Brent W. Beasley

Rehabilitation for patients with chronic obstructive pulmonary disease: meta-analysis of randomized controlled trials

AbstractOBJECTIVE: To develop a meta-analysis to determine the effectiveness of rehabilitation in patients with chronic obstructive pulmonary disease (COPD). DATA SOURCES: MEDLINE, CINHAL, and Cochrane Library searches for trials of rehabilitation for COPD patients. Abstracts presented at national meetings and the reference lists of pertinent articles were reviewed. STUDY SELECTION: Studies were included if: trials were randomized; patients were symptomatic with forced expiratory volume in one second (FEV1) <70% or FEV1 divided by forced vital capacity (FEV1/FVC) <70% predicted; rehabilitation group received at least 4 weeks of rehabilitation; control group received no rehabilitation; and outcome measures included exercise capacity or shortness of breath. We identified 69 trials, of which 20 trials were included in the final analysis. DATA EXTRACTION: Effect of rehabilitation was calculated as the standardized effect size (ES) using random effects estimation techniques. RESULTS: The rehabilitation groups of 20 trials (979 patients) did significantly better than control groups on walking test (ES=0.71; 95% confidence interval [95% CI], 0.43 to 0.99). The rehabilitation groups of 12 trials (723 patients) that used the Chronic Respiratory Disease Questionnaire had less shortness of breath than did the control groups (ES=0.62; 95% CI, 0.35 to 0.89). Trials that used respiratory muscle training only showed no significant difference between rehabilitation and control groups, whereas trials that used at least lower-extremity training showed that rehabilitation groups did significantly better than control groups on walking test and shortness of breath. Trials that included severe COPD patients showed that rehabilitation groups did significantly better than control groups only when the rehabilitation programs were 6 months or longer. Trials that included mild/moderate COPD patients showed that rehabilitation groups did significantly better than control groups with both short- and long-term rehabilitation programs. CONCLUSION: COPD patients who receive rehabilitation have a better exercise capacity and they experience less shortness of breath than patients who do not receive rehabilitation. COPD patients may benefit from rehabilitation programs that include at least lower-extremity training. Patients with mild/moderate COPD benefit from short- and long-term rehabilitation, whereas patients with severe COPD may benefit from rehabilitation programs of at least 6 months.

The State of Evaluation in Internal Medicine Residency

BackgroundThere are no nationwide data on the methods residency programs are using to assess trainee competence. The Accreditation Council for Graduate Medical Education (ACGME) has recommended tools that programs can use to evaluate their trainees. It is unknown if programs are adhering to these recommendations.ObjectiveTo describe evaluation methods used by our nation’s internal medicine residency programs and assess adherence to ACGME methodological recommendations for evaluation.DesignNationwide survey.ParticipantsAll internal medicine programs registered with the Association of Program Directors of Internal Medicine (APDIM).MeasurementsDescriptive statistics of programs and tools used to evaluate competence; compliance with ACGME recommended evaluative methods.ResultsThe response rate was 70%. Programs were using an average of 4.2–6.0 tools to evaluate their trainees with heavy reliance on rating forms. Direct observation and practice and data-based tools were used much less frequently. Most programs were using at least 1 of the Accreditation Council for Graduate Medical Education (ACGME)’s “most desirable” methods of evaluation for all 6 measures of trainee competence. These programs had higher support staff to resident ratios than programs using less desirable evaluative methods.ConclusionsResidency programs are using a large number and variety of tools for evaluating the competence of their trainees. Most are complying with ACGME recommended methods of evaluation especially if the support staff to resident ratio is high.

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 “steppingstone” (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.

Personal growth during internship: A qualitative analysis of interns' responses to key questions

BACKGROUND: During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship.DESIGN: Prospective qualitative study conducted over the course of internship.PARTICIPANTS: Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs.APPROACH: Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns’ writings to identify triggers, facilitators, and barriers related to personal growth.RESULTS: Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs.CONCLUSIONS: Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns’ core values especially in association with powerful triggers.

Personal Growth and its Correlates During Residency Training

Objectives  To explore the characteristics of and factors associated with personal growth during residency training.

