Randy S. Hebert

Resident Research and Scholarly Activity in Internal Medicine Residency Training Programs

OBJECTIVES: 1) To describe how internal medicine residency programs fulfill the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity training requirement including the current context of resident scholarly work, and 2) to compare findings between university and nonuniversity programs.DESIGN: Cross-sectional mailed survey.SETTING: ACGME-accredited internal medicine residency programs.PARTICIPANTS: Internal medicine residency program directors.MEASUREMENTS: Data were collected on 1) interpretation of the scholarly activity requirement, 2) support for resident scholarship, 3) scholarly activities of residents, 4) attitudes toward resident research, and 5) program characteristics. University and nonuniversity programs were compared.MAIN RESULTS: The response rate was 78%. Most residents completed a topic review with presentation (median, 100%) to fulfill the requirement. Residents at nonuniversity programs were more likely to complete case reports (median, 40% vs 25%; P=.04) and present at local or regional meetings (median, 25% vs 20%; P=.01), and were just as likely to conduct hypothesis-driven research (median, 20% vs 20%; P=.75) and present nationally (median, 10% vs 5%; P=.10) as residents at university programs. Nonuniversity programs were more likely to report lack of faculty mentors (61% vs 31%; P<.001) and resident interest (55% vs 40%; P=.01) as major barriers to resident scholarship. Programs support resident scholarship through research curricula (47%), funding (46%), and protected time (32%).CONCLUSIONS: Internal medicine residents complete a variety of projects to fulfill the scholarly activity requirement. Nonuniversity programs are doing as much as university programs in meeting the requirement and supporting resident scholarship despite reporting significant barriers.

Dementia patient suffering and caregiver depression.

Cross-sectional and longitudinal analyses were carried out to assess the relationship between dementia patient suffering, caregiver depression, and antidepressant medication use in 1222 dementia patients and their caregivers. We assessed the prevalence of 2 types of patient suffering, emotional and existential distress, and examined their independent associations with caregiver depression and antidepressant medication use when controlling for sociodemographic characteristics of caregivers and patients, cognitive and physical disability of the patient, the frequency of patient memory problems and disruptive behaviors, and the amount of time spent caring for the patient. Multiple linear regression models showed that both aspects of perceived patient suffering independently contribute to caregiver depression (emotional distress: β=1.24; P<0.001; existential distress: β=0.66; P<0.01) whereas only existential suffering contributes to antidepressant medication use: odds ratio=1.25 95% confidence interval, 1.10-1.42; P<0.01. In longitudinal analyses, increases in both types of suffering were associated with increases in caregiver depression (emotional distress: β=1.02; P<0.01; existential distress: β=0.64; P<0.01). This is the first study to show in a large sample that perceived patient suffering independently contributes to family caregiver depression and medication use. Medical treatment of patients that maintain or improve memory but do not address suffering may have little impact on the caregiver. Alzheimer disease patient suffering should be systematically assessed and treated by clinicians.

Religion, spirituality and the well-being of informal caregivers: A review, critique, and research prospectus

The purpose of this article is to review and critique the published literature examining the relationships between religion/spirituality and caregiver well-being and to provide directions for future research. A systematic search was conducted using bibliographic databases, reference sections of articles, and by contacting experts in the field. Articles were reviewed for measurement, theoretical, and design limitations. Eighty-three studies were retrieved. Research on religion/spirituality and caregiver well-being is a burgeoning area of investigation; 37% of the articles were published in the last five years. Evidence for the effects of religion/spirituality were unclear; the preponderance (n = 71, 86%) of studies found no or a mixed association (i.e., a combination of positive, negative, or non-significant results) between religion/spirituality and well-being. These ambiguous results are a reflection of the multidimensionality of religion/spirituality and the diversity of well-being outcomes examined. They also partially reflect the frequent use of unrefined measures of religion/spirituality and of atheoretical approaches to studying this topic. Investigators have a fairly large number of studies on religion/spirituality and caregiver well-being on which to build. Future studies should be theory driven and utilize psychometrically sound measures of religion/spirituality. Suggestions are provided to help guide future work.

