An Opportunity for Change: Principles for Reforming Internal Medicine Inpatient Conferences.

Inpatient educational conferences are a key part of internal medicine residency training. Many residencies made conferences virtual during the COVID-19 pandemic, and are now returning to in-person sessions. As we navigate this change, we can seize this opportunity to re-evaluate the role that inpatient conferences serve in resident education. In this paper, we briefly review the history of inpatient educational conferences before offering five recommendations for improvement. Our recommendations include grounding conference formats in educational theory, leveraging the expertise of all potential educators, broadening content to include health equity and justice throughout all curricula, and explicitly focusing on cultivating community among participants. Recognizing that each residency program is different, we anticipate that these recommendations may be implemented differently based on program size, available resources, and current institutional practices. We also include examples of prior successful curricular reforms aligned with our principles. We hope these recommendations ensure inpatient conferences continue to be a central part of residency education for future generations of internal medicine residents.

A Multicenter Observational Study Comparing Virtual with In-Person Morning Reports during the COVID-19 Pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic disrupted how educational conferences were delivered, leaving programs to choose between in-person and virtual morning report formats. The objective of our study was to describe morning reports during the COVID-19 pandemic, including the use of virtual formats, attendance, leadership, and content. METHODS: A prospective observational study of morning reports was conducted at 13 Internal Medicine residency programs between September 1, 2020 and March 30, 2021, including a follow-up survey of current morning report format in January 2023. RESULTS: In total, 257 reports were observed; 74% used virtual formats, including single hospital, multiple hospital, and a hybrid format with both in-person and virtual participants. Compared with in-person reports, virtual reports had more participants, with increased numbers of learners (median 21 vs 7; P < 0.001) and attendings (median 4 vs 2; P < 0.001), and they were more likely to involve medical students (83% vs 40%; P < 0.001), interns (99% vs 53%; P < 0.001), and program directors (68% vs 32%; P < 0.001). Attendings were less likely to lead virtual reports (3% vs 28%, P < 0.001). Virtual reports also were more likely to be case based (88% vs 69%; P < 0.001) and to use digital presentation slides (91% vs 36%; P < 0.001). There was a marked increase in the number of slides (median 20 vs 0; P < 0.001). As of January 2023, all 13 programs had returned to in-person reports, with only 1 program offering an option to participate virtually. CONCLUSIONS: During the COVID-19 pandemic, virtual morning report formats predominated. Compared with traditional in-person reports, virtual report increased attendance, favored resident leadership, and approached a similar range of patient diagnoses with a greater number of case-based presentations and slides. In spite of these characteristics, all programs returned to an in-person format for morning report as pandemic restrictions waned.

Outcomes in quality improvement and patient safety training: moving from in-person to synchronous distance education.

BACKGROUND: The COVID-19 pandemic necessitated increased synchronous distance education (SDE) in graduate medical education, presenting challenges for Quality Improvement and Patient Safety (QIPS) best practices, which call for integration with daily clinical care and investigation of real patient safety events. OBJECTIVE: To evaluate educational outcomes for QIPS training after conversion of a mature, in-person curriculum to SDE. METHODS: 68 postgraduate year (PGY)-1 residents were surveyed before and after the SDE Culture of Patient Safety training in June 2020, and 59 PGY-2s were administered the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) before and after the SDE QIPS seminar series in July-August 2020. Values before and after training were compared using sign tests for matched pairs (PGY-1) and Wilcoxon signed-rank tests (PGY-2). RESULTS: 100% (68 of 68) of PGY-1s and 46% (27 of 59) of PGY-2s completed precourse and postcourse surveys. Before the course, 55 PGY-1s (81%) strongly agreed that submitting patient safety event reports are a physician's responsibility, and 63 (93%) did so after (15% increase, p=0.004). For PGY-2s, the median composite QIKAT-R score was 17 (IQR 14.5-20) before and 22.5 (IQR 20-24.5) after the seminars, with a median difference of 4.5 (IQR 1.5-7), a 32% increase in QIPS competency (p=0.001). CONCLUSIONS: Patient safety attitudes and quality improvement knowledge increased after SDE QIPS training at comparable levels to previously published results for in-person training, supporting SDE use in future hybrid curricula to optimise educational value and reach.

