Compliance with CDIM-APDIM Guidelines for Department of Medicine Letters: an Opportunity to Improve Communication Across the Continuum.

BACKGROUND: With rising applications to internal medicine programs and pending changes in United States Medical Licensing Examination Step 1 score reporting, program directors desire transparent data for comparing applicants. The Department of Medicine Letters of Recommendation (DOM LORs) are frequently used to assess applicants and have the potential to provide clearly defined data on performance including stratification of a medical school class. Despite published guidelines on the expected content of the DOM LOR, these LORs do not always meet that need. OBJECTIVES: To better understand the degree to which DOM LORs comply with published guidelines. METHODS: We reviewed DOM LORs from 146 of 155 LCME-accredited medical schools in the 2019 Match cycle, assessing for compliance with published guidelines. RESULTS: Adherence to the recommendation for DOM LORs to provide a final characterization of performance relative to peers was low (68/146, 47%). Of those that provided a final characterization, 19/68 (28%) provided a quantitative measure, and 49/68 (72%) provided a qualitative descriptor. Only 17/49 (35%) with qualitative terms described those terms, and thirteen distinct qualitative scales were identified. Ranking systems varied, with seven different titles given to highest performers. Explanations about determination of ranking groups were provided in 12% of cases. CONCLUSIONS: Adherence to published guidelines for DOM LORs varies but is generally low. For program directors desiring transparent data to use in application review, clearly defined data on student performance, stratification groupings, and common language across schools could improve the utility of DOM LORs.

Internal Medicine Residency Program Directors' Screening Practices and Perceptions About Recruitment Challenges.

PURPOSE: To examine internal medicine residency program directors' (PDs') screening practices and perceptions about current recruitment challenges. METHOD: In March-May 2017, the Association of Program Directors in Internal Medicine Survey Committee sent a survey to 373 Alliance for Academic Internal Medicine member residency programs. PDs rated the importance of 23 inclusion and 11 exclusion criteria for interview invitation decision making, provided United States Medical Licensing Examination (USMLE) cutoff scores for U.S. medical school and international medical graduates, and indicated changes in recruitment practices due to application inflation, including their ability to conduct holistic review and interest in potential solutions to address application inflation. Exploratory factor analysis was used to identify and confirm factors that were most important to interview invitation decision making. RESULTS: The response rate for eligible programs was 64% (233/363). USMLE Step 2 Clinical Knowledge scores were the criteria most frequently reported to be "very important" (131/233, 57%). Among respondents who reported any criteria as "very important," 155/222 (70%) identified a single most important (SMI) criterion. Non-USMLE criteria were frequently reported as an SMI criterion (68%). Concerning exclusion criteria, 157/231 (68%) reported they "absolutely would not invite" applicants with hints of unprofessional behavior. Of the 214/232 (92%) who reported an increase in applications, 138 (64%) adjusted recruitment practices. Respondents were most interested in limiting the number of applications per applicant (163/231, 71%), allowing applicants to indicate high interest in a subset of programs (151/229, 66%), and creating a national database of qualities of matched applicants for each program (121/228, 53%). CONCLUSIONS: PDs rely heavily on USMLE scores when making interview invitation decisions. However, collectively, non-USMLE criteria were more frequently reported as an SMI criterion. Most programs adjusted recruitment practices to respond to application volume. Several potential solutions to address application inflation garnered wide support.

Internal Medicine Residency Program Responses to the Increase of Residency Applications: Differences by Program Type and Characteristics.

BACKGROUND: Over the past decade, the number of residency applications has increased substantially, causing many residency programs to change their recruitment practices. OBJECTIVE: We determined how internal medicine (IM) residency programs have responded to increased applications by program type (community-based, community-based/university-affiliated, and university-based) and characteristics (percentage of international medical graduates, program size, and program director [PD] tenure). METHODS: The Association of Program Directors in Internal Medicine conducted a national survey of 363 IM PDs in 2017. Five questions assessed IM program responses to the increased number of residency applications in 3 areas: changes in recruitment strategies, impact on ability to perform holistic review, and interest in 5 potential solutions. We performed a subgroup analysis to measure differences by program type and characteristics. RESULTS: The response rate was 64% (233 of 363). There were no differences by program type or characteristics for experiencing an increase in the number of applicants, altering recruitment practices, or conducting holistic reviews. There were moderate differences in alterations of recruitment practices by program characteristics and moderate differences in interest in proposed solutions by program type. Community-based programs had the greatest interest in a program-specific statement (59%, P = .032) and the lowest percentage in a national database of matched applicants (44%, P = .034). CONCLUSIONS: IM residency programs are experiencing an increasing number of applications and are accommodating by adjusting recruitment practices in a variety of ways. A majority of IM PDs supported 4 of the 5 solutions, although the level of interest differed by program type.

Use of Filters for Residency Application Review: Results From the Internal Medicine In-Training Examination Program Director Survey.