Measuring the Experience and Perception of Suffering

PURPOSE assess psychometric properties of scales developed to assess experience and perception of physical, psychological, and existential suffering in older individuals. DESIGN AND METHODS scales were administered to 3 populations of older persons and/or their family caregivers: individuals with Alzheimers disease (AD) and their family caregivers (N = 105 dyads), married couples in whom 1 partner had osteoarthritis (N = 53 dyads), and African American and Hispanic caregivers of care recipients with AD (N = 121). Care recipients rated their own suffering, whereas caregivers provided ratings of perceived suffering of their respective care recipients. In addition, quality of life, health, and functional status data were collected from all respondents via structured in-person interviews. RESULTS three scales showed high levels of internal consistency, test-retest reliability, and convergent and discriminant validity. The scales were able to discriminate differences in suffering as a function of type of disease, demonstrated high intra-person correlations and moderately high inter-person correlations and exhibited predicted patterns of association between each type of suffering and indicators of quality of life, health status, and caregiver outcomes of depression and burden. IMPLICATIONS suffering is an important but understudied domain. This article provides valuable tools for assessing the experience and perception of suffering in humans.

Re-examining the value of medical grand rounds.

Purpose To study medical grand rounds, the cornerstone of a department of medicines educational programs. Method Between April and June 2001, a questionnaire was sent to chairs of departments of medicine at the 389 U.S. hospitals with medicine residency programs accredited by the Accreditation Council for Graduate Medical Education. Data were collected on the objectives and attendance, educational structure, perceived quality, and costs of medical grand rounds. Results Three hundred questionnaires were returned (77%). Grand rounds were offered by 97% of departments and accredited for continuing medical education in 96% of hospitals. The most important objectives were to educate, showcase faculty role models, and promote a collegial atmosphere. Patients were present at grand rounds less than 3% of the time. Grand rounds were predominantly lecture based; only 10% were clinical case presentations or interactive workshops/small groups, the formats proven most effective for facilitating adult learning and a humanistic approach to patients. Curricular tenets of needs assessment, program evaluation, and knowledge assessment were performed in only 73%, 59%, and 17% of programs, respectively. University hospitals were less likely to incorporate these principles (p < .01). Although respondents attested to the high quality of grand rounds, many potential attendees missed more than half the sessions. Grand rounds were the most expensive conference in 78% of departments, with the pharmaceutical industry providing the majority of the funding. Conclusions Medical grand rounds are costly and often do not take into account learners’ needs. Departments of medicine should reevaluate their commitment to grand rounds.

Caregiving and bereavement.

Most deaths are preceded by chronic illness and disability and the provision of support by family caregivers. The purpose of this article is to describe how the caregiving experience affects bereavement, with an emphasis on the relationship between challenging caregiving situations and difficult grieving processes − often referred to as ‘complicated grief’. The article starts with a brief summary of the general literature on caregiving and bereavement. It then defines complicated grief and discusses why some caregivers may struggle with the death of their loved one. Finally, it offers practical suggestions for what professionals can do to help caregivers both before and after the death

Conference attendance and performance on the in-training examination in internal medicine.

The objective of this study was to describe the relationship between attendance at conferences during residency training and residents’ performance on the In-Training Examination (ITE) in Internal Medicine. Nineteen house officers participated in the study. Conference attendance records were retrospectively reviewed for the one-year period preceding the ITE (pre-ITE), and in the three-month period after house officers received their ITE scores (post-ITE). After receiving their scores, participants completed a questionnaire asking about study habits and opinions about conferences. Attendance was taken at 126/165 (76.4%) conferences pre-ITE and 32/42 (76.2%) conferences post-ITE. House officers attended a mean of 35% (range, 10–59) of the conferences pre-ITE and 32% (range, 9–75) post-ITE (p = 0.365). There was no correlation between prior conference attendance and ITE scores (Spearman correlation coefficient −0.230, p = 0.34), and no correlation between score and conference attendance post-ITE (Spearman correlation coefficient 0.174, p = 0.48). Participation in clinical rotations also failed to influence ITE scores in that content area (all p > 0.05). The findings of this study suggest conference attendance does not influence ITE scores. Medical educators may need to rethink and study how best to impart medical knowledge.

