Are commonly used resident measurements associated with procedural skills in internal medicine residency training?

BACKGROUND: Acquisition of competence in performing a variety of procedures is essential during Internal Medicine (IM) residency training. PURPOSES: Determine the rate of procedural complications by IM residents; determine whether there was a correlation between having 1 or more complications and institutional procedural certification status or attending ratings of resident procedural skill competence on the American Board of Internal Medicine (ABIM) monthly evaluation form (ABIM-MEF). Assess if an association exists between procedural complications and in-training examination and ABIM board certification scores. METHODS: We retrospectively reviewed all procedure log sheets, procedural certification status, ABIM-MEF procedural skills ratings, in-training exam and certifying examination (ABIM-CE) scores from the period 1990-1999 for IM residency program graduates from a training program. RESULTS: Among 69 graduates, 2,212 monthly procedure log sheets and 2,475 ABIM-MEFs were reviewed. The overall complication rate was 2.3/1,000 procedures (95% CI: 1.4-3.1/1,000 procedure). With the exception of procedural certification status as judged by institutional faculty, there was no association between our resident measurements and procedural complications. CONCLUSIONS: Our findings support the need for a resident procedural competence certification system based on direct observation. Our data support the ABIM's action to remove resident procedural competence from the monthly ABIM-MEF ratings.

Chest pain and ST segment elevation attributable to cholecystitis: a case report and review of the literature.

Chest pain with electrocardiographic changes is usually a life-threatening presentation of cardiac ischemia. There are, however, a variety of noncardiac conditions that have been reported to mimic these clinical and electrocardiographic changes. An Asian woman presented with chest pain and ST segment elevations in the distribution of the left anterior descending artery. She had persisting chest pain and ST segment elevations that were refractory to medical therapy, leading to thrombolytic therapy and rescue angiography, which revealed no evidence of coronary artery disease by coronary catherization. Cholecystitis was subsequently diagnosed with hepatobiliary scintigraphy. The patient's fever and ST segment elevations promptly resolved with antibiotic treatment. Four previous cases of ST segment elevation attributed to cholecystitis have been reported. Although the electrocardiographic changes attributed to cholecystitis have been shown to be correctable, the pathophysiological mechanism underlying these changes remains unclear. Prompt recognition of cholecystitis can ensure appropriate treatment and may prevent the performance of unnecessary diagnostic and therapeutic interventions.

Impact of a residency research program on research activity, faculty involvement, and institutional cost.

BACKGROUND: The impact of residency research programs on resident research activity, faculty involvement, and institutional cost has not been well described. DESCRIPTION: A strategy to increase resident research activity was implemented in a community-based internal medicine residency program. Strategy components included a resident research director, a research elective, cost reimbursement, and a research requirement. Associated outcomes of research activity, faculty involvement, and institutional cost are described. EVALUATION: The annual number of research submissions increased from 0 to 39 over 6 years. The greatest increase in number of research submissions was seen following the dual implementation of the cost reimbursement and research requirement interventions. The annual number of faculty coauthors rose from 0 to 24 in 6 years. Average cost per accepted project was US 1,023.00 dollars. CONCLUSION: The strategy described was associated with a marked increase in resident research activity and faculty involvement. The cost of supporting resident research activity is significant.

A resident research director can improve internal medicine resident research productivity.

BACKGROUND: Resident participation in research projects is felt to be an important component of internal medicine residency training, and accreditation organizations require that residency programs show that their residents and faculty participate in scholarly activity. PURPOSE: To determine the impact of a Resident Research Director (RRD) on scholarly productivity of our internal medicine residents. METHODS: We reviewed the number of presentations and publications of all residents from our institution over a 10-year study period (1992-2001). We used a historical control, comparing resident presentations and publications 5 years before (1992-1996) and after (1997-2001) implementation of the RRD position. We compared cohorts in terms of number of individuals in Alpha Omega Alpha and the number of individuals coming from a top 50 medical school as baseline measurements. We also compared these cohorts in regards to faculty to learner ratio, percentage of residents applying for fellowship, and American Board of Internal Medicine Certifying Examination performance. The Mann-Whitney U test was used for statistical inferences. Eighty-nine residents trained at our institution during the study period. RESULTS: There was a significant increase in the number of regional and national presentations as well as publications after instituting the RRD position. CONCLUSION: Our analysis suggests that an RRD can enhance resident scholarly productivity.

The reliability and validity of the American Board of Internal Medicine Monthly Evaluation Form.

