Diana B. McNeill

‘So you want to be a clinician-educator …’: Designing a clinician-educator curriculum for internal medicine residents

Background: Despite a growing demand for skilled teachers and administrators in graduate medical education, clinician-educator tracks for residents are rare and though some institutions offer ‘resident-as-teacher’ programs to assist residents in developing teaching skills, the need exists to expand training opportunities in this area. Methods: The authors conducted a workshop at a national meeting to develop a description of essential components of a training pathway for internal medicine residents. Through open discussion and small group work, participants defined the various roles of clinician-educators and described goals, training opportunities, assessment and resource needs for such a program. Results: Workshop participants posited that the clinician-educator has several roles to fulfill beyond that of clinician, including those of teacher, curriculum developer, administrator and scholar. A pathway for residents aspiring to become clinician educators must offer structured training in each of these four areas to empower residents to effectively practice clinical education. In addition, the creation of such a track requires securing time and resources to support resident learning experiences and formal faculty development programs to support institutional mentors and leaders. Conclusion: This article provides a framework by which leaders in medical education can begin to prepare current trainees interested in careers as clinician-educators.

Combination insulin and sulfonylurea therapy in insulin-requiring type 2 diabetes mellitus

PURPOSE To determine the effect(s) on glucose control, insulin dose, and circulating insulin levels of the addition of a sulfonylurea (glipizide) to the treatment regimen of patients with insulin-requiring type 2 diabetes mellitus. PATIENTS AND METHODS Thirty seven patients with type 2 diabetes mellitus taking insulin for at least 1 year prior to study and treated with > or = 40 U of insulin per day were recruited for a randomized, double-blind, placebo-controlled, crossover trial. Patients were treated with 3 months of insulin + placebo (I + P) and 3 months of insulin + glipizide (I + G), with an intermediate 1 month washout period using insulin therapy alone. Adjustments were made initially to the maximum dose of glipizide (40 mg/day), followed by insulin dose adjustments. Twenty-nine of the 37 patients demonstrated a significant C-peptide response to Ensure and were selected for analysis. RESULTS The fasting plasma glucose in the I + G arm was 6.8 (121.8 mg/dl) vs. 8.7 mmol/L (156.0 mg/dl) in the I + P arm, P < 0.001. Mean plasma glucose over 24 hours was 9.8 (176.9 mg/dl) for I + G vs. 11.3 mmol/L (203.8 mg/dl) for I + P, P < 0.001. Glycated hemoglobin was significantly different (9.8 I + G vs. 11.4% I + P, P < 0.008). The total daily insulin dose required was significantly lower with I + G (69.1 vs. 87.3 U, P < 0.0005). However, there were no significant differences in free insulin levels. CONCLUSION The addition of a sulfonylurea (glipizide) to insulin therapy in patients with insulin-requiring type 2 diabetes mellitus taking large doses of insulin results in a rapid and substantial improvement in glucose control despite a significant reduction in insulin dose. Therefore, this form of combination therapy should be considered for patients with the above characteristics whose diet and exercise programs are correct but whose response to insulin therapy is inadequate.

The Educational Innovations Project: a community of practice.

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.

Microangiopathic ischemic myopathy of semimembranosus muscle in patient with diabetes mellitus.

Med 316:1376-83, 1987 3. The DCCT Research Group: Diabetes control and complications trial (DCCT): results of the feasibility study. Diabetes Care 10:1-9, 1987 4. Egger M, Davey Smith G, Imhoof H, Teuscher A: Increased risk of severe hypoglycemia in insulin-treated diabetic patients transferred to human insulin: a case-control study. BrMedJ. 303:617-21, 1991 5. Egger M, Davey Smith G, Teuscher AU, Teuscher A: Influence of human insulin on symptoms and awareness of hypoglycemia: a randomised double-blind crossover trial. BrMedJ. 303:622-26, 1991 6. Miihlhauser I, Berger M, Heinemann L, Fritsche E, Lennep K: Hypoglycemicwarning symptoms and incidence of severe hypoglycemia during treatment with human and animal insulin. European Association for the Study of Diabetes. 26th annual meeting, Copenhagen, 10-13 September 1990, Abstract P439

A comparative resident site visit project: a novel approach for implementing programmatic change in the duty hours era.

The Duke University Medical Center Internal Medicine Residency Program did not reach its anticipated quota of applicants during the 2008 National Residency Matching Program. Post-Match feedback regarding workload prompted an effort to redesign the general medicine service. As part of that effort, Duke program leaders sought to learn how peer programs accommodated Accreditation Council for Graduate Medical Education (ACGME) regulations. They launched the Resident Site Visit Project (RSVP). In 2008, Duke resident teams visited six other academic internal medicine residency programs based in university hospitals in the eastern United States. They conducted a systematic survey using a standardized questionnaire, interviewed program leaders and residents, and observed workflow directly. The RSVP identified strategies for accommodating ACGME rules in service design and also highlighted challenges shared by all of the programs. Discussion of the shared challenges yielded six core principles that directly guided Dukes general medicine service redesign: emphasize patient safety, reduce resident work compression, create educational opportunities, ensure automatic duty hours compliance, preserve essential program attributes, and involve stakeholders in the process of change. The Duke RSVP is an approach to programmatic change that applies information collected during site visits in defining core principles for program redesign. Collaboration between programs through resident site visits facilitates innovation, creates a foundation for change that increases stakeholder involvement, and generates opportunities for multicenter research.

Perspective: Autonomic care systems for hospitalized patients.

With advancements of medical technology and improved diagnostic and treatment options, children with severe birth defects who would otherwise have no chance of surviving post birth survive to go home every day. The average lifespan in the United States has increased substantially over the last century. These successes and many other medical breakthroughs in managing complex illnesses, particularly in frail, elderly patients, have resulted in an increasing percentage of patients with comorbidities. This, coupled with a policy change by Medicare (i.e., Medicare will no longer reimburse hospitals for costs associated with treating preventable errors and injuries that a patient acquires while in the hospital), creates an enormous challenge to health care providers. To meet the challenge, the authors propose a new model of health care--the autonomic care system (ACS)--a concept derived from the intensive care unit and the autonomic computing initiative in the computer industry. Using wound care as an example, the authors examine the necessity, feasibility, design, and challenges related to ACS. Specifically, they discuss the role of the human operator, the potential combination of ACS and existing hospital information technology (e.g., electronic medical records and computerized provider order entry), and the costs associated with ACS. ACS may serve as a roadmap to revamp the health care system, bringing down the barriers among different specialties and improving the quality of care for each problem for all hospitalized patients.

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.

Diabetes Quality of Care Before and After Implementation of a Resident Clinic Practice Partnership System.

Deficiencies in resident diabetes care quality may relate to continuity clinic design. This retrospective analysis compared diabetes care processes and outcomes within a traditional resident continuity clinic structure (2005) and after the implementation of a practice partnership system (PPS; 2009). Under PPS, patients were more likely to receive annual foot examinations (odds ratio [OR] = 11.6; 95% confidence interval [CI] = 7.2, 18.5), microalbumin screening (OR = 2.4; 95% CI = 1.6, 3.4), and aspirin use counseling (OR = 3.8; 95% CI = 2.5, 6.0) and were less likely to receive eye examinations (OR = 0.54; 95% CI = 0.36, 0.82). Hemoglobin A1c and lipid testing were similar between periods, and there was no difference in achievement of diabetes and blood pressure goals. Patients were less likely to achieve cholesterol goals under PPS (OR = 0.62; 95% CI = 0.39, 0.98). Resident practice partnerships may improve processes of diabetes care but may not affect intermediate outcomes.