Do Lower Costs for Applicants Come at the Expense of Program Perception? A Cross-Sectional Survey Study of Virtual Residency Interviews.

Background: Travel costs and application fees make in-person residency interviews expensive, compounding existing financial burdens on medical students. We hypothesized virtual interviews (VI) would be associated with decreased costs for applicants compared to in-person interviews (IPI) but at the expense of gathering information with which to assess the program. Objective: To survey senior medical students and postgraduate year (PGY)-1 residents regarding their financial burden and program perception during virtual versus in-person interviews. Methods: The authors conducted a single center, multispecialty study comparing costs of IPI vs VI from 2020-2021. Fourth-year medical students and PGY-1 residents completed one-time surveys regarding interview costs and program perception. The authors compared responses between IPI and VI groups. Potential debt accrual was calculated for 3- and 7-year residencies. Results: Two hundred fifty-two (of 884, 29%) surveys were completed comprising 75 of 169 (44%) IPI and 177 of 715 (25%) VI respondents. The VI group had significantly lower interview costs compared to the IPI group (median $1,000 [$469-$2,050 IQR] $784-$1,216 99% CI vs $3,200 [$1,700-$5,500 IQR] $2,404-$3,996 99% CI, P<.001). The VI group scored lower for feeling the interview process was an accurate representation of the residency program (3.3 [0.5] vs 4.1 [0.7], P<.001). Assuming interview costs were completely loan-funded, the IPI group will have accumulated potential total loan amounts $2,334 higher than the VI group at 2% interest and $2,620 at 6% interest. These differences were magnified for a 7-year residency. Conclusions: Virtual interviews save applicants thousands of dollars at the expense of their perception of the residency program.

Perceptions of Resident Autonomy in Internal Medicine, Pediatrics, and Internal Medicine-Pediatrics.

BACKGROUND: Although graduated autonomy is an essential component of residency training, we have an incomplete understanding of resident and attending faculty perceptions of autonomy. OBJECTIVE: In this study, we assessed differences in perceived autonomy among residents and faculty in pediatrics, internal medicine, and combined internal medicine-pediatrics. METHODS: We surveyed senior-level (PGY-2-5) residents and faculty in pediatrics, internal medicine, and combined internal medicine-pediatrics in three large, urban training centers in November 2014. The survey included domain items such as general perceptions of autonomy, case management, rounding structure, and individual resident and faculty factors that may interplay with the granting or receiving of autonomy. RESULTS: Of 489 eligible respondents, 215 (44%) responded. Internal medicine-pediatrics residents were more likely than categorical pediatrics residents and pediatrics faculty to disagree that they received an appropriate level of autonomy while on inpatient pediatrics general wards (mean = 2.7 relative to 4.0 and 4.3, categorical residents and faculty; 5-point Likert scale; P < .001). On a 5-point Likert scale, the internal medicine-pediatrics residents were more likely to agree that they received too much oversight on pediatrics general ward rotations (mean, 3.9) compared to internal medicine general ward rotations (mean, 1.9) with a P-value between rotations of <.001. Combined internal medicine-pediatrics perceptions of too much oversight while on pediatric general ward rotations were significantly different from their categorical pediatrics peers (pediatrics mean 2.0, P < .001). CONCLUSIONS: Internal medicine-pediatrics residents have differing perceptions of autonomy from their categorical peers as well as categorical supervising faculty. Combined Internal medicine-pediatrics residents' perceived oversight on pediatrics rotations differently from their categorical pediatrics peers and also differently from their experiences on internal medicine wards. A better understanding of combined internal medicine-pediatrics residents' perceptions of autonomy and supervision can help inform future work regarding autonomy-supportive strategies to optimize learning.

A Qualitative Analysis of Resident Adverse Event Reporting: What's Holding Us Back.

This study utilized focus groups of residents, who report adverse events at differing rates depending on their hospital site, to better understand barriers to residents' reporting and identify modifiable aspects of an institution's culture that could encourage resident event reporting. Focus groups included residents who rotated at 3 hospitals and represented 4 training programs. Focus groups were audio recorded and analyzed using qualitative methods. A total of 64 residents participated in 8 focus groups. Reporting behavior varied by hospital culture. Residents worried about damage to their professional relationships and lacked insight into the benefits of multiple reports of the same event or how human factors engineering can prevent errors. Residents did not understand how reporting affects litigation. Residents at other academic institutions likely experience similar barriers. This study illustrates that resident reporting is modifiable by changing hospital culture, but hospitals have only a few opportunities to mishandle reporting before resident reporting attitudes solidify.

A Framework for Inclusive Graduate Medical Education Recruitment Strategies: Meeting the ACGME Standard for a Diverse and Inclusive Workforce.

To help address health care disparities and promote higher-quality, culturally sensitive care in the United States, the Accreditation Council for Graduate Medical Education and other governing bodies propose cultivating a more diverse physician workforce. In addition, improved training and patient outcomes have been demonstrated for diverse care teams. However, prioritizing graduate medical education (GME) diversity and inclusion efforts can be challenging and unidimensional diversity initiatives typically result in failure.Little literature exists regarding actionable steps to promote diversity in GME. