The pediatric resident training on tobacco project: interim findings

OBJECTIVES: The Pediatric Residency Training on Tobacco Project is a four-year randomized prospective study of the efficacy of training pediatric residents to intervene on tobacco. At the start of the study (baseline), the pediatric residents uniformly agreed that environmental tobacco smoke (ETS) and tobacco use pose serious threats to the health of young people, and pediatricians should play a leadership role in the antismoking arena. However, very few went beyond advising patients and parents to modify their behavior by providing actual assistance, and many of them lacked necessary tobacco intervention skills and knowledge. We hypothesized that both standard training and special training programs would yield positive changes in intervention skills and activities, although the changes would be greater in residents exposed to the special training condition. In the present report, we present two-year outcome data from the resident tobacco surveys and objective structured clinical examinations (OSCEs) administered to independent waves of third-year residents in each experimental condition at baseline and year 2. METHODS: Fifteen pediatric residency training programs in the New York/New Jersey metropolitan area were assigned randomly to special and standard training conditions (eight to special and seven to standard training). Resident tobacco surveys and OSCEs were administered to third-year residents at the start of the training programs (baseline) and at years 1 and 2 of the study. Comparisons between sequential waves of third-year residents with no (baseline) or two-year exposure to the training programs permitted assessment of changes in resident beliefs, intervention activities and intervention skills within each experimental condition. RESULTS: By year 2, the residents associated with each training condition benefited from the training program, but the annual surveys and OSCEs revealed more significant positive changes for waves of residents in the special training condition. Most important, third-year residents exposed to the special training condition for two years were more likely than comparable residents in the standard training condition to reveal significant increases in the degree to which they provided active assistance for modifying smoking and ETS. CONCLUSIONS: The two-year findings from the pediatric tobacco project are encouraging and suggest that the special training program is efficacious, although aspects of the program in need of improvement were identified.     

Perceptions of pediatric chief residents on minority house staff recruitment and retention in large pediatric residency programs

This study examined methods of recruiting and retaining minority house staff at US residency training programs. A 28-item questionnaire was mailed to pediatric chief residents at 78 US training programs with more than 35 residents. The response rate was 74%. Programs were characterized by patient populations served, number of ethnic/racial minority house staff and faculty, and the presence of minority house staff support systems within the institution. In this largely urban sample, minority recruitment and retention was reported as an explicit priority by 40% of pediatric chief residents. The majority (71%) reported that their house staff recruitment committees had no explicitly defined recruitment goals regarding minority house staff. Seventy-seven percent reported that within their departments, recruitment efforts toward minorities were no different than for nonminorities. Overall, few minority house staff and minority faculty were identified in the responding institutions. The most frequently reported intra-institutional support systems for minority house staff included individual pairing with faculty advisors from the same minority group (29%), an affirmative-action office located at the institution (8%), and the existence of a minority faculty support group (4%). These results indicate that pediatric chief residents may not be fully aware of the specific challenges related to the recruitment and retention of minority physicians, and most house staff recruitment committees do not have explicit goals in this regard.     

A consortium-based research education program for residents.

With growing pressures to consolidate and reorganize health care delivery systems, graduate medical education (GME) consortia can draw faculty from affiliated members to assemble educational programs. The authors report on consortium-based research education seminars of a quality that many residency programs would be unable to develop and support on their own. Drawing a diverse faculty from consortium members and area universities, the OHEP Center for Medical Education's annual Research Workshop Series focuses on the design of research projects; data analysis and hypothesis testing; and written and oral presentation of scientific research. Each spring, OHEP sponsors a research forum in which the best research projects from consortium members are presented by the resident-researchers, who compete for recognition and prize money. Further, of the 128 presentations made thus far at the annual OHEP Research Forum, 25% were subsequently published. The consortium's research education program has been well received by residents, is cost-effective, and is an integral component of the research curricula of many area residency programs. Including research training in GME provides residents an opportunity to become more competitive for fellowship, faculty, and leadership positions.     

College health services as a site for ambulatory care training of residents and medical students

The education of residents and medical students in ambulatory care settings continues to play a greater role in medical education than was the case even a few years ago. This report documents the use of college health services, commonly called student health centers, at California institutions of higher education, as training sites for residents and medical students in 1988. Directors of residency programs that had used student health centers for their residents reported that they were pleased with the association. The directors of student health centers that had had residents on educational rotations also reported a high level of overall satisfaction. Student health centers represent an untapped resource, as only 20% of such centers in California were being used to train residents at the time of this study.     

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.     

