Integrating an evidence-based medicine rotation into an internal medicine residency program.

PURPOSE: To measure the impact of a resident focused evidence-based medicine (EBM) educational intervention on EBM knowledge of residents and students, to assess its feasibility, and to evaluate residents' attitudes regarding this rotation. METHOD: In 2002, based on the EBM user and EBM practitioner model, the authors designed the EBM elective rotation and conducted a controlled trial of its implementation in the internal medicine residency program in three teaching hospitals affiliated with the University at Buffalo, New York. The intervention group (one hospital, 17 medical students and residents) received a multifaceted intervention. In the control group (two hospitals, 23 medical students and residents), there was no curriculum change. The effectiveness in a pre- and post-test was assessed using the English version of the Berlin Questionnaire. A survey of all internal medicine residents (n = 119) was conducted to evaluate their attitudes toward the EBM elective rotation. RESULTS: In the intervention group, knowledge improved slightly, but not significantly (.71 on a scale ranging from 0-15 on the Berlin questionnaire, p =.3). The mean score in the control group decreased significantly (1.65, p =.005). The difference in change scores between the two groups was significant even after adjustment for covariates (2.52, p =.006). Residents (response rate 83%) had positive attitudes regarding the rotation. CONCLUSION: An EBM elective rotation was successfully integrated into a residency program. This multifaceted educational approach with an "on-the-ward" EBM resident, may improve the EBM knowledge and skills of targeted students and residents.     

Third-year medical students' experiences with dying patients during the internal medicine clerkship: a qualitative study of the informal curriculum.

PURPOSE: To explore third-year medical students' experiences with death and dying patients during the first internal medicine clerkship. METHOD: In August 2002, through purposeful sampling, the authors targeted for open-ended interviews 32 third-year medical students at the University of California, San Francisco in the first core internal medicine clerkship. Interviews averaged 45 minutes in length and were audiotaped, transcribed, and analyzed using a grounded theory approach. RESULTS: Twenty-eight (87.5%) students participated in interviews. All students encountered death or dying patients, and most cared directly for at least one dying patient. Students' relationships with patients were characterized by attachment, empathy, and advocacy. Students valued preparation by preclinical end-of-life (EOL) courses, but assigned greater value to patient care experiences guided by teams that acknowledged deaths, role-modeled EOL care, and respected students' participation in patient care. Clerkship experiences in EOL care affected students' developing professional identities by affording opportunities to manage strong emotions, understand the challenges of transitioning to residency, and gain a sense of self-efficacy as future physicians providing EOL care. CONCLUSIONS: Third-year medical students' experiences with dying patients affect their skills and attitudes in EOL care, as well as the emergence of their professional identities. The behaviors and attitudes modeled by residents and attendings during the clerkships can strongly influence students' perceptions of and self-efficacy in EOL care. Further research and interventions into how residents and attendings model responses to death in the clinical clerkship may suggest strategies not only for EOL training, but also for mentoring professional development.     

The preferred learning style among residents and faculty members of an internal medicine residency program

OBJECTIVE: To determine the preferred learning style, as defined by David Kolb, and predictors of the different learning styles among residents and faculty members at an internal medicine residency program. DESIGN/SETTING: A cross sectional study of internal medicine residents and faculty members at Morehouse School of Medicine was performed using the Kolb Learning Style Inventory (LSI) version 3.1. MEASUREMENTS: The Kolb LSI is a questionnaire of 12 sentences, each with four phrases for sentence completion that are to be ranked according to how they apply to the subject. RESULTS: Forty-two out of 59 questionnaires that were given out to residents and attending physicians were properly completed and returned. Assimilating style was the predominant learning style among residents (42%) and attending physicians (55%). There was no significant association between age, gender or medical education status, and learning styles. CONCLUSIONS: The understanding of residents' learning styles may facilitate instructional rapport between residents and attending physicians, thereby improving residents' academic performance.     

Introducing residents to a career in management: the Physician Management Pathway.

To prepare their students and residents for the practice of medicine in a rapidly changing environment, medical educators must teach the business of medicine as well as the science and art of medicine. Recognizing the value of and demand for physician leaders, the authors sought to introduce residents to diverse aspects of medical administration within the context of an academically rigorous internal medicine residency program. The Physician Management Pathway (PMP) was developed in 1997 to expose interested residents to the management concepts employed by physician managers; to help physician trainees begin to develop the leadership and technical skills they will use as physician managers; to provide career mentoring; to provide experiences that enrich the resident's training in clinical medicine; to enhance resident-directed educational activities; and to produce physicians who can successfully work in any health care environment. The PMP curriculum consists of a monthly seminar series, a preceptorship experience in the second year of residency, and a supervised project in the third year. The program was not designed to provide competency in management, but rather is intended to provide an opportunity for new physicians to explore options in this exciting and changing profession.     

