Paying for Parenthood: Understanding Parental Leave Policies in Infectious Disease Fellowship.

Background: Many physician trainees plan pregnancy during residency and fellowship. A study of internal medicine program directors (PDs) demonstrated frequent misinterpretation of American Board of Internal Medicine (ABIM) leave policies applied to parental leave. The primary aim was to investigate how infectious disease (ID) PDs interpret current ABIM leave policies. Methods: We surveyed 155 ID PDs in an online anonymous questionnaire about knowledge of ABIM leave policies and application toward trainee leaves. Results: Of 155 PDs, 56 (36%) responded to the survey. Nearly 70% incorrectly identified leave limits permitted. A majority mistakenly chose to extend training when a competent fellow was within the allowed duration of leave. PDs reported that the majority of ID trainee maternity/birth parent leaves (60%) were ≤7 weeks and only 7% were ≥12 weeks; 50% of paternity/nonbirth parent leaves were ≤3 weeks. Conclusions: Surveyed ID fellowship PDs often misinterpret ABIM leave policies and apply policies incorrectly when given sample scenarios..

Internal Medicine Resident Perspectives on Virtual Recruitment.

This survey study describes the perceived implications of virtual-only recruitment and the preferred application process for residents and fellows.

Effect of Increased Interprofessional Familiarity on Team Performance, Communication, and Psychological Safety on Inpatient Medical Teams: A Randomized Clinical Trial.

Importance: In large academic centers, medical residents work on multiple clinical floors with transient interactions with nursing colleagues. Although teamwork is critical in delivering high-quality medical care, little research has evaluated the effect of interprofessional familiarity on inpatient team performance. Objective: To determine the effectiveness of increased familiarity between medical residents and nurses on team performance, psychological safety, and communication. Design, Setting, and Participants: A 12-month randomized clinical trial in an inpatient general medical service at a large academic medical center was completed from June 25, 2019, to June 24, 2020. Participants included 33 postgraduate year (PGY)-1 residents in an internal medicine residency program and 91 general medicine nurses. Interventions: Fifteen PGY-1 residents were randomized to complete all 16 weeks of their general medicine inpatient time on 1 medical nursing floor (intervention group with 43 nurses). Eighteen PGY-1 residents completed 16 weeks on 4 different general medical floors as per usual care (control group with 48 nurses). Main Outcomes and Measures: The primary outcome was an assessment of team performance in physician-nurse simulation scenarios completed at 6 and 12 months. Interprofessional communication was assessed via a time-motion study of both work rounds and individual resident clinical work. Psychological safety and teamwork culture were assessed via surveys of both residents and nurses at multiple time points. Results: Of the intervention and control PGY-1 residents, 8 of 15 (54%) and 8 of 18 (44%) were women, respectively. Of the nurses in the intervention and control groups with information available, 37 of 40 (93%) and 34 of 38 (90%) were women, respectively, and more than 70% had less than 10 years of clinical experience. There was no difference in overall team performance during the first simulation. At the 12-month simulation, the intervention teams received a higher mean overall score in leadership and management (mean [SD], 2.47 [0.53] vs 2.17 [0.39]; P = .045, Cohen d = 0.65) and on individually rated items were more likely to work as 1 unit (100% vs 62%; P = .003), negotiate with the patient (61% vs 10%; P = .001), support other team members (61% vs 24%; P = .02), and communicate as a team (56% vs 19%; P = .02). The intervention teams were more successful in achieving the correct simulation case outcome of negotiating a specific insulin dose with the patient (67% vs 14%; P = .001). Time-motion analysis noted intervention teams were more likely to have a nurse present on work rounds (47% vs 28%; P = .03). At 6 months, nurses in the intervention group were more likely to report their relationship with PGY-1 residents to be excellent to outstanding (74% vs 40%; P = .003), feel that the input of all clinical practitioners was valued (95% vs 53%; P < .001), and say that feedback between practitioners was delivered in a way to promote positive interactions (90% vs 60%; P = .003). These differences diminished at the 12-month survey. Conclusions and Relevance: In this randomized clinical trial, increased familiarity between nurses and residents promoted more rapid improvement of nursing perception of team relationships and, over time, led to higher team performance on complex cognitive tasks in medical simulations. Medical centers should consider team familiarity as a potential metric to improve physician-nursing teamwork and patient care. Trial Registration: ClinicalTrials.gov Identifier: NCT05213117.