Getting residents involved in research: a challenge in the era of managed care.

The changing climate of health care, with the associated increasing financial constraints, challenges faculty and residents to find time for mentoring and pursuing research. Departments and institutions can encourage residents to conduct research by assuring them that they have a supportive infrastructure. Only when the institution and faculty value research will residents do the same. More than half of academic surgeons spend less than 20% of their effort in research; how can residency programs expect residents to enthusiastically pursue research when members of the teaching faculty are themselves not writing and publishing? If the ACGME is serious about asking residents to devote their time and energy to becoming more active in research activities, we must be prepared to decrease service commitments, and we must provide clinically active mentors and visible career models.     

Perceptions of stress among pathology residents: survey results and some strategies to reduce them

We conducted a survey to attempt to identify stressors perceived by pathology residents. A comparison of survey results from pathology residents with stressors perceived by residents in other specialties was done to evaluate whether the stressors in pathology are unique. A confidential e-mail survey of residency programs in the United States generated a response rate from program directors of 23.3% and a resident response rate of 6.4%. Although the study is limited by response rates and the data are primarily from university-based residency programs, the concordance between the identifiable risk factors for stress by the resident and program director groups validates the importance of this issue among pathology residency programs. Both groups identified variability in faculty expectations and work overload that inhibits optimal learning as the top 2 stressors for residents. We discuss various factors that contribute to stress and some strategies that pathology residency programs can implement to address the stressors.     

Two perspectives on the indicators of quality in psychiatry residencies: program directors' and residents'.

PURPOSE: To determine whether psychiatry program directors and residents agree on the characteristics most important in determining the quality of a residency program. METHOD: The authors carried out factor analyses of the results of two national surveys that asked participants to rate the importance of 41 items in determining the quality of residency programs: a 1997 survey completed by 180 psychiatry residents and a 1998 survey completed by 234 psychiatry program directors and rotation heads. RESULTS: Residents' factors determining program quality were the interpersonal culture in the program, the curriculum, academic resources and opportunities, clinical resources and opportunities, and outcomes. Program directors' factors were program administration, curriculum and clinical resources, the quality of the institution, the supportiveness of the program, and individual preferences. CONCLUSIONS: Program directors and residents focus on different indicators of the quality of residency programs, differences that can be conceptualized as those between the "producer" and the "consumer" of the program. Four domains appear to underlie the results of the resident and faculty factor analyses: the context, content, culture, and consequences of the program. Multidimensional evaluations by multiple stakeholders may be the most appropriate way to evaluate the quality of residency programs. These results also strongly suggest that the interpersonal culture of a program should be assessed as part of its evaluation process.     

Addressing the leadership gap in medicine: residents' need for systematic leadership development training

All clinicians take on leadership responsibilities when delivering care. Evidence suggests that effective clinical leadership yields superior clinical outcomes. However, few residency programs systematically teach all residents how to lead, and many clinicians are inadequately prepared to meet their day-to-day clinical leadership responsibilities. The purpose of this article is twofold: first, to make the case for the need to refocus residency education around the development of outstanding "frontline" clinical leaders and, second, to provide an evidence-based framework for designing formal leadership development programs for residents. The authors first present a definition of clinical leadership and highlight evidence that effective frontline clinical leadership improves both clinical outcomes and satisfaction for patients and providers. The authors then discuss the health care "leadership gap" and describe barriers to implementing leadership development training in health care. Next, they present evidence that leaders are not just "born" but, rather, can be "made," and offer a set of best practices to facilitate the design of leadership development programs. Finally, the authors suggest approaches to mitigating barriers to implementing leadership development programs and highlight the major reasons why health care delivery organizations, residency programs, and national accreditation bodies must make comprehensive leadership education an explicit goal of residency training.     

Health and disease in context: a community-based social medicine curriculum.

Despite the increasing attention paid to the role of social forces in determining health, most physicians finish their training ill-prepared to address these issues. The authors describe their efforts to fill that training gap for internal medicine residents at Oregon Health and Science University through a community-based social medicine curriculum, designed in 2006 in conjunction with community partners at Central City Concern (CCC), an organization addressing homelessness, poverty, and addiction in downtown Portland, Oregon. The challenge was to develop a curriculum that would (1) fit within the scheduling constraints of an established categorical internal medicine residency program, (2) give all internal medicine residents a chance to better understand how social forces affect health, and (3) help show how they, as health professionals, might intervene to improve health and health care. The authors maintain that by developing this curriculum with community partners--who took the lead in deciding what residents should learn about their community and how they should learn it--the residency program is providing a relatively brief but extremely rich opportunity for residents to engage the personal, social, and health-related issues experienced by clients served by CCC.The authors first provide a brief overview of the curriculum and describe how the principles and practices of community-based participatory research were used in its development. They then discuss the challenges involved in teaching medical residents about social determinants of health, how their academic-community partnership approaches those challenges, and the recently established methods of evaluating the curriculum.     

