Evaluation of procedural skills of internal medicine residents

In 1983 the American Board of Internal Medicine mandated that training programs assess residents in procedural skills prior to board certification. Beginning in 1984, the University of Hawaii developed an assessment and testing program that consists of a three-phase evaluation process for qualifying internal medicine residents in basic procedural skills: an observation period spanning the three-year residency, a 100-question multiple-choice examination, and a slide-identification examination involving simple identification of body fluid elements. From 1984 through 1987 the mean scores of both examinations were analyzed for each level of residency and for each year of testing to assess whether curriculum changes were effective. There was a statistically significant improvement (p less than .005) in performance on both the multiple-choice and the slide-identification examinations as the residents progressed through the program. No difference in performance was found for the multiple-choice examination between calendar years, but a significant difference (p less than .01) was found for the slide-identification examination between calendar years. Despite perceptions by the faculty that their increased emphasis on the learning of procedural skills has been successful, the multiple-choice examination results over time do not support this belief. These findings suggest that residents need more structured curriculum guidelines to aid their learning and faculty members require better direction in the educational goals for procedural skills training.     

Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries

BACKGROUND: Hospital discharge summaries have traditionally been paper-based (handwritten or dictated), and deficiencies have often been reported. On the increase is the utilisation of electronic summaries, which are considered of higher quality than paper-based summaries. However, comparisons between electronic and paper-based summaries regarding documentation deficiencies have rarely been made and there have been none in recent years. OBJECTIVES: (1) To study the hospital discharge summaries, which were either handwritten or electronic, of a population of inpatients, with regard to documentation of information required for ongoing care; and (2) to compare the electronic with the handwritten summaries concerning documentation of this information. METHODS: The discharge summaries of 245 inpatients were examined for documentation of the items: discharge date; additional diagnoses; summary of the patient's progress in hospital; investigations; discharge medications; and follow-up (instructions to the patient's general practitioner). One hundred and fifty-one (62%) discharge summaries were electronically created and 94 (38%) were handwritten. Odds ratios (ORs) with their confidence intervals (CI) were estimated to show strength of association between the electronic summary and documentation of individual study items. RESULTS: Across all items studied, the electronic summaries contained a higher number of errors and/or omissions than the handwritten ones (OR 1.74, 95% CI 1.26-2.39, p<0.05). Electronic summaries more commonly documented a summary of the patient's progress in hospital (OR 18.3, 95% CI 3.33-100, p<0.05) and less commonly recorded date of discharge and additional diagnoses (respective ORs 0.17 (95% CI 0.09-0.31, p<0.05) and 0.33 (95% CI 0.15-0.89, p<0.05). CONCLUSION: It is not necessarily the case that electronic discharge summaries are of higher quality than handwritten ones, but free text items such as summary of the patient's progress may less likely be omitted in electronic summaries. It is unknown what factors contributed to incompleteness in creating the electronic discharge summaries investigated in this study. Possible causes for deficiencies include: insufficient training; insufficient education of, and thus realisation by, doctors regarding the importance of accurate, complete discharge summaries; inadequate computer literacy; inadequate user interaction design, and insufficient integration into routine work processes. Research into these factors is recommended. This study suggests that not enough care is taken by doctors when creating discharge summaries, and that this is independent of the type of method used. The importance of the discharge summary as a chief means of transferring patient information from the hospital to the primary care provider needs to be strongly emphasised.     

A women's health track for internal medicine residents using evidence-based medicine.

