Psychosocial training in U.S. internal medicine and family practice residency programs.

PURPOSE: Competence in the psychosocial aspects of medical care is necessary for primary care physicians to function effectively. This study investigated the psychosocial training internal medicine and family practice residents receive in U.S. programs. METHODS: In 1996, program directors of all U.S. internal medicine (IM) and family practice (FP) residency programs were surveyed regarding the format, content, and quantity of psychosocial training provided in their programs, their opinions on topics related to psychosocial training, and demographics of their programs. RESULTS: The response rate was 61%. Ninety-nine percent of FP and 62% of IM program directors reported requiring at least one psychosocial training experience. Family practice programs required an average of 352 hours (SD +/- 175; range 27-2,664) of psychosocial training compared with 118 hours (SD +/- 272; range 0-1,050) for IM programs. Most IM and FP program directors expected residents to achieve at least basic competency in virtually all psychosocial topic areas; however, FP programs provided a greater range of psychosocial experiences. FP program directors most often identified psychologists and IM program directors most often identified internists as providing the most psychosocial training in their programs. Both IM and FP program directors considered lack of curricular time to be the main obstacle to development of psychosocial training. CONCLUSION: Residents' competence in psychosocial areas is important to both IM and FP program directors. However, content and time devoted to psychosocial training vary considerably both within and between program types.     

Physicians at the medicine/psychiatric interface: what do internist/psychiatrists do?

Studies have convincingly demonstrated that some 50% of patients in primary care settings have both medical and psychiatric diagnoses requiring dual treatment. The concept of primary care psychiatry has emerged in recent years as one way to address this problem. In 1979 the first combined medicine-psychiatry residency was formed. There are now over 20 such programs, but there is little information on how these doubly trained physicians actually practice. In 1997, the authors surveyed the 268 physicians with board certification in both internal medicine and psychiatry that were listed with the American Board of Medical Specialties. Only 15% practiced any type of medicine at all; the rest were involved only in the practice of psychiatry. Although 75% identified themselves only as psychiatrists and worked predominantly in psychiatry, 95% reported using both their medical and psychiatric training in their professional work. They reported that the dual training made them better physicians, improved their professional credibility, and enhanced their diagnostic skills. Several significant barriers were discovered that directly affect the ability of physicians to practice in two fields. Findings, study limitations, and potential implications for the field and its patients are discussed.     

Lessons from pediatrics residency program directors' experiences with work hour limitations in New York State.

PURPOSE: To evaluate the impact of residency work hour limitations on pediatrics residency programs in New York State, and to learn lessons that can be used nationally with the implementation of the Accreditation Council of Graduate Medical Education's similar rules. METHOD: A three-page questionnaire was mailed to all pediatrics residency program directors in New York. The questionnaire assessed methods used to accommodate the work hour limitations and perceptions of the limitations' effects. RESULTS: Twenty-one program directors responded (68%). Only large programs used night floats and night teams to meet work hour requirements. Programs of all sizes and in all settings used cross coverage and sent residents home immediately post call. About half of the programs hired additional nonresident staff, usually nurse practitioners, physician assistants, and/or attendings. The most frequently reported effects were decreases in the amount of time residents spent in inpatient settings, patient continuity in inpatient settings, flexibility of residents' scheduling, and increased logistical work needed to maintain continuity clinic. A summary of advice to other program directors was "be creative" and "be flexible." CONCLUSIONS: New York's pediatrics residency programs used a variety of mechanisms to meet work hour restrictions. Smaller programs had fewer methods available to them to meet such restrictions. Although the logistical work needed to maintain continuity clinic increased greatly, continuity and outpatient settings themselves were not greatly affected by work hour limitations. Inpatient settings were more affected and experienced much more in the way of change.     

The meagerness of physicians' training in emergency psychiatric intervention

This study was undertaken to determine how much training physicians receive in emergency psychiatric intervention (EPI) during their residency programs. In 1988 the author mailed a questionnaire to 256 program directors of residencies in the major nonpsychiatry specialties. A total of 236 (92%) responded. Their responses indicate that emergency medicine and family practice residency programs provide the most training in EPI, followed by pediatrics, internal medicine, obstetrics-gynecology, and surgery. But overall, EPI training was meager. The findings indicate that 75% of the programs never assigned EPI-oriented readings to the residents and 70% of the programs never gave lectures or seminars on that subject. The author concludes that EPI skills are frequently absent in current medical practice because physicians have not been taught these skills; he recommends that more training is essential and indicates what it might consist of.     

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.     