BACKGROUND: The increase in applications to residency programs, known as "application inflation," creates challenges for program directors (PDs). Prior studies have shown that internal medicine (IM) PDs utilize criteria, such as United States Medical Licensing Examination (USMLE) Step examination performance, when reviewing applications. However, little is known about how early these filters are utilized in the application review cycle. OBJECTIVE: This study sought to assess the frequency and types of filters utilized by IM PDs during initial residency application screening and prior to more in-depth application review. METHODS: A web-based request for the 2016 Internal Medicine In-Training Examination (IM-ITE) PD Survey was sent to IM PDs. Responses from this survey were analyzed, excluding non-US programs. RESULTS: With a 50% response rate (214 of 424), IM PDs responded that the most commonly used data points to filter applicants prior to in-depth application review were the USMLE Step 2 Clinical Knowledge score (32%, 67 of 208), USMLE Step 1 score (24%, 50 of 208), and medical school attended (12%, 25 of 208). Over half of US IM PD respondents (55%, 114 of 208) indicated that they list qualifying interview criteria on their program website, and 31% of respondents (50 of 160) indicated that more than half of their applicant pool does not meet the program's specified interview criteria. CONCLUSIONS: Results from the 2016 IM-ITE PD Survey indicate many IM PDs use filters for initial application screening, and that these filters, when available to applicants, do not affect many applicants' decisions to apply.

The New Internal Medicine Subinternship Curriculum Guide: a Report from the Alliance for Academic Internal Medicine.

The internal medicine (IM) subinternship has been a long-established clinical experience in the final phase of medical school deemed by key stakeholders as a crucial rotation to prepare senior medical students for internship. Medical education has changed greatly since the first national curriculum for this course was developed in 2002 by the Clerkship Directors in Internal Medicine (CDIM). Most notably, competency-based medical education (CBME) has become a fixture in graduate medical education and has gradually expanded into medical school curricula. Still, residency program directors and empirical studies have identified gaps and inconsistencies in knowledge and skills among new interns. Recognizing these gaps, the Association of Program Directors in Internal Medicine (APDIM) surveyed its members in 2010 and identified four core skills essential for intern readiness. The Association of American Medical Colleges (AAMC) also published 13 core entrustable professional activities (EPAs) for entering residency to be expected of all medical school graduates. Results from the APDIM survey along with the widespread adoption of CBME informed this redesign of the IM subinternship curriculum. The authors provide an overview of this new guide developed by the Alliance for Academic Internal Medicine (AAIM) Medical Student-to-Resident Interface Committee (MSRIC).

Internal Medicine Residency Program Directors' Views of the Core Entrustable Professional Activities for Entering Residency: An Opportunity to Enhance Communication of Competency Along the Continuum.

PURPOSE: To examine internal medicine (IM) residency program directors' (PDs') perspectives on the Core Entrustable Professional Activities for Entering Residency (Core EPAs)-introduced into undergraduate medical education to further competency-based assessment-and on communicating competency-based information during transitions. METHOD: A spring 2015 Association of Program Directors in Internal Medicine survey asked PDs of U.S. IM residency programs for their perspectives on which Core EPAs new interns must or should possess on day 1, which are most essential, and which have the largest gap between expected and observed performance. Their views and preferences were also requested regarding communicating competency-based information at transitions from medical school to residency and residency to fellowship/employment. RESULTS: The response rate was 57% (204/361 programs). The majority of PDs felt new interns must/should possess 12 of the 13 Core EPAs. PDs' rankings of Core EPAs by relative importance were more varied than their rankings by the largest gaps in performance. Although preferred timing varied, most PDs (82%) considered it important for medical schools to communicate Core EPA-based information to PDs; nearly three-quarters (71%) would prefer a checklist format. Many (60%) would be willing to provide competency-based evaluations to fellowship directors/employers. Most (> 80%) agreed that there should be a bidirectional communication mechanism for programs/employers to provide feedback on competency assessments. CONCLUSIONS: The gaps identified in Core EPA performance may help guide medical schools' curricular and assessment tool design. Sharing competency-based information at transitions along the medical education continuum could help ensure production of competent, practice-ready physicians.

Teaching Risk Management: Addressing ACGME Core Competencies.

BACKGROUND: Risk management is an important aspect of education for all residents. Unfortunately, few curricula currently exist to fulfill this educational need. OBJECTIVE: We developed a curriculum that teaches residents basic principles of risk management with the goals of (1) educating residents about the medical-legal environment in which they operate, (2) helping residents identify common malpractice exposures, and (3) teaching practical risk management/patient safety interventions that can be implemented in their practice that could reduce malpractice exposure and improve patient safety. METHODS: The curriculum was developed by Medical Risk Management, LLC, a Connecticut-based risk management firm, in conjunction with academic leadership at the University of Connecticut. The program uses 3 learning modalities: live lectures, web-based video modules, and e-mailed learning publications. Gains in resident knowledge through participation in the curriculum were measured using pretests and posttests. Learner satisfaction with the curriculum was measured through web-based surveys. RESULTS: We found a significant improvement in knowledge in residents who took the pretest and posttest (P < .001). Of the survey respondents, 97% said the content was relevant to their specialty practice and 95% responded that these sessions should be held annually. Most respondents indicated they would change their practice as a result of what they learned from the live lectures. CONCLUSION: This risk management curriculum has been successful in providing our residents with learning activities in risk management, improving their knowledge of risk management principles, and changing their attitudes and behaviors. These improvements may lead to fewer malpractice claims against them and the hospitals they train in.