How internal medicine residents resolve conflicts with attending physicians

Forty-three of 49 residents in an internal medicine residency answered questionnaires in 1988 about resolving conflicts with attending physicians concerning patient care, using ten case scenarios. The residents indicated their likelihoods of using various methods of addressing the conflicts via Likert-type scales. The residents were most likely to negotiate with the attending physician and least likely to ignore the attending physician or withdraw from the case for all scenarios, though the type of procedure affected the decision. The residents planning careers in general medicine or nonmedical specialties were more likely to agree with the attending physician than were the residents planning medicine subspecialty careers (p less than .005); the graduates from osteopathic schools were more likely to withdraw from the case than were the residents from allopathic schools (p = .05). Conflicts between the residents and attending physicians were resolved by negotiation and interaction with the attending physicians, but the nature of the procedure, medical school attended, and future career plans affected the means of resolving the dilemma chosen by the individual resident.     

The relationship of residents' autonomy and use of a teaching hospital's resources

This 1990 study examines the relationship between the degree of use of patient care resources and the degree of supervision of residents by attending physicians (as perceived by residents) at a large midwestern teaching hospital. Ratings of the degree of clinical autonomy allowed residents by 65 attending physicians--each of whom had a general internal medicine practice with a significant hospital component--were provided by 23 former internal medicine chief residents and 17 internal medicine residents who were in their third year at the time of the study. A regression model was used to test the association between hospital resource use (as shown by total hospital charges to patients and their lengths of stay) and the residents' mean ratings of the degrees of autonomy the attending physicians permitted residents, for 7,169 of these physicians' patients discharged between 1986 and 1989 in 28 diagnosis-related groups. The analysis was controlled for patients' insurance status and chronic disease comorbidities. The patients whose attending physicians were rated as allowing substantial clinical autonomy had significantly lower total charges and lengths of stay (p less than .0001). These results suggest that internal medicine residents have an inherently conservative practice style that values low-intensity workups and rapid discharge of patients.     

Views of managed care--a survey of students, residents, faculty, and deans at medical schools in the United States

BACKGROUND AND METHODS: Views of managed care among academic physicians and medical students in the United States are not well known. In 1997, we conducted a telephone survey of a national sample of medical students (506 respondents), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S. medical schools to determine their experiences in and perspectives on managed care. The overall rate of response was 80.1 percent. RESULTS: Respondents rated their attitudes toward managed care on a 0-to-10 scale, with 0 defined as "as negative as possible" and 10 as "as positive as possible." The expressed attitudes toward managed care were negative, ranging from a low mean (+/-SD) score of 3.9+/-1.7 for residents to a high of 5.0+/-1.3 for deans. When asked about specific aspects of care, fee-for-service medicine was rated better than managed care in terms of access (by 80.2 percent of respondents), minimizing ethical conflicts (74.8 percent), and the quality of the doctor-patient relationship (70.6 percent). With respect to the continuity of care, 52.0 percent of respondents preferred fee-for-service medicine, and 29.3 percent preferred managed care. For care at the end of life, 49.1 percent preferred fee-for-service medicine, and 20.5 percent preferred managed care. With respect to care for patients with chronic illness, 41.8 percent preferred fee-for-service care, and 30.8 percent preferred managed care. Faculty members, residency-training directors, and department chairs responded that managed care had reduced the time they had available for research (63.1 percent agreed) and teaching (58.9 percent) and had reduced their income (55.8 percent). Overall, 46.6 percent of faculty members, 26.7 percent of residency-training directors, and 42.7 percent of department chairs reported that the message they delivered to students about managed care was negative. CONCLUSIONS: Negative views of managed care are widespread among medical students, residents, faculty members, and medical school deans.     

Impact of reduced duty hours on residents' educational satisfaction at the University of California, San Francisco.

