Anne Pereira

Important Skills for Internship and the Fourth-year Medical School Courses to Acquire Them: A National Survey of Internal Medicine Residents

Purpose To obtain feedback from internal medicine residents, a key stakeholder group, regarding both the skills needed for internship and the fourth-year medical school courses that prepared them for residency. This feedback could inform fourth-year curriculum redesign efforts. Method All internal medicine residents taking the 2013–2014 Internal Medicine In-Training Examination were asked to rank the importance of learning 10 predefined skills prior to internship and to use a dropdown menu of 11 common fourth-year courses to rank the 3 most helpful in preparing for internship. The predefined skills were chosen based on a review of the literature, a national subinternship curriculum, and expert consensus. Chi-square statistics were used to test for differences in responses between training levels. Results Of the 24,820 internal medicine residents who completed the exam, 20,484 (83%) completed the survey, had complete identification numbers, and consented to have their responses used for research. The three skills most frequently rated as very important were identifying when to seek additional help and expertise, prioritizing clinical tasks and managing time efficiently, and communicating with other providers around care transitions. The subinternship/acting internship was most often selected as being the most helpful course in preparing for internship. Conclusions These findings indicate which skills and fourth-year medical school courses internal medicine residents found most helpful in preparing for internship and confirm the findings of prior studies highlighting the perceived value of subinternships. Internal medicine residents and medical educators agree on the skills students should learn prior to internship.

Burnout and Physical Activity in Minnesota Internal Medicine Resident Physicians

BACKGROUND Regular physical activity plays an important role in the amelioration of several mental health disorders; however, its relationship with burnout has not yet been clarified. OBJECTIVE To determine the association between achievement of national physical activity guidelines and burnout in internal medicine resident physicians. METHODS A Web-based survey of internal medicine resident physicians at the University of Minnesota and Hennepin County Medical Center was conducted from September to October 2012. Survey measures included the Maslach Burnout Inventory-Human Services Survey and the International Physical Activity Questionnaire. RESULTS Of 149 eligible residents, 76 (51.0%) completed surveys, which were used in the analysis. Burnout prevalence, determined by the Maslach Burnout Inventory, was 53.9% (41 of 76). Prevalence of failure to achieve US Department of Health and Human Services physical activity guidelines was 40.8% (31 of 76), and 78.9% (60 of 76) of residents reported that their level of physical activity has decreased since they began medical training. Residents who were able to meet physical activity guidelines were less likely to be burned out than their fellow residents (OR, 0.38, 95% CI 0.147-0.99). CONCLUSIONS Among internal medicine resident physicians, achievement of national physical activity guidelines appears to be inversely associated with burnout. Given the high national prevalence of burnout and inactivity, additional investigation of this relationship appears warranted.

Improving learner handovers in medical education

Multiple studies have demonstrated that the information included in the Medical Student Performance Evaluation fails to reliably predict medical students’ future performance. This faulty transfer of information can lead to harm when poorly prepared students fail out of residency or, worse, are shuttled through the medical education system without an honest accounting of their performance. Such poor learner handovers likely arise from two root causes: (1) the absence of agreed-on outcomes of training and/or accepted assessments of those outcomes, and (2) the lack of standardized ways to communicate the results of those assessments. To improve the current learner handover situation, an authentic, shared mental model of competency is needed; high-quality tools to assess that competency must be developed and tested; and transparent, reliable, and safe ways to communicate this information must be created. To achieve these goals, the authors propose using a learner handover process modeled after a patient handover process. The CLASS model includes a description of the learner’s Competency attainment, a summary of the Learner’s performance, an Action list and statement of Situational awareness, and Synthesis by the receiving program. This model also includes coaching oriented towards improvement along the continuum of education and care. Just as studies have evaluated patient handover models using metrics that matter most to patients, studies must evaluate this learner handover model using metrics that matter most to providers, patients, and learners.

An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

Continuity Clinic Model and Diabetic Outcomes in Internal Medicine Residencies: Findings of the Educational Innovations Project Ambulatory Collaborative.