Educating residents about managed care: a partnership between an academic medical center and a managed care organization.

Physicians are taught to think in terms of individual patients rather than in terms of the health of a population, a view typically reinforced by residency training. Managers of managed care organizations estimate that it takes between one and two years of additional post-residency experience to prepare graduates of U.S. residency programs to practice in managed care settings. The authors describe a two-week block rotation in managed care and health system change that is required of all third-year medical residents at New York-Presbyterian Hospital/ Weill Cornell Medical Center. The program was developed through a partnership between the Joan and Sanford I. Weill Medical College of Cornell University, the New York-Presbyterian Hospital, and Empire BlueCross BlueShield. The authors discuss the rationale, curriculum content, teaching methods, and evaluation of the program, which is designed not only to educate residents about managed care but also to enable them to think critically about the changing health care system. The results of the program have exceeded expectations. Residents' knowledge of health economics, managed care concepts, and health system change, as measured by pre- and post-rotation tests, has shown a steep learning curve. Further, the residents have consistently given the rotation the highest ratings, and some residents have changed their career plans as a result of their participation. The program, which continues to expand, has demonstrated the potential of collaboration between traditional adversaries, an academic medical center and a managed care insurance company, and provides a replicable model for similar partnerships.     

U.S. residency directors' views of the importances of seven roles that pediatrics residents should master

Pediatrics residency programs should define and evaluate for their residents and faculty the competencies that residents should acquire during their three years of training. This 1987 survey of 129 pediatrics residency directors sought data about the demographic characteristics of the programs and asked the program directors to what degree they agreed that seven roles (each comprising several competencies) of the general and ambulatory-care pediatrician were essential. There was strong agreement on the seven roles and no demonstrated association between these responses and the residency programs' university affiliations, types of facilities, ages, lengths of training, or geographic locations. The results of this survey may be useful in developing ways to document and evaluate residents' performances and define subspecialty objectives that are consistent with the seven basic roles.     

A systematic approach to faculty development in Women's health: lessons from education, feminism, and conflict theory.

The authors present a strategy for residency faculty development in women's health, the reasons that such a strategy is necessary (e.g., women's health encompasses much more than reproductive and disease issues, and is cross-disciplinary and intrinsic to all of family practice), and their residency program's experience with its development and implementation from 1994 to the present. In creating the program, the residency program's faculty used as a context some lessons learned from family medicine, since the rapid growth of family medicine provides a historical example of dealing with a critical shortage of faculty for new residency programs and the need for a new way to train educators. Also, the faculty reviewed the literature about faculty development in medicine, models of teaching and learning from women's studies, and group theory, specifically the skills concerning conflict and diversity. They used the salient elements from each (which the authors outline) in fashioning their new faculty development program. The resulting program also grew out of focus groups with patients, input from staff, residents, and faculty, and meetings and workshops, including some intense and highly charged discussions in which the faculty participants, both men and women, confronted their own views and biases and worked hard to successfully forge a common and relevant vision of women's health. The program has fostered faculty who are knowledgeable about the diverse educational skills required to teach women's health. They use these skills in all curricular content, thus demonstrating a new way to educate residents as well as faculty.     

Teaching medical residents about teenagers: an introductory curriculum in adolescent medicine.