Residency Program Responses to Early COVID-19 Surges Highlight Tension as to Whether Residents Are Learners or Essential Workers.

PURPOSE: To quantify the extent to which internal medicine (IM) residents provided care for patients with COVID-19 and examine characteristics of residency programs with or without plans (at some point) to exclude residents from COVID-19 care during the first 6 months of the pandemic. METHOD: The authors used data from a nationally representative, annually recurring survey of U.S. IM program directors (PDs) to quantify early (March-August 2020) resident participation in COVID-19 care. The survey was fielded from August to December 2020. PDs reported whether they had planned to exclude residents from COVID-19 care (i.e., PTE status). PTE status was tested for association with program and COVID-19 temporal characteristics, resident schedule accommodations, and resident COVID-19 cases. RESULTS: The response rate was 61.5% (264/429). Nearly half of PDs (45.4%, 118/260) reported their program had planned at some point to exclude residents from COVID-19 care. Northeastern U.S. programs represented a smaller percentage of PTE than non-PTE programs (26.3% vs 36.6%; P = .050). PTE programs represented a higher percentage of programs with later surges than non-PTE programs (33.0% vs 13.6%, P = .048). Median percentage of residents involved in COVID-19 care was 75.0 (interquartile range [IQR]: 22.5-100.0) for PTE programs, compared with 95.0 (IQR: 60.0-100.0) for non-PTE programs ( P < .001). Residents participated most in intensive care units (87.6%, 227/259) and inpatient wards (80.8%, 210/260). Accommodations did not differ by PTE status. PTE programs reported fewer resident COVID-19 cases than non-PTE programs (median percentage = 2.7 [IQR: 0.0-8.6] vs 5.1 [IQR: 1.6-10.7]; P = .011). CONCLUSIONS: IM programs varied widely in their reported plans to exclude residents from COVID-19 care during the early pandemic. A high percentage of residents provided COVID-19 care, even in PTE programs. Thus, the pandemic highlighted the tension as to whether residents are learners or employees.

Hazard pay for internal medicine resident physicians during the COVID-19 pandemic: A national survey of program directors.

BACKGROUND: Hazard pay for resident physicians has been controversial in the COVID-19 pandemic. Program director (PD) beliefs about hazard pay and the extent of provision to internal medicine (IM) residents are unknown. OBJECTIVE: To evaluate hazard pay provision to residents early in the COVID-19 pandemic and pandemic and residency program characteristics associated with hazard pay. DESIGN, SETTING, AND PARTICIPANTS: A nationally representative survey was conducted of 429 US/US territory-based IM PDs from August to December 2020. MAIN OUTCOME AND MEASURES: Hazard pay provision and PD beliefs about hazard pay were tested for association with factors related to the pandemic surge and program characteristics. RESULTS: Response rate was 61.5% (264/429); 19.5% of PDs reported hazard pay provision. PD belief about hazard pay was equivocal: 33.2% agreed, 43.1% disagreed, and 23.7% were uncertain. Hazard pay occurred more commonly in the Middle-Atlantic Census Division (including New York City) and with earlier surges and greater resident participation in COVID-19 patient care. Hazard pay occurred more commonly where PDs supported hazard pay (74.5% vs. 22.1%, p = .018). Reasons most frequently given in support of hazard pay were essential worker status, equity, and schedule disruption. Those opposed cited professional obligation and equity. CONCLUSION: Hazard pay for IM residents early in the COVID-19 pandemic was nominal but more commonly associated with heavily impacted institutions. Although PD beliefs were mixed, positive belief was associated with provision. The unique role of residents as both essential workers and trainees might explain our varied results. Further investigation may inform future policy, especially in times of crisis.