What internal medicine attendings talk about at morning report: a multicenter study.

BACKGROUND: Morning report is a core educational activity in internal medicine resident education. Attending physicians regularly participate in morning report and influence the learning environment, though no previous study has described the contribution of attending physicians to this conference. This study aims to describe attending comments at internal medicine morning reports. METHODS: We conducted a prospective, observational study of morning reports conducted at 13 internal medicine residency programs between September 1, 2020, and March 30, 2021. Each attending comment was described including its duration, whether the comment was teaching or non-teaching, teaching topic, and field of practice of the commenter. We also recorded morning report-related variables including number of learners, report format, program director participation, and whether report was scripted (facilitator has advance knowledge of the case). A regression model was developed to describe variables associated with the number of attending comments per report. RESULTS: There were 2,344 attending comments during 250 conferences. The median number of attendings present was 3 (IQR, 2-5). The number of comments per report ranged across different sites from 3.9 to 16.8 with a mean of 9.4 comments/report (SD, 7.4). 66% of comments were shorter than one minute in duration and 73% were categorized as teaching by observers. The most common subjects of teaching comments were differential diagnosis, management, and testing. Report duration, number of general internists, unscripted reports, and in-person format were associated with significantly increased number of attending comments. CONCLUSIONS: Attending comments in morning report were generally brief, focused on clinical teaching, and covered a wide range of topics. There were substantial differences between programs in terms of the number of comments and their duration which likely affects the local learning environment. Morning report stakeholders that are interested in increasing attending involvement in morning report should consider employing in-person and unscripted reports. Additional studies are needed to explore best practice models of attending participation in morning report.

A Comparative Study of Scripted versus Unscripted Morning Reports: Results from a Prospective Multicenter Study.

OBJECTIVES: Morning report is one of the central activities of internal medicine residency education. The two most common morning report formats are scripted reports, which use preselected cases with prepared didactics, and unscripted reports in which a case is discussed without preparation. No previous study has compared these two formats. METHODS: We conducted a prospective observational study of morning report conducted at 10 academic medical centers across the United States. RESULTS: A total of 198 case-based morning reports were observed. Of these, 169 (85%) were scripted and 29 (15%) were unscripted. Scripted reports were more likely to present a case with a known final diagnosis (89% vs 76%, P = 0.04), use electronic slides (76% vs 52%, P = 0.01), involve more than 15 slides (55% vs 3%, P < 0.001), and reference the medical literature (61% vs 34%, P = 0.02), including professional guidelines (32% vs 10%, P = 0.02) and original research (25% vs 0%, P = 0.001). Scripted reports also consumed more time in prepared didactics (8.0 vs 0 minutes, P < 0.001). Unscripted reports consumed more time in case history (10.0 vs 7.0 minutes, P < 0.001), physical examination (3.0 vs 2.0 minutes, P = 0.06), and differential diagnosis (10.0 vs 7.0 minutes, P = 0.01). CONCLUSIONS: Most contemporary morning reports are scripted. Compared with traditional unscripted reports, scripted reports are more likely to involve a case with a known diagnosis, use extensive electronic presentation slides, and consume more time in didactics, while unscripted reports consume more time in the early diagnostic process, including history, physical examination, and differential diagnosis. Residency programs interested in emphasizing these aspects of medical education should encourage unscripted morning reports.

52-year-old man • hematemesis • history of cirrhosis • persistent fevers • Dx?

► Hematemesis ► History of cirrhosis ► Persistent fevers.

Chief Residency Selection in Internal Medicine: Who Is Left Out?