Psychiatric training in primary care medicine residency programs. A national survey

The authors conducted a national survey to investigate the current status of psychiatric training in primary care/internal medicine residencies. Fifty-four residency training directors completed and returned the survey. The survey results show that an average of 99 hours (69.5 hours clinical plus 29.8 hours didactics) is devoted to psychiatric training during the 3 years of primary care/internal medicine residency training. Responding residency training directors indicated that psychiatric training is important (an average of 7 out of 10 on a 10-point rating scale), and 63% of respondents indicated that more training in psychiatry is needed.     

An analysis of attrition from Canadian neurosurgery residency programs.

PURPOSE: To determine the magnitude of and reasons for attrition from neurosurgical residency programs in Canada. METHOD: Directors of the 13 Canadian neurosurgery residency programs were asked to complete questionnaires on their programs, magnitude of attrition, reasons for attrition, and selection criteria. Open-ended questions were assessed with content analysis and quantified with dual-scaling techniques. Similar questionnaires were sent to 30 residents who had completed training; six residents who had voluntarily withdrawn were interviewed. RESULTS: Twelve of the 13 directors (92%) responded. Forty-two residents voluntarily withdrew from residency training between 1980 and 1992; withdrawal rates grew during that period. The number of dismissals--approximately 1.8 per year--remained constant. Reasons for voluntary withdrawal focused on excessive workloads and unexpected residency demands, whereas reasons for dismissal related primarily to deficits in professional attitudes and behaviors such as interpersonal skills and ethics. In selecting residents, programs with low attrition rates gave more importance to a candidate's work ethic than did programs with high attrition rates. The low-attrition programs also gave more importance to the relationship developed with residents during training. CONCLUSION: These results suggest that voluntary attrition from neurosurgical residency is significant and is related to issues of lifestyle control. Dismissal is rarely related to cognitive or psychomotor deficits, but usually occurs for concerns about professionalism such as ethics and interpersonal skills and behaviors. Further studies are necessary to confirm these findings across specialties and countries.     

Job turnover and its correlates among residency program directors in internal medicine: a three-year cohort study.

PURPOSE: In 1983, 43% of internal medicine residency program directors had held their positions for less than three years. The purposes of this study were to determine the job turnover rate for internal medicine program directors, and the characteristics of program directors and residency programs that are associated with job turnover. METHOD: In October 1996, questionnaires were sent to all non-military internal medicine residency program directors in the continental United States listed by the Accreditation Council for Graduate Medical Education (ACGME). The questionnaire covered demographics, program characteristics, and job satisfaction. In October 1999, an updated ACGME list was used to contact programs to verify changes in program directors and determine the dates of change. RESULTS: A total of 262 usable responses were received. At the beginning of the study, 49% of the respondents had been on the job for three years or less, and 74 (29%) were no longer program directors three years later. Overall job satisfaction was highly associated (p <.01) with turnover. Multivariate Cox regression modeling yielded four variables independently associated with turnover: low satisfaction with colleague relationships (hazard ratio = 3.2, 95% CI = 1.6-6.4), a high percentage of administrative work time (HR = 2.9, 95% CI = 1.4-6.2), perceiving the job as a "stepping stone" (HR = 1.8, 95% CI = 1.0-3.2), and having had formal training to deal with problem residents (HR = 0.6, 95% CI = 0.4-1.1). Respondents with burnout, with the titles of program director and chair or department chief, and with less than two years on the job had nonsignificant trends toward job turnover. Variables not associated with turnover included gender, rank, salary, and program size. CONCLUSIONS: Yearly turnover for internal medicine residency program directors is substantial. The four independent predictors of turnover identified in this study should be of interest to institutions recruiting or retaining program directors and to aspiring program directors.     

Informed consent skills in internal medicine residency: how are residents taught, and what do they learn?

PURPOSE: Obtaining informed consent is an essential skill in internal medicine (IM). The authors' informal observations and formal testing revealed deficiencies in residents' informed consent skills. This study evaluated how residents acquire informed consent skills and how informed consent skills are addressed in Canadian IM residency programs. METHOD: A questionnaire was delivered to all 16 IM program directors in Canada, asking how informed consent is taught and assessed. At the University of Saskatchewan IM residency program, residents were assessed through an objective structured clinical examination station, written examination, and a self-assessment questionnaire. RESULTS: No consistent approach to teaching or evaluating informed consent skills exists within Canadian IM programs. Program directors and residents identified informal mentoring by residents as an important learning modality. Although residents performed well in discussing procedural indications and techniques, discussing risks was inadequate. Residents focused on general and minor risks but avoided discussing serious risks and had difficulty discussing the frequency of complications. Residents lacked a structured approach to assessing capacity and often assessed only comprehension. Residents were unfamiliar with concepts such as material risk, implied consent, and therapeutic privilege. CONCLUSION: Explicit training in informed consent skills is urgently needed. Informal mentoring must be recognized as an important training method for informed consent and supported by appropriate teaching and evaluation strategies to ensure that resident-instructors do so effectively.     