Parental Leave Policies in Residency: A National Survey of Internal Medicine Program Directors.

PURPOSE: To characterize the existence, accessibility, and content of parental leave policies, as well as barriers to program-level policy implementation among internal medicine (IM) program directors (PDs) and to assess the willingness of PDs to implement a national standardized policy. METHOD: In 2019, the Association of Program Directors in Internal Medicine conducted a survey of 422 IM PDs. Along with other content, 38 questions addressed 4 primary outcomes: parental leave policy existence, accessibility, content, and barriers. The authors compared programs with and without a program-level policy and applied qualitative content analysis to open-ended questions about barriers to policy implementation and openness to a national standard. RESULTS: The response rate was 69.4% (293/422). Of responding programs, 86% (250/290) reported a written parental leave policy with 43% (97/225) of these originating at the program level. Program-level policies, compared with policies at other levels, were more likely to address scheduling during pregnancy (38%, 36/95 vs 22%, 27/124; P = .018); peer coverage (24%, 21/89 vs 15%, 16/109; P = .037), how the duration of extended training is determined (81%, 72/89 vs 44%, 48/109; P < .001), and associated pay and benefits 61%, 54/89 vs 44%, 48/109; P = .009). PDs without program-level policy reported lacking guidance to develop policy, deferring upward to institutional policies, and wishing to retain flexibility. More than half of PDs (60%, 170/282) expressed agreement that a national standard for a residency program-level parental leave policy should exist. Those not in favor cited organization equity, lack of resources, implementation challenges, loss of flexibility, and potentially disadvantaging recruitment. CONCLUSIONS: While existing program-level policies included important content, most PDs reported not having them. A national standard to guide the development of program-level parental leave policies could be embraced if it provided flexibility for programs with limited resources.

The State of Morning Report in the Current Healthcare Landscape: a National Survey of Internal Medicine Program Directors.

BACKGROUND: Case-based Morning Report (MR) has long been the predominant educational conference in Internal Medicine (IM) residency programs. The last comprehensive survey of IM MR was in 1986. Much has changed in the healthcare landscape since 1986 that may impact MR. OBJECTIVE: We sought to determine the current state of MR across all US IM programs. DESIGN: In 2018, US IM program directors (PDs) were surveyed about the dynamics of MR at their institutions, perceived pressures, and realized changes. KEY RESULTS: The response rate was 70.2% (275/392). MR remains highly prevalent (97.5% of programs), although held less frequently (mean 3.9 days/week, SD 1.2), for less time (mean 49.4 min, SD 12.3), and often later in the day compared to 1986. MR attendees have changed, with more diversity of learners but less presence of educational leaders. PD presence at MR is associated with increased resident attendance (high attendance: 78% vs 61%, p=0.0062) and punctuality (strongly agree/agree: 59% vs 43%, p=0.0161). The most cited goal for MR is utilizing cases to practice clinical reasoning. Nearly 40% of PDs feel pressure to move or cancel MR; of those, 61.2% have done so, most commonly changing the timing (48.5%), reducing the length (18.4%), and reducing the number of sessions per week (11.7%). Compared to community-based and to community-based, university-affiliated programs, university-based programs have 2.9 times greater odds (95% CI: 1.3, 6.9; p = 0.0081) and 2.5 times greater odds (95% CI 1.5, 4.4; p =0.0007), respectively, of holding MR after 9 AM, and 1.8 times greater odds (95% CI: 0.8, 4.2; p = 0.1367) and 2.0 times greater odds (95% CI: 1.2, 3.5; p = 0.0117), respectively, of reporting pressure to cancel or move MR compared to their counterparts. CONCLUSIONS: While MR ubiquity reflects its continued perceived value, PDs have modified MR to accommodate changes in the healthcare environment. This includes reduced frequency, shorter length, and moving conferences later in the day. Additional studies are needed to understand how these changes impact learning.

Clinical Decision Support for Symptom Management in Lung Cancer Patients: A Group RCT.

