Lawrence G. Smith

Supportive Programs Increase Medical Students' Research Interest and Productivity

Background Advances in biomedical research during the last decade have highlighted the necessity of attracting greater numbers of physicians to careers that include a research component. Physician participation in research is essential to increase the number of clinical and translational studies performed, as well as to educate the public about the importance of clinical trials and to assist in recruiting participants. We hypothesized that attractive research opportunities that included faculty mentoring, recognition of participation, and rewards for accomplishments would encourage medical student participation. Methods The Medical Student Research Office was created at Mount Sinai School of Medicine in 1996 to develop structured research programs and advise students looking to undertake a research project. Data from students participating in the summer research program and Medical Student Research Day, from the research section of the Medical Student Performance Evaluation, were collected from 1996 to 2004. Results For the last 4 years, the majority of medical students did research following the first year of school. Students did basic and clinical research, although most preferred clinically oriented or translational projects. Participation in Research Day and the number of publications suggest that interest is growing, including that by traditionally underrepresented groups. Conclusion Although it is too early to assess the long-term effects, the research programs offered led to greater numbers of students who did research, including those in traditionally underrepresented groups. Moreover, students were highly satisfied with their experiences, with 80% feeling that it increased their interest in applying principles they learned to the practice of medicine.

Improving Geriatrics Training in Internal Medicine Residency Programs: Best Practices and Sustainable Solutions