Little progress has been made in improving racial, gender, or intersectional diversity within academic internal medicine (IM). Chief Residency fulfills a unique opportunity to target diversity efforts; Chief Residents (CR) are integral in creating an inclusive environment and support system for IM trainees, and the position serves as a steppingstone for future leadership positions within academia. However, the CR selection process often lacks transparency and includes steps that are fraught with bias, thereby disadvantaging underrepresented minority groups from gaining important experience needed to climb the academic ladder. We describe a more standardized selection process that will improve recruitment and selection of more diverse CRs and ultimately improve the recruitment, retention, and promotion of more diverse faculty within academic internal medicine. Key recommendations include an open call for applications, the use of standardized and structured interviews, and the formation of a diverse selection committee to conduct a transparent selection process based on explicitly defined criteria.

Internal Medicine Residents' Perceptions of Virtual Morning Report: a Multicenter Survey.

IMPORTANCE: The COVID-19 pandemic disrupted graduate medical education, compelling training programs to abruptly transition to virtual educational formats despite minimal experience or proficiency. We surveyed residents from a national sample of internal medicine (IM) residency programs to describe their experiences with the transition to virtual morning report (MR), a highly valued core educational conference. OBJECTIVE: Assess resident views about virtual MR content and teaching strategies during the COVID-19 pandemic. DESIGN: Anonymous, web-based survey. PARTICIPANTS: Residents from 14 academically affiliated IM residency programs. MAIN MEASURES: The 25-item survey on virtual MR included questions on demographics; frequency and reason for attending; opinions on who should attend and teach; how the virtual format affects the learning environment; how virtual MR compares to in-person MR with regard to participation, engagement, and overall education; and whether virtual MR should continue after in-person conferences can safely resume. The survey included a combination of Likert-style, multiple option, and open-ended questions. RESULTS: Six hundred fifteen residents (35%) completed the survey, with a balanced sample of interns (39%), second-year (31%), and third-year (30%) residents. When comparing their overall assessment of in-person and virtual MR formats, 42% of residents preferred in-person, 18% preferred virtual, and 40% felt they were equivalent. Most respondents endorsed better peer-engagement, camaraderie, and group participation with in-person MR. Chat boxes, video participation, audience response systems, and smart boards/tablets enhanced respondents' educational experience during virtual MR. Most respondents (72%) felt that the option of virtual MR should continue when it is safe to resume in-person conferences. CONCLUSIONS: Virtual MR was a valued alternative to traditional in-person MR during the COVID-19 pandemic. Residents feel that the virtual platform offers unique educational benefits independent of and in conjunction with in-person conferences. Residents support the integration of a virtual platform into the delivery of MR in the future.

Virtual Interactive Case-Based Education (VICE): A Conference for Deliberate Practice of Diagnostic Reasoning.

Introduction: Current approaches to teaching diagnostic reasoning minimally address the need for deliberate practice. We developed an educational conference for internal medicine residents to practice diagnostic reasoning and examine how biases affect their differential diagnoses through cognitive autopsies. Methods: We formatted the Virtual Interactive Case-Based Education (VICE) conference as a clinical problem-solving exercise, in which a facilitator presents a case to a single discussant selected from the audience. We delivered VICE on an internet-based conferencing platform with screen-sharing capability over approximately 30 minutes. To maximize learners' psychological safety, we employed an active facilitation model that normalized uncertainty and prioritized the diagnostic process over arriving at the correct diagnosis. Results: Resident attitudes toward VICE were assessed by utilizing a postconference survey and gathering descriptive data for 11 sessions. Ninety-seven percent of respondents (n = 35) felt that VICE was a novel and valuable addition to their curriculum. Qualitative data suggested that positive features of the conference included the opportunity to practice diagnostic reasoning, the single-discussant format, and the supportive learning environment. Discussants reported that holding the conference in person would have negatively impacted their experience. Discussion: Internal medicine residents universally valued the opportunity to engage in deliberate practice of case-based reasoning in a psychologically safe environment during the VICE conference. The virtual nature of the conference contributed significantly to discussants' positive experience. This resource includes all materials necessary to implement VICE, as well as an instructional video on facilitation.

A Cross-Sectional Survey of Internal Medicine Residents' Knowledge, Attitudes, and Current Practices Regarding Patient Transitions to Post-Acute Care.