OBJECTIVES: Evidenced-based medicine has established itself as an integral part of medical education and practice. The explosion of new knowledge in women's health and the need to teach this to internal medicine residents in an evidence-based fashion have presented a challenge to medical educators. To address this need, we developed and implemented an evidence-based women's health curriculum to be used in addition to clinical training in a women's health center for internal medicine residents. The objectives of the curriculum are to (1) define and utilize basic evidence-based medicine concepts to critically analyze women's health literature, (2) understand recent innovations in women's health from an evidence-based viewpoint, (3) gain clinical experience in women's health, and (4) apply evidence-based medicine to the clinical practice of women's health. DESCRIPTION: We designed our curriculum based on recommendations from the National Academy of Women's Health Medical Education, the American Board of Internal Medicine, the Fifth Report of the Council on Graduate Medical Education, and the results of needs assessments of internal medicine residents at our institution. Using Medline to create a women's health bibliography, an extensive literature search was performed on the following topics: osteoporosis, breast cancer, hormone replacement therapy, domestic violence, coronary artery disease in women, menopause, headaches, substance abuse in women, urinary incontinence, dementia, sexual dysfunction, and evidence-based medicine. Peer-reviewed journal articles were compiled by subject matter for placement in our clinic's resource center and were entered into a computerized database that will link with online journals and be available for electronic access. Most articles were selected based on the criteria of data published since 1990, and randomized, double-blinded, placebo-controlled studies were given preference. Weekly 45-minute sessions preceding the resident clinic in the women's health center are held in a journal-club format to review literature in a systematic fashion. Faculty and residents review and analyze one to two articles weekly. Content experts provide context and clinical expertise to resident discussions. Clinical questions, such as "Should I prescribe hormone replacement therapy to my postmenopausal patient?" are addressed in each session. Evidence-based medicine core concepts are reviewed and applied; these core concepts include the number needed to treat, absolute risk reduction, and relative risk. DISCUSSION: The women's health curriculum, weekly conferences, and clinical experience serve to update residents and clinicians in women's health literature, to exchange ideas for the improvement of women's health as it is taught in internal medicine, and to further elucidate the evidence behind what we practice and teach. The curriculum equips physicians to provide patients with solid, evidence-based interpretations of new scientific knowledge to discern truth from fallacy.     

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.     

Sleep and motor performance in on-call internal medicine residents

STUDY OBJECTIVES: To compare vigilance and performance among internal medicine residents doing in-house call versus residents not doing in-house call. DESIGN: Prospective study of resident cohorts with repeated testing. SETTING: University Teaching Hospital. PARTICIPANTS: Internal medicine residents doing in-house call and residents not doing in-house call (pathology, endocrinology) (controls). MEASUREMENTS AND RESULTS: Subjective sleepiness scores (daily Stanford Sleepiness Scale and Epworth Sleepiness Scale at start and end of the test period), actigraphy, and daily sleep logs as well as regular psychomotor vigilance testing using a Palm version (Walter Reed Army Institute of Research) of the Psychomotor Vigilance Test (PVT). Subjects were enrolled for a period of 28 to 32 days, which included 4 to 6 on-call nights for the internal medicine residents. Controls took call from home. Participants were compensated for their time. RESULTS: Twenty residents were evaluated, 13 internal medicine and 7 controls. Overall median reaction time was slower in the internal medicine residents (264.7 +/- 102.9 vs 239.2 +/- 26.1 milliseconds; P < .001). Internal medicine residents showed no difference in reaction time postcall versus other periods (269.9 +/- 131.2 vs 263.6 +/- 95.6; P = .65). Actigraphic sleep time was shorter during on-call than noncall nights and in internal medicine residents as compared with controls (287.48 +/- 143.8 vs 453.49 +/- 178.5 and 476.08 +/- 71.9 minutes; P < .001). Internal medicine residents had significantly greater major and minor reaction-time lapses compared with controls (1.26 +/- 3.4 vs 0.53 +/- 1.1 & 2.4 +/- 7.4 vs 0.45 +/- 1.0; P < .001). They reported increased sleepiness on postcall days compared with the start of their call (Stanford Sleepiness Scale: 3.26 +/- 1.2 vs 2.22 +/- 0.8; P < .001) but had scores similar to those of controls by their next call (2.22 +/- 0.8 vs 2.07 +/- 0.8; P = .13). CONCLUSIONS: Internal medicine residents have impaired reaction time and reduced vigilance compared with controls. Despite subjective improvements in sleepiness postcall, there was no change in their objective performance across the study period, suggesting no recovery. Internal medicine residents did not get extra sleep on postcall nights in an attempt to recover their lost sleep time. Implications for residents' well-being and patient care remain unclear.     

Associations between subspecialty fellowship interest and knowledge of internal medicine: A hypothesis-generating study of internal medicine residents

Background  

Little is known about whether and how medical knowledge relates to interest in subspecialty fellowship training. The purpose of this study was to examine the relationships between residents' interest in subspecialty fellowship training and their knowledge of internal medicine (IM).     