BACKGROUND Efforts to improve diabetes care in residency programs are ongoing and in the midst of continuity clinic redesign at many institutions. While there appears to be a link between resident continuity and improvement in glycemic control for diabetic patients, it is uncertain whether clinic structure affects quality measures and patient outcomes. METHODS This multi-institutional, cross-sectional study included 12 internal medicine programs. Three outcomes (glycemic control, blood pressure control, and achievement of target low-density lipoprotein [LDL]) and 2 process measures (A1C and LDL measurement) were reported for diabetic patients. Traditional, block, and combination clinic models were compared using analysis of covariance (ANCOVA). Analysis was adjusted for continuity, utilization, workload, and panel size. RESULTS No significant differences were found in glycemic control across clinic models (P = .06). The percentage of diabetic patients with LDL < 100 mg/dL was 60% in block, compared to 54.9% and 55% in traditional and combination models (P = .006). The percentage of diabetic patients with blood pressure < 130/80 mmHg was 48.4% in block, compared to 36.7% and 36.9% in other models (P < .001). The percentage of diabetic patients with HbA1C measured was 92.1% in block compared to 75.2% and 82.1% in other models (P < .001). Also, the percentage of diabetic patients with LDL measured was significantly different across all groups, with 91.2% in traditional, 70.4% in combination, and 83.3% in block model programs (P < .001). CONCLUSIONS While high scores on diabetic quality measures are achievable in any clinic model, the block model design was associated with better performance.

Drivers of Application Inflation: A National Survey of Internal Medicine Residents

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Collaborating for Competency—A Model for Single Electronic Health Record Onboarding for Medical Students Rotating among Separate Health Systems

BACKGROUND Use of the electronic health record (EHR) is widespread in academic medical centers, and hands-on EHR experience in medical school is essential for new residents to be able to meaningfully contribute to patient care. As system-specific EHR training is not portable across institutions-even when the same EHR platform is used-students rotating across health systems are often required to spend time away from clinical training to complete each systems, often duplicative, EHR training regardless of their competency within the EHR. METHODS We aimed to create a single competency-based Epic onboarding process that would be portable across all the institutions in which our medical students complete clinical rotations. In collaboration with six health systems, we created online EHR training modules using a systematic approach to curriculum development and created an assessment within the Epic practice environment. RESULTS All six collaborating health systems accepted successful completion of the developed assessment in lieu of standard site-specific medical student EHR training. In the pilot year, 443 students (94%) completed the modules and assessment prior to their clinical training and successfully entered clinical rotations without time consuming, often repetitive onsite training, decreasing the cumulative time as student might be expected to engage in Epic onboarding as much as 20-fold. CONCLUSION Medical schools with multisystem training sites with a single type of EHR can adopt this approach to minimize training burden for their learners and to allow them more time in the clinical setting with optimized access to the EHR.

Competency-Based Medical Education in the Internal Medicine Clerkship: A Report From the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force

As medical educators continue to redefine learning and assessment across the continuum, implementation of competency-based medical education in the undergraduate setting has become a focus of many medical schools. While standards of competency have been defined for the graduating student, there is no uniform approach for defining competency expectations for students during their core clerkship year. The authors describe the process by which an Alliance for Academic Internal Medicine task force developed a paradigm for competency-based assessment of students during their inpatient internal medicine (IM) clerkship. Building on work at the resident and fellowship levels, the task force focused on the development of key learning outcomes as defined by entrustable professional activities (EPAs) that were specific to educational experiences on the IM clerkship, as well as identification of high-priority assessment domains. The work was informed by a national survey of clerkship directors.Six key EPAs emerged: generating a differential diagnosis, obtaining a complete and accurate history and physical exam, obtaining focused histories and clinically relevant physical exams, preparing an oral presentation, interpreting the results of basic diagnostic studies, and providing well-organized clinical documentation. A model for assessment was proposed, with descriptors aligned to the scale of supervision and mapped to Accreditation Council for Graduate Medical Education domains of competence. The proposed paradigm offers a standardized template that may be used across IM clerkships, and which would effectively bridge competency evaluation in the clerkship to fourth-year assessment as well as eventual postgraduate training.