Preparing graduates for the first year of residency: are medical schools meeting the need?

PURPOSE: Changes in graduate medical education associated with full implementation of the Balanced Budget Act of 1997 have required medical schools to review and revise their curricula. As limited funding increases pressures to streamline training, residencies will potentially expect an entry level of skill and competence that is greater than that which schools are currently providing. To determine whether medical school curricular requirements correlate with residency needs, this multidisciplinary pilot study investigated expectations and prerequisites for postgraduate specialty training. METHOD: A questionnaire about 100 skills and competencies expected of new first-year residents was sent to 50 U.S. residency directors from surgery, internal medicine, family medicine, pediatrics, and obstetrics-gynecology programs. Each director was asked to state expectations of a first-year resident's competence in each skill at entry to residency and after three months of training. Skills deemed most appropriately acquired in residency were also identified. Competencies included diagnosis, management, triage, interpretation of data, informatics and technology, record keeping, interpersonal communications, and manual skills. RESULTS: A total of 39 residency directors responded, including seven surgery, nine medicine, seven family medicine, eight pediatrics, and eight obstetrics-gynecology. In addition to physical examination skills, 13 competencies achieved more than 70% agreement as being entry-level skills. There was wide variability as to the relative importance of the remaining skills, with residency directors expecting to devote significant resources and time in early training to ensure competence. CONCLUSIONS: Medical schools should consider the expectations of their students' future residency directors when developing new curricula. Assuring students' competencies through focused curricular change should save both time and resources during residency.     

A successful combination

In 1967, the American Board of Pediatrics and the American Board of Internal Medicine uniformly recognized the 4-year combined medicine and pediatrics training program. Since that time, the number of combined internal medicine and pediatrics programs has increased. Today, there are more than 78 combined residency programs with more than 354 first-year residency positions throughout the United States. Medicine/pediatrics residency programs give the resident the opportunity to rotate 24 months in each specialty. Graduates of combined medicine/pediatrics residency programs have several career options available to them. In 2007, a total of 55% of medicine/pediatrics residents went into primary care practice, 18% went into subspecialty training, 17% went into hospital medicine, and 10% chose other careers.     

Benchmarks of support in internal medicine residency training programs.

PURPOSE: To identify benchmarks of financial and staff support in internal medicine residency training programs and their correlation with indicators of quality. METHOD: A survey instrument to determine characteristics of support of residency training programs was mailed to each member program of the Association of Program Directors of Internal Medicine. Results were correlated with the three-year running average of the pass rates on the American Board of Internal Medicine certifying examination using bivariate and multivariate analyses. RESULTS: Of 394 surveys, 287 (73%) were completed: 74% of respondents were program directors and 20% were both chair and program director. The mean duration as program director was 7.5 years (median = 5), but it was significantly lower for women than for men (4.9 versus 8.1; p =.001). Respondents spent 62% of their time in educational and administrative duties, 30% in clinical activities, 5% in research, and 2% in other activities. Most chief residents were PGY4s, with 72% receiving compensation additional to base salary. On average, there was one associate program director for every 33 residents, one chief resident for every 27 residents, and one staff person for every 21 residents. Most programs provided trainees with incremental educational stipends, meals while oncall, travel and meeting expenses, and parking. Support from pharmaceutical companies was used for meals, books, and meeting expenses. Almost all programs provided meals for applicants, with 15% providing travel allowances and 37% providing lodging. The programs' board pass rates significantly correlated with the numbers of faculty fulltime equivalents (FTEs), the numbers of resident FTEs per office staff FTEs, and the numbers of categorical and preliminary applications received and ranked by the programs in 1998 and 1999. Regression analyses demonstrated three independent predictors of the programs' board pass rates: number of faculty (a positive predictor), percentage of clinical work performed by the program director (a negative predictor), and financial support from pharmaceutical companies (also a negative predictor). CONCLUSIONS: These results identify benchmarks of financial and staff support provided to internal medicine residency programs. Some of these benchmarks are correlated with board pass rate, an accepted indicator of quality in residency training. Program directors and chairs can use this information to identify areas that may benefit from enhanced financial and administrative support.     