Opinions about management of geriatric syndromes given by internal medicine residents in two programs

Internal medicine residents in two programs providing different amounts of training in geriatrics were surveyed in 1988 regarding their opinions about the management of four geriatric problems and two traditional internal medicine problems. The residents generally agreed that geriatric problems were legitimate concerns in a general internal medicine practice but demonstrated less confidence in the management of geriatric problems than in the management of traditional problems. Residents from the program that provided more extensive training in geriatrics evidenced greater support for nondiscriminatory care of elderly diabetics; otherwise there was no convincing evidence of differences between the two programs. The authors conclude that educational efforts in geriatrics need to target trainees' confidence in the management of geriatric problems.     

Effects of call on sleep and mood in internal medicine residents

Residents on call experience decreased total sleep time (TST) and increased dysphoria. This study monitored changes in mood and sleepiness for 3 post-call days. Fifty-two internal medicine residents participated in the study. The residents wore actigraphs for the 4 to 9 days of the study. Each morning resident completed mood scales, a sleepiness scale, and estimated their prior night TST. The residents were on a 1-in-4 schedule. Call decreased subjective- and actigraphy-derived TST to less than 4 hr. During the 3 days post call, mood measures improved. Tension, depression, and anxiety stabilized on the first post-call day following the first night of off-call sleep during which the residents obtained about 7 hr of sleep. Vigor, fatigue, and confusion stabilized on the second post-call day. The Epworth Sleepiness Scale dropped to less than 11 after 1 post-call night and continued to decrease up to 3 post-call days. The effects of call linger past the first recovery night. For these residents, recovery sleep appeared inadequate, and the negative effects of call persisted across succeeding off-call days. Thus, for these residents on a 1-in-4 schedule, call affects their mood for much of the time when off call and potentially their personal and professional interactions during this period as well.     

Evaluation of emergency medicine residents by nurses

Emergency medicine residents at William Beaumont Hospital are evaluated quarterly by the nursing staff. The nurse discuss each resident and reach consensus on each evaluation item. Copies of the evaluations are given to each resident, and a copy is used at the resident's biannual evaluation meeting with the program director. Between September 1985 and December 1987, 45 residents in all three years of training were evaluated by the nursing staff on four aspects of performance: managerial skills, communication, teamwork, and clinical organization. The nurses were able to evaluate behavior not usually seen by supervising physicians. Although the residents' attitudes toward these evaluations have not been entirely favorable, overall their behavioral interactions have improved markedly.     

From hagfish to humans: teaching comparative physiology to internal medicine residents

With more clinical information for trainees to master in the face of increasing time pressures, discussions about underlying physiology and the mechanisms of disease seem to have been de-emphasized during residency training. This reduced focus on pathophysiology and basic science may weaken trainees' clinical effectiveness and reduce their interest in pursuing research careers.In response, the authors helped to develop in 2006 a one-week immersive comparative physiology course for second- and third-year internal medicine residents at Beth Israel Deaconess Medical Center. The course, held at the Mount Desert Island Biological Laboratory, includes four modules (hematology, vascular physiology, secretory physiology, and salt and water homeostasis), each composed of basic science experiments using aquatic species and accompanied by clinical correlation discussions and group presentations.From 2007 to 2010, 72 residents rotated through the course. Most reported that it enhanced their understanding of the mechanisms of disease in their patients. After the course, residents reported that physiology played a more prominent role in their teaching and clinical decision making during both ward and intensive care unit rotations. They also reported being more likely than before the course to read about the pathophysiology of disease when faced with a clinical problem.Although cost-intensive and geographically unique, this model for teaching the mechanisms of disease could be applied elsewhere with the help of physician-scientists and clinician-educators. In this article, the authors describe the development of the course, share preliminary data evaluating progress toward its goals, and discuss future directions and lessons learned.     