CONTEXT: Clinical guidelines are available to enhance symptom management during cancer treatment but often are not used in the practice setting. Clinical decision support can facilitate the implementation and adherence to clinical guidelines. and improve the quality of cancer care. OBJECTIVES: Clinical decision support offers an innovative approach to integrate guideline-based symptom management into oncology care. This study evaluated the effect of clinical decision support-based recommendations on clinical management of symptoms and health-related quality of life (HR-QOL) among outpatients with lung cancer. METHODS: Twenty providers and 179 patients were allotted in group randomization to attention control (AC) or Symptom Assessment and Management Intervention (SAMI) arms. SAMI entailed patient-report of symptoms and delivery of recommendations to manage pain, fatigue, dyspnea, depression, and anxiety; AC entailed symptom reporting prior to the visit. Outcomes were collected at baseline, two, four and six-months. Adherence to recommendations was assessed through masked chart review. HR-QOL was measured by the Functional Assessment of Cancer Therapy-Lung questionnaire. Descriptive statistics with linear and logistic regression accounting for the clustering structure of the design and a modified chi-square test were used for analyses. RESULTS: Median age of patients was 63 years, 58% female, 88% white, and 32% ≤high school education. Significant differences in clinical management were evident in SAMI vs. AC for all target symptoms that passed threshold. Patients in SAMI were more likely to receive sustained-release opioids for constant pain, adjuvant medications for neuropathic pain, opioids for dyspnea, stimulants for fatigue and mental health referrals for anxiety. However, there were no statistically significant differences in HR-QOL at any time point. CONCLUSION: SAMI improved clinical management for all target symptoms but did not improve patient outcomes. A larger study is warranted to evaluate effectiveness.

Does Increased Schedule Flexibility Lead to Change? A National Survey of Program Directors on 2017 Work Hours Requirements.

BACKGROUND: The learning and working environment for resident physicians shifted dramatically over the past two decades, with increased focus on work hours, resident wellness, and patient safety. Following two multi-center randomized trials comparing 16-h work limits for PGY-1 trainees to more flexible rules, the ACGME implemented new flexible work hours standards in 2017. OBJECTIVE: We sought to determine program directors' (PDs) support for the work hour changes and programmatic response. DESIGN: In 2017, US Internal Medicine PDs were surveyed about their degree of support for extension of PGY-1 work hour limits, whether they adopted the new maximum continuous work hours permitted, and reasons for their decisions. KEY RESULTS: The response rate was 70% (266/379). Fifty-seven percent of PDs (n = 151) somewhat/strongly support the new work hour rules for PGY-1 residents, while only 25% of programs (N = 66) introduced work periods greater than 16-h on any rotation. Higher rates of adopting change were seen in PDs who strongly/somewhat supported the change (56/151 [37%], P < 0.001), had tenure of 6+ years (33/93 [35%], P = 0.005), were of non-general internal medicine subspecialty (30/80 [38%], P = 0.003), at university-based programs (35/101 [35%], P = 0.009), and with increasing number of approved positions (< 38, 10/63 [16%]; 38-58, 13/69 [19%]; 59-100, 15/64 [23%]; > 100, 28/68 [41%], P = 0.005). Areas with the greatest influence for PDs not extending work hours were the 16-h rule working well (56%) and risk to PGY1 well-being (47%). CONCLUSIONS: Although the majority of PDs support the ACGME 2017 work hours rules, only 25% of programs made immediate changes to extend hours. These data reveal that complex, often competing, forces influence PDs' decisions to change trainee schedules.

The effect of waveform asymmetry on perception with epiretinal prostheses.