OBJECTIVE: Adolescents in the United States have high morbidity rates, which are attributable to injuries, behavioral disorders, sexually transmitted diseases, and unplanned pregnancies. This has led to a call to action for health care educators to better prepare future practitioners to meet adolescent health care needs. Although pediatrics residency programs have required one-month curricula dedicated to adolescent medicine, many internal medicine (IM) residency programs do not have such requirements despite an American College of Physicians position paper recognizing the importance of internists' providing health care to adolescents. Thus, an introductory curriculum in adolescent medicine was developed for a community hospital IM residency program. The curriculum was designed to train IM residents to effectively interview, provide preventive care for, and evaluate common medical problems of older adolescents (ages 16-21) in an outpatient setting. DESCRIPTION: The curriculum was based on the results of an extensive needs assessment, which included surveys sent to practicing internists and current IM residents. It included three units, each a series of one-hour lessons delivered via morning report or grand rounds sessions. The first unit was interviewing, which covered specific interviewing questions, communication methods, and confidentiality issues. The second unit was preventive medicine care, which addressed immunizations, injury prevention, and adolescent drug and alcohol use. The third unit was diagnosis and management of common problems, which focused on topics frequently encountered during adolescent outpatient visits, including acne, sexually transmitted diseases, reproductive health care needs, and menstrual abnormalities. Other topics pertinent to the care of adolescents, notably depression, eating disorders, and sports medicine, were covered by previously established curricula, and thus omitted. This curriculum was created through the support of the Michigan State University Primary Care Faculty Development Fellowship Program, and was reviewed by curricular and adolescent medicine content experts. The residency program director supported its implementation over the course of two academic years. The pilot unit interviewing was conducted in February 2001, during two one-hour morning report sessions. In the first session, a short lecture outlining interviewing concepts and principles was given, followed by several case-based studies describing office presentations of adolescent patients. In the second session, an actual office visit was simulated; the residents observed adolescent volunteers being interviewed, and were then given an opportunity to ask the patients further questions. Residents completed a brief quiz and evaluation survey at the end of the pilot unit. DISCUSSION: Twenty-one of 40 residents participated in the pilot unit. Evaluations were overall very positive. Quiz scores confirmed that the residents achieved the desired learning objectives. Given these results from the pilot unit, the remaining two units of the curriculum have been integrated into the residency curriculum. Additional faculty members have been selected to deliver future sessions and support this important educational activity. The adolescent medicine curriculum can be used as an model by other IM residency programs for teaching adolescent health care, with an emphasis on both the knowledge base of adolescent issues and awareness of the unique skills necessary for the establishment of a physician-patient relationship between internists and older adolescents.     

Predicting performance using background characteristics of international medical graduates in an inner-city university-affiliated Internal Medicine residency training program

Background  

IMGs constitute about a third of the United States (US) internal medicine graduates. US residency training programs face challenges in selection of IMGs with varied background features. However data on this topic is limited. We analyzed whether any pre-selection characteristics of IMG residents in our internal medicine program are associated with selected outcomes, namely competency based evaluation, examination performance and success in acquiring fellowship positions after graduation.     

Analysis of residents' performances on the In-Training Examination of the American Board of Anesthesiology-American Society of Anesthesiologists

An analysis of the results of the In-Training Examination of the American Board of Anesthesiology-American Society of Anesthesiologists has been developed using a new question-categorization method and a new form of calculation, the resident index score. Resident index scores permit comparison of the performance of any program's residents with the performance of all U.S. residents who took the examination. This study analyzed examination results from eight residency programs for a five-year period, 1983-1987. Statistically significant differences in the residents' performances were found both within and among the residency programs during this time. Areas of educational strength and weakness were identified by levels of training for each program. The analyses of the individual programs' results were provided to the respective program directors on a confidential basis, and have been used to change curriculum content, modify lectures for residents, and provide structured review for residents. Similar analyses can be provided as a service to other residency program directors.     

Internal medicine-pediatrics residency training: current program trends and outcomes.

PURPOSE: Combined internal medicine-pediatrics (med-peds) residency programs have existed since 1967. Due to the rapid growth in the number and size of programs during the 1990s, most current med-peds physicians completed their residency in the last ten years, making older studies of med-peds programs obsolete. The authors sought to determine completion rates of med-peds residency programs and describe the initial career plans for five cohorts of graduating residents from combined med-peds training programs. METHOD: Program directors of all U.S. med-peds residency programs were asked to complete a Web-based survey and base their responses on the records of cohorts of residents completing their programs from 1998 through 2002. To allow sufficient time to complete both the American Board of Pediatrics (ABP) and American Board of Internal Medicine (ABIM) certification examinations, certification status was requested only for the cohort completing training in 1998. RESULTS: Responses were obtained from 92% (83/90) of the programs, reflecting 1,595 residents entering med-peds programs. Of these residents, 91% graduated from a med-peds program. Among the graduates, 82% were seeing both adults and children, 22% went on to subspecialty residencies, 21% began practice in rural or underserved areas, and 25% entered an academic position. ABIM and ABP pass rates for the 1998 cohort were 97% and 96%, respectively. Overall, 79% of the 1998 graduates are board certified in both specialties. CONCLUSIONS: Compared with previous studies, a greater proportion of residents who recently entered med-peds programs completed their dual training, and a larger percentage of graduates are seeing both adults and children. The proportion of residents entering subspecialty residencies has increased significantly, but the proportion of graduates in academic careers has remained stable.