Most internal medicine residency programs provide geriatrics training to their residents. In the 19971998 National Study of Graduate Education in Internal Medicine survey, 99% of respondents indicated that geriatrics topics are part of their didactic curriculum, while 79% required that their residents have an ambulatory geriatrics experience. Yet in a recent national survey, 31% of internal medicine residents who had nearly completed their training indicated that they were somewhat or very unprepared to care for nursing home patients (1). The need for additional geriatrics training is apparent even to graduates of internal medicine residency programs with well-developed geriatrics experiences (2). The best ways to ensure that graduating internal medicine residents possess the competencies required to care for geriatric patients are not known. In this paper, we have taken a best evidence approach to identifying 1) successful strategies for implementing geriatrics education experiences in internal medicine residency programs, 2) the remaining barriers to this implementation, and 3) possible solutions to improve geriatrics training for internal medicine residents. Methods Literature Review We did a systematic review of the literature to identify education interventions and curriculum recommendations for training internal medicine residents in geriatrics. We searched medical (MEDLINE), age (AARP Ageline), nursing and allied health (CINAHL), social work (Social Work Abstracts), and education (ERIC) databases; searches covered 1979 to December 2001. We used the terms internship and residency AND geriatrics/education and education, medical, graduate AND internal medicine AND geriatrics and the text words geriatric training and internal medicine and (residents or residency or residencies). In addition, we manually searched proceedings of the annual meetings of the American Geriatrics Society, the Society for Teachers of Family Medicine, and the Society of General Internal Medicine and the annual In Progress issues of Academic Medicine from 1997 to 2001. We identified 263 relevant articles and meeting abstracts; 2 independent reviewers abstracted the reports using a structured form. An annotated bibliography is available at www.sgim.org/hartfordoverview.cfm. Interviews Two authors conducted 1-hour interviews with leaders of 15 nationally recognized geriatrics programs (all were John A. Hartford Foundation Centers of Excellence) and 11 programs that had identified themselves as focusing on geriatrics training for internal medicine residents (6 responded to an Association of Program Directors in Internal Medicine listserver inquiry and 5 were John A. Hartford Generalists Initiative consultation sites) (see Appendix), for a total of 26 interviews. These interviews included questions on experience with education interventions in each site of care, and they explored what worked, what didnt work, and why. Defining Best Practices Approximately 70 articles or abstracts described interventions for teaching geriatrics to internal medicine residents, but only a few evaluated these interventions. Best practices were defined as interventions described in the literature or in interviews for which evaluation showed 1) improvement in housestaff knowledge, attitudes, or skills or 2) high levels of resident satisfaction (for example, on the residents rotation evaluations). Three authors reviewed and categorized the list of interventions, compared their results, and resolved disagreements by consensus. Results Current State of Geriatrics in Internal Medicine Residency Programs In a 2002 national survey (3), 93% of general internal medicine residencies reported that they had a required geriatrics curriculum, a sizable increase from the findings of a 1988 survey (4). This increase may be a result of the Accreditation Council of Graduate Medical Education requirement for geriatrics content in internal medicine residency programs that went into effect 1 October 1989, although full compliance with this requirement was not mandatory until 1995. Since July 1998, the requirement has been as follows [5]: 1) Residents must have formal instruction and regular, supervised clinical experience in geriatric medicine. 2) The written curriculum must include experiences in the care of a broad range of elderly patients. 3) Geriatric clinical experiences must be offered. They may occur at 1 or more specifically designated geriatric inpatient units, geriatric consultation services, geriatric long-term care facilities, geriatric ambulatory clinics, or in home-care settings. Curriculum guidelines by site of care were developed by expert consensus from surveys of internal medicine and family practice residencies conducted by the Society of General Internal Medicine Task Force on Geriatrics Medicine (1993 to 1995) (6, 7; Sullivan G. Personal communication). Specific recommendations were also issued for training in geriatric psychiatry and interdisciplinary teamwork (8, 9). More recently, integrated curricular guidelines from the Education Committee of the American Geriatrics Society and a list of competencies for internal medicine residents from the Federation Council of Internal Medicine were published (10, 11). Table 1 provides examples of the learning objectives found in these guidelines. Table 1. Examples of Geriatrics Learning Objectives for Internal Medicine Residents Best Practices The most successful residency programs involve clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, the hospital or ambulatory practice), care of patients across sites or through transitions of care, and interdisciplinary teamwork. In this section, we describe best practices for teaching each of these elements. Model Geriatric Care by Site Residents may master various curriculum objectives in several settings. In any program, the local environment will determine which settings are most appropriate for resident education. Although experiences at other settings (for example, a continuous-care retirement facility or assisted-living facility) may qualify as best practice, we found no descriptions of other settings that met our inclusion criteria. Hospital Units. Both general medical floors (12-16) and specialty geriatrics units, including Veterans Affairs Geriatric Evaluation and Management Units and Acute Care for Elders Units (17, 18), can be used for teaching geriatrics to residents (19). Because the patients admitted to these units determine the geriatrics issues that can be discussed, unfolding cases or geriatrics lectures can be incorporated into attending rounds or the existing schedule of noon lectures to ensure coverage of major curricular areas (12). Although a lack of geriatrics-oriented faculty may make this difficult, 1 study (12) suggests that if the medical floor has geriatrics enhancements (for example, conferences on aging held 3 times per week, syllabus of geriatrics articles distributed to each resident), it may not matter whether the attending physician has special geriatric training to improve residents knowledge and attitudes. Limitations of this model include a relatively short period of exposure to patients and a larger proportion of frail and vulnerable older adults compared with nonfrail elderly persons in the community. Hospital Consultation Services. Both geriatric and specialty consultation services (such as geriatric orthopedics, rehabilitation, and psychiatry) have been used for teaching geriatrics. In addition to the limitations of hospital units described above, barriers to success may include a paucity of consultations (particularly from the medicine service) and the lack of control that consultants have over patient care, which causes many treatment recommendations to go unheeded. Some programs have been able to mandate geriatrics consultations for certain types of patients, such as those older than 75 years of age or older adults with hip fracture. Ambulatory Care Settings. Introducing geriatrics faculty members as preceptors in the ambulatory care clinic gives residents one-on-one contact with faculty who can be role models as well as content experts (18). Housestaff receive geriatrics-specific input about their own patients for whom they provide primary care. The faculty member can then address the issue of caring for well older patients and maintaining their level of function while providing preventive care. Several programs noted that a dearth of appropriate faculty is a major barrier to use of this setting. Nursing Homes. Nursing homes should supply only 1 component of geriatrics training. Most older persons do not live in nursing homes, and those who do are not representative of the full spectrum of age-related disease (20). Recommendations for a successful nursing home experience include the creation and use of an organized, structured curriculum; interdisciplinary teamwork; a longitudinal rotation format; enthusiastic faculty; the opportunity for residents to see patients with faculty; and having faculty on site. To be successful, nursing home experiences require support from a motivated administration and collaboration with medical and nursing staff (20-22). Several collaborative practice models have been designed by using advanced practice nurses and attending physicians who are faculty members; these models include block rotations (12, 23-28); longitudinal rotations; and the Academic Group Practice, in which faculty are the attending physicians for the patients followed by the residents (29). Barriers to implementing a nursing home experience include an already full program, too few qualified faculty, and medical residents lack of interest (30, 31). Home Care Settings. Most home care visits are incorporated into block rotations in ambulatory care (32) or geriatrics (33). Successful home visits involve the resident as an active participant in patient care, not just as an observer, whil

Teaching Evidence-Based Medicine: A Regional Dissemination Model.

Background: Evidence-based medicine (EBM) is a framework for critically appraising medical literature and applying it to the care of individual patients. Lack of faculty skilled in practicing and teaching EBM limits the ability to train residents in this area. Description: A 31/2-day interactive course, called Teaching Evidence-Based Medicine, was given in 1996, 1998, and 1999. The goal of the course was to create a cadre of faculty within New York States internal medicine residency programs educated in EBM knowledge and skills who could integrate EBM into their training program. Thirty (58.8%) of 51 metropolitan New York internal medicine residency programs and three of 12 upstate programs sent participants. Evaluation: The postcourse ratings showed increased self-rated knowledge and a willingness to apply the teaching methods at their home institutions. Conclusions: There is a high demand for the opportunity to learn EBM skills and in turn to implement EBM at home institutions.

Screening and intervention for alcohol and illicit drug abuse:a survey of internal medicine housestaff.