OBJECTIVES: Prior studies have found suboptimal knowledge about post-acute care (PAC) among inpatient providers and poor communication at discharge that can lead to unsafe discharge transitions, but little is known about residents and the PAC transition. The aim of this study is to assess internal medicine residents' knowledge, attitudes, and current practice regarding patient transitions to PAC. DESIGN: A multisite, cross-sectional 36-question survey. SETTING AND PARTICIPANTS: Internal Medicine and Medicine-Pediatrics residents at 3 university-based Internal Medicine training programs in the United States. METHODS: Survey delivered electronically to residents in 2018 and 2019. Survey responses were described by collapsing 4-point Likert responses into dichotomous variables, and thematic content analysis was used to evaluate free text responses. RESULTS: Of 482 residents surveyed, 236 responded (49%). Despite high reported confidence in their ability to transition patients to PAC, only 31% of residents knew how often patients received skilled therapies at skilled nursing facilities (SNFs) and 23% knew how frequently nursing services are provided. The majority of residents (79%) identified the discharge summary as the main way they communicated care instructions to the SNF, but only 55% reported always completing it prior to discharge. Upper-level residents were more likely to know how much therapy patients received at a SNF, but resident knowledge about PAC did not vary by residency year in other domains. Residents who experienced a clinical rotation at a SNF had higher levels of knowledge compared to residents who did not. CONCLUSIONS: This national survey of internal medicine residents identified common knowledge gaps regarding PAC. These knowledge gaps did not improve throughout residency without deliberate exposure to PAC environments. This suggests a need for dedicated curriculum development as discharges to PAC continue to rise exponentially.

Internal Medicine Residents' Perceptions of Morning Report: a Multicenter Survey.

BACKGROUND: Residents rate morning report (MR) as an essential educational activity. Little contemporary evidence exists to guide medical educators on the optimal content or most effective delivery strategies, particularly in the era of resident duty-hour limitations and shifts towards learner-centric pedagogy in graduate medical education. OBJECTIVE: Assess resident views about MR content and teaching strategies. DESIGN: Anonymous, online survey. PARTICIPANTS: Internal medicine residents from 10 VA-affiliated residency programs. MAIN MEASURES: The 20-item survey included questions on demographics; frequency and reason for attending; opinions on who should attend, who should teach, and how to prioritize the teaching; and respondents' comfort level with participating in MR. The survey included a combination of Likert-style and multiple-choice questions with the option for multiple responses. KEY RESULTS: A total of 497 residents (46%) completed the survey, with a balanced sample of R1s (33%), R2s (35%), and R3s (31%). Self-reported MR attendance was high (31% always attend; 39% attend > 50% of the time), with clinical duties being the primary barrier to attendance (85%). Most respondents felt that medical students (89%), R1 (96%), and R2/R3s (96%) should attend MR; there was less consensus regarding including attendings (61%) or fellows (34%). Top-rated educational topics included demonstration of clinical reasoning (82%), evidence-based medicine (77%), and disease pathophysiology (53%). Respondents valued time spent on diagnostic work-up (94%), management (93%), and differential building (90%). Overall, 82% endorsed feeling comfortable speaking; fewer R1s reported comfort (76%) compared with R2s (87%) or R3s (83%, p = 0.018). Most (81%) endorsed that MR was an inclusive learning environment (81%), with no differences by level of training. CONCLUSIONS: MR remains a highly regarded, well-attended educational conference. Residents value high-quality cases that emphasize clinical reasoning, diagnosis, and management. A supportive, engaging learning environment with expert input and concise, evidence-based teaching is desired.

Risk and Protective Factors in the COVID-19 Pandemic: A Rapid Evidence Map.