Objective: Retinal prosthetic implants have helped improve vision in patients blinded by photoreceptor degeneration. Retinal implant users report improvements in light perception and performing visual tasks, but their ability to perceive shapes and letters is limited due to the low precision of retinal activation, which is exacerbated by axonal stimulation and high perceptual thresholds. A previous in vitro study in our lab used calcium imaging to measure the spatial activity of mouse retinal ganglion cells (RGCs) in response to electrical stimulation. Based on this study, symmetric anodic-first (SA) stimulation effectively avoided axonal activation and asymmetric anodic-first stimulation (AA) with duration ratios (ratio of the anodic to cathodic phase) greater than 10 reduced RGC activation thresholds significantly. Applying these novel stimulation strategies in clinic may increase perception precision and improve the overall patient outcomes. Approach: We combined human subject testing and computational modeling to further examine the effect of SA and AA stimuli on perception shapes and thresholds for epiretinal stimulation of RGCs. Main results: Threshold measurement in three Argus II participants indicated that AA stimulation could increase perception probabilities compared to a standard symmetric cathodic-first (SC) pulse, and this effect can be intensified by addition of an interphae gap (IPG). Our in silico RGC model predicts lower thresholds with AA and asymmetric cathodic-first (AC) stimuli compared to a SC pulse. This effect was more pronounced at shorter pulse widths. The most effective pulse for threshold reduction with short pulse durations (≤0.12 ms) was AA stimulation with small duration ratios (≤5) and long IPGs (≥2 ms). For the 0.5 ms pulse duration, SC stimulation with IPGs longer than 0.5 ms, or asymmetric stimuli with large duration ratios (≥20) were most effective in threshold reduction. Phosphene shape analysis did not reveal a significant change in percept elongation with SA stimulation. However, there was a significant increase in percept size (P < 0.01) with AA stimulation compared to the standard pulse in one participant. Significane: Including asymmetric waveform capability will provide more flexible options for optimization and personalized fitting of retinal implants.

A Patient-Specific Computational Framework for the Argus II Implant.

GOAL: Retinal prosthesis performance is limited by the variability of elicited phosphenes. The stimulating electrode's position with respect to retinal ganglion cells (RGCs) affects both perceptual threshold and phosphene shape. We created a modeling framework incorporating patient-specific anatomy and electrode location to investigate RGC activation and predict inter-electrode differences for one Argus II user. METHODS: We used ocular imaging to build a three-dimensional finite element model characterizing retinal morphology and implant placement. To predict the neural response to stimulation, we coupled electric fields with multi-compartment cable models of RGCs. We evaluated our model predictions by comparing them to patient-reported perceptual threshold measurements. RESULTS: Our model was validated by the ability to replicate clinical impedance and threshold values, along with known neurophysiological trends. Inter-electrode threshold differences in silico correlated with in vivo results. CONCLUSIONS: We developed a patient-specific retinal stimulation framework to quantitatively predict RGC activation and better explain phosphene variations.

Measuring Patient Preferences and Clinic Follow-Up Utilizing an Embedded Discharge Appointment Scheduler: A Pilot Study.

BACKGROUND: Scheduling timely outpatient follow-up appointments is part of a high-quality discharge process. In many centers, residents and hospitalists schedule follow-up appointments, often without patient input due to time constraints. METHODS: A needs assessment was conducted to quantify clinician time spent making discharge appointments and to identify barriers to successful appointment scheduling. A four-week pilot intervention subsequently embedded a discharge scheduler responsible for scheduling discharge appointments into five house staff teams. The goals of the pilot were to incorporate patients' scheduling preferences when making appointments, to improve appointment attendance, and to reduce administrative burden on residents. Results were analyzed using chi-square and Fisher's exact tests. RESULTS: Patients expressed a strong preference to be involved in scheduling follow-up appointments. In the intervention, there was a statistically significant increase in successfully scheduled appointments (66.7% vs. 87.7%; p < 0.0001) and attendance at follow-up appointments (43.9% baseline vs. 62.9% intervention; p = 0.011), a statistically significant reduction in rescheduled appointments (16.7% baseline vs. 4.9% intervention; p = 0.008), a nonsignificant trend toward increased number of canceled appointments (7.6% baseline vs. 17.5% intervention; p = 0.088), and no significant difference in no-show rates (18.2% baseline vs. 14.7% intervention; p = 0.544). Of residents involved in the pilot, 100% reported that the scheduler improved their ability to care for patients. CONCLUSION: This pilot suggests that adding a nonclinical team member tasked with scheduling discharge appointments improved alignment of the discharge process with patients' preferences and may be of value to residents, hospitalists, and the health care system.