PURPOSE: To assess the impact of the Accreditation Council for Graduate Medical Education duty-hour limitations on residents' educational satisfaction. METHOD: In 2003, the authors surveyed 164 internal medicine residents at three clinical training sites affiliated with the University of California, San Francisco, after system changes were introduced to reduce duty hours. On a questionnaire that used various rating scales, residents reported the value of educational activities, frequency of administrative tasks interfering with education, and educational satisfaction after duty hours were reduced. The authors compared univariate statistics and developed multivariable models to discern the relationship between hours worked and educational outcomes. RESULTS: In all, 125 residents (76%) responded. Residents rated the educational activities, morning report, and teaching others most highly. Answering pages and tasks related to scheduling were the most frequent barriers to educational activities. Residents reported that time spent in administrative activities did not change after duty-hour restrictions, and 68% said that decreased duty hours had no impact or a negative impact on education. In multivariable models, postgraduate year (PGY)-1 residents (p = .004), residents who reported feeling overwhelmed at work (p < .0001), and residents who reported working more than 80 hours per week (p < .05) had lower work satisfaction. However, only PGY-1 residents (p < .05) and those who felt overwhelmed with work (p = .01) were less satisfied with their education. CONCLUSIONS: In this residency program, duty-hour reduction did not improve educational satisfaction. Educational satisfaction may be more a function of workload than hours worked; therefore, systematic changes to residents' work-life may be necessary to improve educational satisfaction.     

A comparison of the personality profiles of internal medicine residents, physician role models, and the general population.

PURPOSE: To compare personality profiles of internal medicine residents with those of the general population and positive role models in medicine. METHOD: A widely used personality inventory, NEO PI-R, which measures five major personality factors and 30 important personality facets, was administered in 1998 to 104 physicians in internal medicine residency and earlier to a nationwide sample of 188 physicians selected as positive role models in medicine. RESULTS: The internal medicine residents, compared with the general population, were more likely to be attentive, to have deeper intellectual curiosity, to have higher aspiration levels, to have more vivid imaginations, to be more receptive to their emotions, to be interested in mental stimulation, and to think carefully before acting. The residents, compared with role models in medicine, were less eager to face challenges, less able to control their impulses, less able to cope with adversity, less easygoing, and less relaxed, but were more likely to crave excitement. CONCLUSION: Internal medicine residents and positive role models in medicine have some distinct personal qualities. Understanding the qualities of successful physicians can be helpful in career counseling of medical students and young physicians.     

Hospital to home: Improving internal medicine residents' understanding of the needs of older persons after a hospital stay.

Physicians-in-training discharge many older patients from the hospital, but few have any knowledge of what happens to the patients they send home, of how discharge plans are applied, or of the difficulties patients and their families face. The authors describe a pilot program, Hospital to Home, at the University of Rochester School of Medicine and Dentistry's internal medicine residency program, which uses home visits as an educational tool in geriatrics training. The program was begun in July 2001, and 23 residents have participated. Home visits expose residents in their first-year geriatrics rotation to the elements and outcomes of discharge planning and create a heightened awareness of the needs of older persons recently discharged from the hospital. The home visits are videotaped, and the residents present a videoconference based on the visits, which are attended by internal medicine residents, family medicine residents, and medical students. The authors describe the three-part Hospital to Home program, three vignettes that highlight learning experiences, and the residents' feedback about the experience and the use of audiovisual recording for education.     

An innovative, longitudinal program to teach residents about end-of-life care.

At the University of California, Irvine Medical Center, an end-of-life curriculum was implemented in 2000 for an internal medicine residency utilizing a longitudinal approach that allowed residents to follow patients through their entire hospice experience. An elective home hospice rotation was developed for which third-year residents served as primary care physicians for patients at the end of life over a one-year period. Residents were supervised by faculty who were hospice medical directors. They also learned through case vignettes, quarterly meetings, textbook reading, and personal projects. From July 2000 to June 2002, residents demonstrated positive attitudes towards hospice care and recommended the rotation highly (mean 8.86 on a scale of 1-10). The rotation grew in popularity from six initial residents to ten residents the next year, and has since become a mandatory rotation for all senior residents. A 360-degree evaluation uniformly indicated positive resident performance from the hospice team (mean scores 7.56-8.69 on a 1-9 scale), family (mean scores 9.3-9.7 on a 1-10 scale) and faculty (mean scores 7.29-7.72 on a 1-9 scale). Residents were also pleased with the level of teaching (mean 8.86 on a scale of 1-10) and felt that the patient care load was "just right." Their knowledge improved by 8% (p =.0175). In conclusion, a longitudinal hospice rotation was implemented that fulfilled curricular goals without undue burden on the residents or residency program.     

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.     

The effect of a teaching skills course on interns' and students' evaluations of their resident--teachers.