Residency directors' assessments of which selection criteria best predict the performances of foreign-born foreign medical graduates during internal medicine residencies.

In the summer of 1990, 102 directors of internal medicine residency programs from nine areas of the country with the largest numbers of foreign-born foreign medical graduates (FFMGs) were surveyed by mail to determine what criteria used to select FFMGs for residency positions best predicted performance. The directors felt that the most important predictors were performance on the Foreign Medical Graduate Examination in the Medical Sciences or the National Board of Medical Examiners examinations; performance during the interview; and postgraduate clinical experience in the United States. Recent graduation from medical school was felt to be a better predictor than postgraduate clinical experience in a foreign country. Seventy-three percent of the directors found letters of recommendation from a foreign country to be useless. The author suggests the results of this study may be useful to residency programs in evaluating FFMG applicants and to FFMGs in assessing their own credentials.     

Home care training in internal medicine residencies: a national survey.

PURPOSE: To determine the amount and type of training U.S. internal medicine residents receive in providing home care to patients. METHOD: A four-item questionnaire was developed and sent to the program directors of all accredited internal medicine residencies in the United States (n = 397) to assess the amounts and types of training (didactic sessions or lectures, house calls, or both) internal medicine residents receive in providing home care. Demographic information about the residency programs was also collected and analyzed. RESULTS: A total of 312 (78.6%) of the program directors responded. Sixty-eight percent of their programs included instruction in home care consisting of house calls, lectures, or both. Fewer than half of the responding programs offered any lecture in home care in their curricula, and only 25% of them included a mandatory house-call experience for trainees. Residency programs that had primary care tracks were more likely than were other programs to include either of these experiences in their curricula. CONCLUSIONS: Most internal medicine residents receive limited training in home care. As a consequence, future internists may be inadequately prepared to meet the needs of their patients, particularly as the population ages.     

Determining the predictors of internal medicine residency accreditation: what they do (not what they say).

PURPOSE: The Accreditation Council for Graduate Medical Education and the Residency Review Committee for Internal Medicine (RRC-IM) evaluate internal medicine residency programs using a list of 301 program requirements. The authors investigated which requirements, program demographics, and site-visitor characteristics were the strongest predictors of accreditation. METHOD: The authors surveyed the program directors of all 405 accredited internal medicine residency programs in February 1998, obtaining data on the duration of the accreditation process, site visitors, and number and quality of citations. They also requested a copy of the notification letter containing citations and length of time until the next accreditation site visit (cycle length). RESULTS: A total of 217 responses (54%) was received. The mean cycle length was 3.0 years, and the accreditation process averaged 14.5 months. Smaller programs had a shorter average cycle length. Site visitors were reported to be prepared and professional overall. However, site visitors with the lowest evaluations by program directors were associated with shorter cycle lengths. Four program characteristics and program citations accounted for 60% of the variation in cycle length: total number of citations in the notification letter, percentage of graduates passing the American Board of Internal Medicine Certifying Examination, inadequate demonstration of resident scholarship, and inadequate ambulatory care experience. CONCLUSION: The authors devised an independent mechanism for determining the duration of the RRC-IM review process, influence of program demographics on the process, influence of site visitors on the accreditation action, and program requirements having the greatest effect on cycle length.     

Surveying the current landscape of clinical genetics residency training

PurposeFurther knowledge about medical genetics residency training structure and function could help advance this educational process.MethodsMedical genetics residency program directors were surveyed about their trainees' backgrounds and skills as well as the recruitment and matching process.ResultsPrevious resident training was predominantly in pediatrics (49%). Average ratings of residents' beginning clinical knowledge (scale of 1–10, minimal to superior) were: dysmorphology - 3.5, inborn errors of metabolism - 2.5, prenatal genetics - 2.6, and cancer genetics - 2.8. On average, four months of research were required for categorical residency and fifteen months for combined residency. For the 2011 transition to ERAS/NRMP, 69% of program directors were extremely or somewhat prepared; however, 21% felt unprepared. The number of trainees at most institutions remained unchanged. 36% of respondents reported that ERAS/NRMP has had no impact on recruitment of trainees, and 26% felt it has had a slightly positive impact. Continued utilization was recommended by 71% while 5% disagreed.ConclusionGenetics residents come from diverse training backgrounds. Their education can be directed toward specific areas of perceived initial weakness. ERAS/NRMP has not drastically increased entrance into the field. Further discussions are merited regarding enhancement of medical genetics residency recruitment and training.Genet Med17 5, 386–390.     

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.