," which includes BU as a necessary skill. OBJECTIVE: The authors sought to determine the current status of BU training in EM residency programs. METHODS: A survey was mailed in early 2001 to all 122 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs. The survey instrument asked whether BU was currently being taught, how much didactic and hands-on training time was incorporated into the curriculum, and what specialty representation was present in the faculty instructors. In addition, questions concerning the type of tests performed, the number considered necessary for competency, the role of BU in clinical decision making, and the type of quality assurance program were included in the survey. RESULTS: A total of 96 out of 122 surveys were completed (response rate of 79%). Ninety-one EM programs (95% of respondents) reported they teach BU, either clinically and/or didactically, as part of their formal residency curriculum. Eighty-one (89%) respondents reported their residency program or primary hospital emergency department (ED) had a dedicated ultrasound machine. BU was performed most commonly for the following: the FAST scan (focused abdominal sonography for trauma, 79/87%); cardiac examination (for tamponade, pulseless electrical activity, etc., 65/71%); transabdominal (for intrauterine pregnancy, ectopic pregnancy, etc., 58/64%); and transvaginal (for intrauterine pregnancy, ectopic pregnancy, etc., 45/49%). One to ten hours of lecture on BU was provided in 43%, and one to ten hours of hands-on clinical instruction was provided in 48% of the EM programs. Emergency physicians were identified as the faculty most commonly involved in teaching BU to EM residents (86/95%). Sixty-one (69%) programs reported that EM faculty and/or residents made clinical decisions and patient dispositions based on the ED BU interpretation alone. Fourteen (19%) programs reported that no formal quality assurance program was in place. CONCLUSIONS: The majority of ACGME-accredited EM residency programs currently incorporate BU training as part of their curriculum. The majority of BU instruction is done by EM faculty. The most commonly performed BU study is the FAST scan. The didactic component and clinical time devoted to BU instruction are variable between programs. Further standardization of training requirements between programs may promote increasing standardization of BU in future EM practice.