Lia S. Logio

Beyond a Curricular Design of Convenience: Replacing the Noon Conference With an Academic Half Day in Three Internal Medicine Residency Programs

Several residency programs have created an academic half day (AHD) for the delivery of core curriculum, and some program Web sites provide narrative descriptions of individual AHD curricula; nonetheless, little published literature on the AHD format exists. This article details three distinctive internal medicine residency programs (Cambridge Health Alliance, University of Cincinnati, and New York Presbyterian/Weill Cornell Medical College) whose leaders replaced the traditional noon conference curriculum with an AHD. Although each program’s AHD developed independently of the other two, retrospective comparative review reveals instructive similarities and differences that may be useful to other residency directors. In this article, the authors describe the distinct approaches to the AHD at the three institutions through a framework of six core principles: (1) protect time and space to facilitate learning, (2) nurture active learning in residents, (3) choose and sequence curricular content deliberately, (4) develop faculty, (5) encourage resident preparation and accountability for learning, and (6) employ a continuous improvement approach to curriculum development and evaluation. The authors chronicle curricular adaptations at each institution over the first three years of experience. Preliminary outcome data, presented in the article, suggests that the transition from the traditional noon conference to an AHD may increase conference attendance, improve resident and faculty satisfaction with the curriculum, and improve resident performance on the In Training Examination.

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.

(Re)turning the pages of residency: The impact of localizing resident physicians to hospital units on paging frequency

BACKGROUND Geographic localization of physicians to patient care units may improve communication, decrease interruptions, and reduce resident workload. This study examines whether interns on geographically localized patient care units receive fewer pages than those on teams that are not. METHODS The study is a retrospective analysis of the number of pages received by interns on 5 internal medicine teams: 2 in a geographically localized model (GLM), 2 in a partial localization model (PLM), and 1 in a standard model (SM) over 1 month at New York-Presbyterian Hospital/Weill Cornell. Multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team. RESULTS The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.2 (95% confidence interval [CI]: 2.0-2.4) in the GLM, 2.8 (95% CI: 2.6-3.0) in the PLM, and 3.9 (95% CI: 3.6-4.2) in the SM; all differences were statistically significant (P < 0.001). CONCLUSION Geographic localization of resident teams to patient care units was associated with significantly fewer pages received by interns during the day. Such patient care models may improve resident workload in part by decreasing pages, and consequently has important implications for patient safety and medical education.

Guidelines for Writing Department of Medicine Summary Letters

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.

Shifting Approaches for Evaluation of Resident Performance: From Competencies to Milestones

Outcome measures have replaced process measures as the new currency of quality. For example, the quality of care for patients with diabetes is now measured by results of hemoglobin A1C tests, not just the percentage of patients who received the test. The same shift has occurred in graduate medical education (GME). Competency-based education serves to hold residency programs accountable for the outcomes of its graduates. In 2001, the Accreditation Council for Graduate Medical Education (ACGME) implemented its Outcomes Project defining 6 core professional competencies for physicians.1,2 Residency training programs and advanced subspecialty fellowships were asked to measure the competence of trainees in patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. For the first time, all ACGME-accredited programs were using a standard language to describe performance of physicians in training. In July 2013, the ACGME rolled out the Next Accreditation System with one of its key elements to measure and report outcomes through the use of educational milestones.3 The ACGME invited each specialty to define the stepping-stones within each of the 6 core competencies that represented the usual trajectory of progression in the professional development of that specialty. Through consensus, narrative criteria for each step of these defined milestones were mapped using a developmental scale with the goal rating in each subcompetency labeled “ready for unsupervised practice.” These milestones provided trainees with a more explicit set of the expectations for performance at every level with considerably more granular detail about the composite of “good doctoring” within each discipline. Within internal medicine, resident performance shifted from ratings grouped into 6 core competencies to ratings split into 22 reporting subcompetencies. For example, interpersonal and communication skills now include 3 components: communicates effectively with patients and caregivers, communicates effectively in interprofessional teams, and appropriately uses and completes health records. In this issue of JAMA, Hauer and colleagues4 present a cross-sectional comparative study of grouping vs splitting to measure the performance of 21 284 internal medicine resident trainees—7048 postgraduate year 1 [PGY-1], 7233 PGY-2, 7003 PGY-3 residents—during the 2013-2014 academic year. During the 2013-2014 inaugural year of reporting milestones, programs used both the milestone ratings and the preceding tool, the resident annual evaluation summary (RAES), collected each year by the American Board of Internal Medicine as part of tracking individuals toward board eligibility. With both assessment tools submitted simultaneously, the authors were able to compare data collected by each on the same set of residents. The authors explored the validity of milestones and attempted to determine if use of milestones improved the assessment of competence. Although milestones may lead to better assessment, it is still too early to tell. The study findings suggest evidence for the validity of milestones through 3 key findings. First, there was a small correlation between the RAES system and the milestones system; corresponding RAES ratings and milestone ratings demonstrated progressively higher Spearman correlations across training years, ranging among competencies from 0.31 to 0.35 for PGY-1 residents to 0.43 to 0.52 for PGY-3 residents. Second, for graduating residents, poor ratings in medical knowledge using milestones, as previously demonstrated with low medical knowledge scores on RAES,5 correlated with failure to pass the ABIM certification examination. Among the 6260 PGY-3 residents who attempted the certification examination, higher medical knowledge ratings were correlated with higher examination scores (RAES Spearman r, 0.40; milestone medical knowledge 1 r, 0.37; and milestone medical knowledge 2 r, 0.30). The 618 residents who failed the ABIM examination had lower ratings using both rating systems for medical knowledge than those who passed (RAES rating difference, −0.9; milestone medical knowledge 1 rating difference, −0.3; and milestone medical knowledge 2 rating difference, −0.2). Third, the 4 milestones that measure professionalism provided a higher level of discrimination through their narrative anchors to identify lapses in professional behavior than did the RAES. For instance, of the 1190 residents across all training years with a professionalism milestone rating of less than 2.5, indicating concern about professional behavior, 1161 (97.6%) were rated as satisfactory (n = 809) or superior (n = 352) in professionalism on the RAES rating system. In addition, a comparison of low ratings in medical knowledge with low rating in professionalism revealed that of the 7003 PGY-3 residents, only 26 had a milestone rating lower than 2.5 on either of the 2 medical knowledge subcompetencies (0.3%), whereas 1190 of the 21 284 in all training Related article page 2253 Opinion

Authors' reply: "(re)turning the pages of residency: the impact of localizing resident physicians to hospital units on paging frequency".

METHODS: The study is a retrospective analysis of the number of pages received by interns on 5 internal medicine teams: 2 in a geographically localized model (GLM), 2 in a partial localization model (PLM), and 1 in a standard model (SM) over 1 month at New York–Presbyterian Hospital/Weill Cornell. Multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team. RESULTS: The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.2 (95% confidence interval [CI]: 2.0–2.4) in the GLM, 2.8 (95% CI: 2.6–3.0) in the PLM, and 3.9 (95% CI: 3.6–4.2) in the SM; all differences were statistically significant (P<0.001).