独立值班考核制度在内科住院医师规范化培训中的应用

目的介绍北京协和医院内科创立的独立值班考核制度,分析该考核制度在住院医师独立值班能力评价和分层中的作用。方法对北京协和医院内科2017年和2018年内科住院医师独立值班考核的结果进行统计,分析不同来源的住院医师在考试次数、通过考试所需时间和通过率方面的分布。结果内科临床医学博士后、专业型临床硕士研究生和北京市基地规培住院医师在通过独立值班考核所需次数方面无差异;内科临床博士后通过考核用时最短,专业型临床硕士研究生次之,北京市规培住院医师用时最长(χ²=96.27,P<0.05),可以进行初步分层;通过临床带教,大部分住院医师都能在实习6个月内通过独立值班考核,承担独立值班工作。结论在内科住院医师规范化培训中,独立值班考核制度能够客观评价住院医师的值班能力,最大限度的保证临床安全。北京市基地规培住院医师通过考核时间较长,应注意加强临床教学、提高学员能力。     

Training experiences of U.S. combined internal medicine and pediatrics residents.

PURPOSE: To investigate the demographics and training experiences of internal medicine and pediatrics (med-peds) physicians. METHOD: A cross-sectional survey addressing demographics, training experiences, and career plans of fourth-year residents graduating from combined internal medicine and pediatrics programs that were identified in the American Academy of Pediatrics database was initiated in May 2003. Questionnaires were mailed up to four times to nonresponders through August 2003. RESULTS: Valid responses were received from 212 of the 340 graduating residents (62% response rate). The majority (186/208 [89%]) reported that they would choose med-peds training again. Career planning (135/210 [64%]), office management (173/212 [82%]), and outpatient procedures (155/211 [73%]) were the only areas where the majority desired more training. Neonatal intensive care training was the only topic area that the majority of residents (142/212 [67%]) reported could have been carried out in less time. Nearly all residents (183/196 [93%]) planned to care for children and adults. Residents' self-assessment of their preparation was good to excellent for evidence-based medicine (192/210 [91%]), caring for patients with special health care needs (179/209 [86%]), and use of information technology (169/208 [81%]). Residents felt equally well prepared for postgraduate activities in internal medicine and pediatrics primary care (170/212 [80%] versus 163/211 [77%], p = .305, NS) and internal medicine and pediatric fellowships (186/207 [90%] versus 181/208 [87%], p = .058, NS). Only 112 of 209 residents (54%) felt their preparation for research was good to excellent. CONCLUSIONS: The study findings suggest that med-peds residents are satisfied with their decision to train in med-peds and with their level of preparation. They feel equally well prepared to care for adults and children, and well prepared to care for patients that may transition to adulthood with complex needs, to assess evidence, and to use information technology.     

Recognition of medication information from discharge summaries using ensembles of classifiers

ABSTRACT: BACKGROUND: Extraction of clinical information such as medications or problems from clinical text is an important task of clinical natural language processing (NLP). Rule-based methods are often used in clinical NLP systems because they are easy to adapt and customize. Recently, supervised machine learning methods have proven to be effective in clinical NLP as well. However, combining different classifiers to further improve the performance of clinical entity recognition systems has not been investigated extensively. Combining classifiers into an ensemble classifier presents both challenges and opportunities to improve performance in such NLP tasks. METHODS: We investigated ensemble classifiers that used different voting strategies to combine outputs from three individual classifiers: a rule-based system, a support vector machine (SVM) based system, and a conditional random field (CRF) based system. Three voting methods were proposed and evaluated using the annotated data sets from the 2009 i2b2 NLP challenge: simple majority, local SVM-based voting, and local CRF-based voting. RESULTS: Evaluation on 268 manually annotated discharge summaries from the i2b2 challenge showed that the local CRF-based voting method achieved the best F-score of 90.84% (94.11% Precision, 87.81% Recall) for 10-fold cross-validation. We then compared our systems with the first-ranked system in the challenge by using the same training and test sets. Our system based on majority voting achieved a better F-score of 89.65% (93.91% Precision, 85.76% Recall) than the previously reported F-score of 89.19% (93.78% Precision, 85.03% Recall) by the first-ranked system in the challenge. CONCLUSIONS: Our experimental results using the 2009 i2b2 challenge datasets showed that ensemble classifiers that combine individual classifiers into a voting system could achieve better performance than a single classifier in recognizing medication information from clinical text. It suggests that simple strategies that can be easily implemented such as majority voting could have the potential to significantly improve clinical entity recognition.