Prominent medical journals often provide insufficient information to assess the validity of studies with negative results.

BackgroundPhysicians reading the medical literature attempt to determine whether research studies are valid. However, articles with negative results may not provide sufficient information to allow physicians to properly assess validity.MethodsWe analyzed all original research articles with negative results published in 1997 in the weekly journals BMJ, JAMA, Lancet, and New England Journal of Medicine as well as those published in the 1997 and 1998 issues of the bimonthly Annals of Internal Medicine (N = 234). Our primary objective was to quantify the proportion of studies with negative results that comment on power and present confidence intervals. Secondary outcomes were to quantify the proportion of these studies with a specified effect size and a defined primary outcome. Stratified analyses by study design were also performed.ResultsOnly 30% of the articles with negative results comment on power. The reporting of power (range: 15%-52%) and confidence intervals (range: 55–81%) varied significantly among journals. Observational studies of etiology/risk factors addressed power less frequently (15%, 95% CI, 8–21%) than did clinical trials (56%, 95% CI, 46–67%, p < 0.001). While 87% of articles with power calculations specified an effect size the authors sought to detect, a minority gave a rationale for the effect size. Only half of the studies with negative results clearly defined a primary outcome.ConclusionProminent medical journals often provide insufficient information to assess the validity of studies with negative results.

Pilot testing of a question prompt sheet to encourage family caregivers of cancer patients and physicians to discuss end-of-life issues.

Family members of patients with advanced illness have many questions. Unfortunately, several barriers prevent caregivers from discussing their questions with the physicians caring for the patient. Although question prompt sheets can be helpful in overcoming barriers to communication, few have been developed for family caregivers. The goal of this study, therefore, was to develop and test the acceptability and feasibility of a short question prompt sheet designed to encourage discussions about end-of-life concerns in an outpatient palliative care clinic. Our results demonstrated that caregivers wanted to discuss a variety of questions, primarily questions about medications, symptoms, support services, and what to expect. All caregivers thought that the question prompt sheets was easy to understand and felt comfortable completing it in clinic and the majority reported that the question prompt sheets made it easier for them to ask questions.

Factors Associated with Citation of Internal Medicine Residency Programs for Lack of Scholarly Activity

Background: The Accreditation Council for Graduate Medical Education requires that residents demonstrate scholarly activity prior to completion of training. Purpose: To determine which factors are associated with program citation for failure to comply with the Residency Review Committee (RRC) scholarly activity requirement for internal medicine residencies. Methods: All 391 internal medicine residency program directors were surveyed in March 2002. Data were collected on program characteristics and factors (research curriculum, research director, faculty mentors, protected time for research, funding, and presence of a mandatory research requirement) that have been associated with successful resident research. Multiple logistic regression analysis identified factors associated with citation. Results: The response rate was 78%. Ten percent of respondents report having been cited for lack of demonstration of scholarly activity. Factors that reduced the odds of citation were being a university-based program, odds ratio (OR) 0.13, 95% confidence interval (CI) 0.03-0.54, p =. 005; having a greater number of residents, OR 0.95, 95% CI 0.93-0.98, p =. 001; and having funding to support resident scholarship, OR 0.39, 95% CI 0.17-0.91, p =. 03. Using multiple logistic regression analysis, having designated funding for resident scholarship was the only factor independently associated with a decreased odds of citation, OR 0.27, 95% CI 0.10-0.72, p =. 009. Conclusions: To improve compliance with the RRC requirement for scholarly activity and avoid citation, residency programs may wish to consider devoting more resources, particularly money, to support resident scholarly activity.