Hospitalist involvement in internal medicine residencies

CONTEXT The ways hospitalists interact with and contribute to internal medicine residencies in the United States have been described locally, but have not been documented on a national level. OBJECTIVES To describe the penetration of hospitalists into medicine residency faculty nationally, and document their contributions to teaching activities. DESIGN, SETTING, AND PARTICIPANTS Survey of all 386 internal medicine residency directors in the United States in 2005 (272 respondents) and 2007 (236 respondents). MEASUREMENTS Number of teaching hospitals utilizing hospitalists, number of programs utilizing hospitalists to teach, hospitalist teaching duties, and number with hospitalist tracks. RESULTS In 2005, program directors recalled 54% of teaching hospitals employed hospitalists before and 73% after implementation of work-hour limitations. Of those employing hospitalists, 92% of programs in the Northeast and West used them to teach. Two years later, the Midwest (78%) and South (76%) continued to lag behind in the proportion of teaching hospitalists. Specific teaching activities of hospitalists included: attending on teaching service (92%), conducting rounds (81%), observation of clinical skills (67%), lectures (68%), and morning report (52%). Seven percent of program directors reported other duties of hospitalists, including: supervising procedures, reviewing night float patients, serving as associate program directors, and writing curricula. Eleven percent of training programs had hospitalist tracks. CONCLUSIONS As hospitalists have become prevalent and have become efficient clinicians in community and university hospitals, the majority of internal medicine residencies have enlisted them to provide rounds, lectures, and bedside teaching. A small number of residencies are beginning to develop tracks to facilitate this new career option for graduates.

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.

Pharmaceutical Industry Support and Residency Education: A Survey of Internal Medicine Program Directors

BACKGROUND Interactions with the pharmaceutical industry are known to affect the attitudes and behaviors of medical residents; however, to our knowledge, a nationally representative description of current practices has not been reported. METHODS The Association of Program Directors in Internal Medicine surveyed 381 US internal medicine residency program directors in 2006-2007 regarding pharmaceutical industry support to their training programs. The primary outcome measure was program director report of pharmaceutical financial support to their residency. Demographic and performance variables were analyzed with regard to these responses. RESULTS In all, 236 program directors (61.9%) responded to the survey. Of these, 132 (55.9%) reported accepting support from the pharmaceutical industry. One hundred seventy of the 236 program directors (72.0%) expressed the opinion that pharmaceutical support is not desirable. Residency programs were less likely to receive pharmaceutical support when the program director held the opinion that industry support was not acceptable (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.02-0.22). Programs located in the southern United States were more likely to accept pharmaceutical support (OR, 8.45; 95% CI, 1.95-36.57). The American Board of Internal Medicine pass rate was inversely associated with acceptance of industry support: each 1% decrease in the pass rate was associated with a 21% increase in the odds of accepting industry support (OR, 1.21; 95% CI, 1.07-1.36). CONCLUSIONS Although most of the program directors did not find pharmaceutical support desirable, more than half reported acceptance of industry support. Acceptance of pharmaceutical industry support was less prevalent among residency programs with a program director who considered support unacceptable and those with higher American Board of Internal Medicine pass rates.

Demographic and work-life study of chief residents: a survey of the program directors in internal medicine residency programs in the United States.

CONTEXT Chief residents play a crucial role in internal medicine residency programs in administration, academics, team building, and coordination between residents and faculty. The work-life and demographic characteristics of chief residents has not been documented. OBJECTIVE To delineate the demographics and day-to-day activities of chief residents. DESIGN, SETTING, AND PARTICIPANTS The Survey Committee of the Association of Program Directors in Internal Medicine (APDIM) developed a Web-based questionnaire. A link was sent in November 2006 by e-mail to 381 member programs (98%). Data collection ended in April 2007. MEASUREMENTS Data collected include the number of chief residents per residency, the ratio of chief residents per resident, demographics, and information on salary/benefits, training and mentoring, and work life. RESULTS The response rate was 62% (N  =  236). There was a mean of 2.5 chief residents per program, and on average there was 1 chief resident for 17.3 residents. Of the chief residents, 40% were women, 38% international medical graduates, and 11% minorities. Community-based programs had a higher percentage of postgraduate year 3 (PGY-3)-level chief residents compared to university-based programs (22% versus 8%; P  =  .02). Mean annual salary was

What predicts residency accreditation cycle length? Results of a national survey.

60 000, and the added value of benefits was