PURPOSE: To determine the effect that a six-hour course on resident teaching and leadership skills had on residents' teaching evaluations. METHOD: The authors analyzed six years of teaching evaluations of second- and third-year internal medicine residents at the University of Washington: three years before and three years after a resident teaching skills course was introduced in 1992. Interns and students rated their resident-teachers using a nine-question standardized clinical teaching assessment form (CTAF). Evaluations at baseline (the three years before the course) were compared with evaluations for the three years after the intervention. RESULTS: The authors analyzed 3,946 evaluations of 235 second-year and 211 third-year residents. Despite already high baseline evaluations, mean ratings of the CTAF showed continuous and statistically significant improvement in each year after the introduction of the course (p < .001). There was no significant difference between evaluations from students and those from interns. CONCLUSION: A six-hour teaching skills course significantly improved residents' teacher ratings. Residents are important teachers of interns and medical students and serve as their primary ward supervisors; therefore, sessions on teaching skills should be part of required curricula for all residency programs.     

Using standardized patients to assess the geriatrics medicine skills of medical students, internal medicine residents, and geriatrics medicine fellows.

PURPOSE: Medical schools and residency programs are placing additional emphasis on including clinical geriatrics competencies within their curricula. An eight-station, Geriatric Medicine Standardized Patient Examination (GSPX) was studied as a method to assess bedside geriatrics clinical skills over the continuum of medical education from medical school through residency and fellowship training. METHOD: The GSPX was administered to 39 medical students, 49 internal medicine residents, and 11 geriatrics medicine fellows in 2001-02. Reliability of standardized patient (SP) checklists and rating scales used to assess examinees' performance was measured by Cronbach's alpha. Validity was measured by surveying the examinees' assessment of fairness, individual case length, difficulty, and believability, and by faculty standard setting for each level of trainee. RESULTS: Reliability was high (alpha =.89). All levels of examinees found the SPs to be believable, station lengths to be adequate, and rated the GSPX as a fair assessment. Students rated the cases as more difficult. Previous experience with similar real patients increased significantly with level of training (Pearson's r =.48, p <.0001). Faculty set passing scores that increased from students to residents to fellows. However, GSPX scores decreased with level of training (r = -.25, p =.01). CONCLUSION: The GSPX is a reliable measure of geriatrics medicine skills with adequate face validity for examinees at all levels. However, GSPX scores did not increase with level of training, suggesting that a single form of the examination cannot be used across the continuum of training. Potential modifications to the GSPX that might provide more discrimination between levels of training are currently being explored.     

A prospective study of internal medicine residents' emotions and attitudes throughout their training

To evaluate whether the negative emotions and attitudes that residents develop during internship continue throughout the remaining years of their residency, the authors undertook a four-year prospective study of two classes of internal medicine residents who completed their training in 1985 and 1986 in a residency program based at the Oregon Health Sciences University. Every two to three months over all three years of training, the residents indicated on Likert-type scales their levels of agreement with questions about their career satisfaction and emotional states, and the satisfying and dissatisfying aspects of their residency experiences. Between the internship and the end of their residencies, the physicians indicated significant improvements in their emotions and attitudes. Those experiences identified as satisfying continued to be so, whereas those considered dissatisfying became less so. Although more research of other classes of residents is needed, the findings suggest that while internal medicine internships may be dysphoric, the residents' emotional states and attitudes tend to normalize during the remainder of the residency.     

Making fun of patients: medical students' perceptions and use of derogatory and cynical humor in clinical settings.

PURPOSE: It has long been known that medical students become more cynical as they move through their training, and at times even exhibit "ethical erosion." This study examines one dimension of this phenomenon: how medical students perceive and use derogatory and cynical humor directed at patients. METHOD: The authors conducted five voluntary focus groups over a three-month period with 58 third- and fourth-year medical students at the Northeastern Ohio Universities College of Medicine in 2005. After transcribing the taped interviews, the authors analyzed the data using qualitative methods and identified themes found across groups. RESULTS: The categories that emerged from the data were (1) categories of patients who are objects of humor, including those deemed "fair game" due to obesity or other conditions perceived as preventable or self-inflicted; (2) locations for humor; (3) the "humor game," including student, resident, and faculty interaction and initiation of humor; (4) not-funny humor; and (5) motives for humor, including coping and stress relief. CONCLUSIONS: The authors offer recommendations for addressing the use of derogatory humor directed at patients that include a more critical, open discussion of these attitudes and behaviors with medical students, residents, and attending physicians, and more vigorous attention to faculty development for residents.