Abstract This study attempts to determine how internal medicine housestaff screen and intervene for problematic alcohol and illicit drug use, as well as identify factors correlating with favorable practices. A crosssectional survey was administered to 93 medical housestaff. Of 64 (69%) respondents, 94% reported routinely screening new patients for alcohol or illicit drug use, while only 52% routinely quantified alcohol consumption and 28% routinely used a screening instrument. Housestaff were unfamiliar with national guidelines and felt unprepared to diagnose substance use disorders, particularly prescription drug abuse. Most routinely counseled patients with alcohol (89%) or illicitdrug problems (91%), although only a third of these patients were referred for formal treatment. More thorough screening practices were associated with greater treatment optimism, while favorable referral practices were associated with greater optimism about 12-step program benefit and difficulty with management. These findings suggest areas to be addressed in residency curricula on substance abuse.

Teaching evidence-based medicine skills to medical students and residents

Introduction methodology. An excellent review by Bigby5 illustrates how this methodology can be used in a logical, stepThe rapid expansion of biomedical knowledge has made bystep manner to answer questions commonly seen in the challenge to acquire and evaluate new information quite dermatologic practice. formidable. Evidence-based medicine (EBM), a clinical As seen in Table 1, six guides can be used to distinguish problem-solving paradigm designed to help clinicians meet useful from useless or even harmful therapy.6 Sackett and the challenge of incorporating the best available external colleagues offer a striking illustration of how erroneous evidence in caring for patients, consists of four elements: conclusions can be reached when the last of these guidelines defining the clinical problem presented by the patient, is not adhered to. A study of surgical vs. medical therapy searching for the best evidence in the literature, appraising for bilateral carotid stenosis appears to demonstrate a the validity of this evidence, and applying it to the clinical significant risk reduction for ischemic attacks, stroke, or question.1 In a recent article in the International Journal death in the surgically treated group (P 0.02); however, of Dermatology, Ladhani2 presented an excellent overview the P value becomes 0.09 when the outcomes for 16 of EBM and underscored the importance of its application patients ‘‘not available for follow-up’’ (who died or had to dermatologic practice. strokes during initial hospitalization) are included in the calculations. Barriers and solutions

Death in Springtime

An expression of shocked grief, a phone thrust into my hands, and the words falling on disbelieving ears: She wont be at work tomorrow. Shes dead. An accident had cut short the life of one of my interns. The story was tragic: last day of vacation, bags packed, a friend waiting at the hotel, and one final jog before a long flight home. A speeding car, a distracted runner, and an unfamiliar city combined to produce massive injuries; an ambulance rescue; intensive resuscitation; respirator support; and, ultimately, recognition of brain death. With her stunned parents at her bedside, the machines were stopped, and she left us. She stood out among the housestaff. Her appearance was striking, yet she had an unassuming warmth and a palpable vitality. A hint of Europe flavored her speech, revealing her immigrant past and adding a touch of the exotic to her all-American looks. Always excited about working as a physician, she defined joyful for all of us. At the hospital, everyone liked her. Her success as a role model was never doubted by anyone who met her. No one was more alive and more incongruous with the idea of death. As I hung up the phone, I knew that I needed to tell everyone about the tragedy. The bond created by the long hours of doctoring side by side makes housestaff a unique family; as the program director, I am the head of the family. They had to be told quickly. Whispered rumor was not the way to find out. Although I was nervous, I knew I would find the right way to do this. After all, I am a physician, experienced in breaking bad news. We called an emergency housestaff meeting for 5:00 p.m. Find a room! Everyone had to be there, no exceptions. The chief residents did their job well, and as I sat on the conference table, the room quickly filled with tentative, concerned residents. What were they thinking as they waited and quietly talked among themselves? Did they think that they were in trouble? No. They sensed that this was about a tragedy. They knew. After all, they too are physicians. When the room was full, I told them, We are a close group. We all care about each other very much. Today is a painful, sad day for us. Klaudia died today in Madrid. It was a terrible accident. Im sorry. There was shock and pain in the 100 eyes riveted to mine as each word brought home the tragic reality. And then there was silence, a long silence. Tears. Hugs. Caring for one another. Gradually, in small, tight groups, we left to find private places to think, to cry, to grieve, and to try to understand. It was so clear that calling the group together was the right thing to have done. The housestaff came together as never before. Although they were already veterans of encounters with death, this was very different, so personal and so close. The psychological defenses that work so well in the clinical setting offered no protection from this devastating loss. The evening after Klaudia died, many residents were out walking the neighborhood streets until late at night. They were in pairs and in small groups, talking, grieving, and trying to make sense of this tragic loss. There were formal support sessions to help people deal with their feelings, and although these meetings helped, the greatest support came from the support of one another. The memorial services, funeral, and burial were all rituals to help us accept the unacceptable. The pain and emptiness will lessen with the passage of time. Already a new group of interns has arrived. However, we will not forget that we lost Klaudia, one of our own, in springtime.