Background: Given the worldwide spread of the 2019 Novel Coronavirus (COVID-19), there is an urgent need to identify risk and protective factors and expose areas of insufficient understanding. Emerging tools, such as the Rapid Evidence Map (rEM), are being developed to systematically characterize large collections of scientific literature. We sought to generate an rEM of risk and protective factors to comprehensively inform areas that impact COVID-19 outcomes for different sub-populations in order to better protect the public. Methods: We developed a protocol that includes a study goal, study questions, a PECO statement, and a process for screening literature by combining semi-automated machine learning with the expertise of our review team. We applied this protocol to reports within the COVID-19 Open Research Dataset (CORD-19) that were published in early 2020. SWIFT-Active Screener was used to prioritize records according to pre-defined inclusion criteria. Relevant studies were categorized by risk and protective status; susceptibility category (Behavioral, Physiological, Demographic, and Environmental); and affected sub-populations. Using tagged studies, we created an rEM for COVID-19 susceptibility that reveals: (1) current lines of evidence; (2) knowledge gaps; and (3) areas that may benefit from systematic review. Results: We imported 4,330 titles and abstracts from CORD-19. After screening 3,521 of these to achieve 99% estimated recall, 217 relevant studies were identified. Most included studies concerned the impact of underlying comorbidities (Physiological); age and gender (Demographic); and social factors (Environmental) on COVID-19 outcomes. Among the relevant studies, older males with comorbidities were commonly reported to have the poorest outcomes. We noted a paucity of COVID-19 studies among children and susceptible sub-groups, including pregnant women, racial minorities, refugees/migrants, and healthcare workers, with few studies examining protective factors. Conclusion: Using rEM analysis, we synthesized the recent body of evidence related to COVID-19 risk and protective factors. The results provide a comprehensive tool for rapidly elucidating COVID-19 susceptibility patterns and identifying resource-rich/resource-poor areas of research that may benefit from future investigation as the pandemic evolves.

A Multicenter VA Study of the Format and Content of Internal Medicine Morning Report.

BACKGROUND: There are more than five hundred internal medicine residency programs in the USA, involving 27,000 residents. Morning report is a central educational activity in resident education, but no recent studies describe its format or content. OBJECTIVE: To describe the format and content of internal medicine morning reports. DESIGN AND PARTICIPANTS: Prospective observational study of morning reports occurring between September 1, 2018, and April 30, 2019, in ten different VA academic medical centers in the USA. MAIN MEASURES: Report format, number and type of learner, number and background of attending, frequency of learner participation, and the type of media used. Content areas including quality and safety, high-value care, social determinants of health, evidence-based medicine, ethics, and bedside teaching. For case-based reports, the duration of different aspects of the case was recorded, the ultimate diagnosis when known, and if the case was scripted or unscripted. RESULTS: A total of 225 morning reports were observed. Reports were predominantly case-based, moderated by a chief resident, utilized digital presentation slides, and involved a range of learners including medicine residents, medical students, and non-physician learners. The most common attending physician present was a hospitalist. Reports typically involved a single case, which the chief resident reviewed prior to report and prepared a teaching presentation using digital presentation slides. One-half of cases were categorized as either rare or life-threatening. The most common category of diagnosis was medication side effects. Quality and safety, high-value care, social determinants of health, and evidence-based medicine were commonly discussed. Medical ethics was rarely addressed. CONCLUSIONS: Although a wide range of formats and content were described, internal medicine morning report most commonly involves a single case that is prepared ahead of time by the chief resident, uses digital presentation slides, and emphasizes history, differential diagnosis, didactics, and rare or life-threatening diseases.

A 68-Year-Old Man With Skin Rash and a Pleural Effusion.

CASE PRESENTATION: A 68-year-old man developed an erythematous, papular, pruritic rash on his right thigh 1 month prior to presentation. It subsequently spread to his other extremities and trunk. He also endorsed fevers of > 38.3°C, night sweats, fatigue, shortness of breath, and a dry cough. He was prescribed triamcinolone 0.1% cream for his rash and azithromycin for presumed community-acquired pneumonia, with no improvement in symptoms. He had a history of relapsing polychondritis for which he was prescribed infliximab and low-dose prednisone. He had never smoked tobacco, did not use alcohol or illicit substances, and had no significant travel history.