PURPOSE: To report indicators of reliability and validity of the American Board of Internal Medicine Evaluation Form (ABIM-MEF) at one institution (Wright-Patterson Medical Center). METHOD: Completed ABIM-MEFs from 1990-1999 were reviewed. Reliability measures included Cronbach alpha, interrater reliability, and rating consistency between different types of staff and rotations. Construct validity was investigated by tracking ABIM-MEF scores over time and with factor analysis. Predictive validity was assessed by correlating ABIM-MEF scores with the In-training Examination and ABIM Certifying Examination results RESULTS: The 71 residents averaged 12 ABIM-MEFs per year. The forms had a Cronbach alpha of 0.96 and high interrater reliability (intraclass correlation coefficients > 0.80). Ratings did not differ by type of attending or rotation, except that noninternists rated residents lower on procedural skills. ABIM-MEF questions about judgment, knowledge, and clinical skills showed significant improvement from month to month during each academic year as well as year to year. In contrast, questions on professional attitudes, humanism, and procedural skills sections improved between postgraduate year 1 and postgraduate year 2 only. ABIM-MEF questions collapsed into two domains in factor analysis: judgment-knowledge-skills and attitude-humanism. ABIM-MEF questions from judgment and knowledge sections modestly predicted In-training Examination and ABIM Certifying Examination results. In contrast, professional attitude, humanism, and clinical as well as procedural skill questions had little discriminative ability. CONCLUSIONS: The ABIM-MEF appears to be reliable and valid. Further, factor analysis results support the ABIM's movement to simplify the monthly evaluation form to the new Accreditation Council for Graduate Medical Education core competencies.

Procedure skill competence and certification in internal medicine residency training.

BACKGROUND: Procedure skill training and competency certification are an important part of internal medicine residency training. Expert guidelines exist on the minimum number of procedures recommended to attain competence, but these have not been validated. PURPOSE: To study the validity of the American Board of Internal Medicine (ABIM) recommended procedure guidelines. METHODS: We performed a retrospective review of all monthly procedure log sheets collected during residency training for the graduates of our internal medicine residency program. The number of procedure attempts and the length of time needed to be certified as competent in 13 different procedures were recorded and compared with ABIM guidelines. RESULTS: There were 69 graduates with an average of 32.7 monthly procedure log sheets per resident. There was a wide variation in the number of attempts and time needed to attain competence in the measured procedures. Overall, our residents received their competency certification for each required procedure within 1 SD of the corresponding ABIM recommendation. CONCLUSIONS: Our study suggests that the ABIM recommended guidelines on procedure skill competence may be valid on the program level

Morning Report: an analysis of curricular content and comparison to national guidelines.

BACKGROUND: Morning Report is a long-standing tradition for internal medicine residency programs, but format and content vary greatly and have not been compared to any accepted curriculum standards. The Federated Council for Internal Medicine (FCIM) Task Force on the Internal Medicine Residency Curriculum has published curriculum guidelines for residency programs. PURPOSE: We compared our institution's Morning Report topics with FCIM curriculum guidelines to determine the feasibility and validity of these guidelines in a residency program. METHODS: A review was performed of all Morning Report conferences over 3 years. RESULTS: With the exception of general internal medicine topics, between 60% to 86% of all FCIM organ and system competency focus areas were the subject of one or more of 583 consecutive Morning Reports. CONCLUSIONS: The content of our Morning Report conferences closely paralleled FCIM guidelines, suggesting that the FCIM guidelines may be feasible and valid. These guidelines can provide guidance for Morning Report content.

Assessing the reliability and validity of the mini-clinical evaluation exercise for internal medicine residency training.

PURPOSE: The mini-clinical evaluation exercise, or mini-CEX, assesses residents' history and physical examination skills. To date, no study has assessed the validity of the mini-CEX (mCEX) evaluation format. The authors' objective was to determine the reliability and validity of the mCEX evaluation format. METHOD: Twenty-three first-year residents at Wright-Patterson Medical Center in Dayton, Ohio, were included in the study (academic years 1996-97, 1997-98, and 1998-99). Validity of the instrument was determined by comparing mCEX scores with scores from corresponding sections of a modified version of the standard American Board of Internal Medicine's (ABIM's) monthly evaluation form (MEF) and the American College of Physicians-American Society of Internal Medicine In-Training Examination (ITE). All ABIM MEFs were used without exclusionary criteria, including ABIM MEFs from months where a corresponding mCEX evaluation was not performed. RESULTS: Each resident in the study had an average of seven mCEX evaluations and 12 ABIM MEFs. Of the 168 required mCEX evaluations, 162 were studied. Internal consistency reliability was .90. Statistically significant correlations were found for the following: mCEX history with ABIM history; mCEX physical exam with ABIM physical exam; mCEX clinical judgment with ABIM clinical judgment, medical care, medical knowledge, and the ITE; mCEX humanistic attributes with ABIM humanistic attributes, and mCEX overall clinical competence with ABIM overall clinical competence, medical care, medical knowledge, and the ITE. Analysis of variance comparing sequential mean mCEX scores yielded no significant difference. CONCLUSIONS: This study suggests that the mCEX is a feasible and reliable evaluation tool. The validity of the mCEX is supported by the strong correlations between mCEX scores and corresponding ABIM MEF scores as well as the ITE.

Military internal medicine resident performance on the American Board of Internal Medicine Certifying Examination.

The mission of military graduate medical education in internal medicine is to produce high-quality military internists prepared to practice in military environments. Board certification in internal medicine is an important outcome of internal medicine residency training. The American Board of Internal Medicine Certifying Examination (ABIMCE) first-taker pass rate of the graduates of an internal medicine residency program is a key measure of the quality of the program. We compared the ABIMCE first-taker pass rates for military and civilian internal medicine residency program graduates. Military internal medicine residency graduates had higher first-taker pass rates than their civilian counterparts. This is likely a reflection of the high-quality residents and the faculty at military programs. These results support the notion that military internal medicine residency programs continue to fulfill their mission of training high-quality internists.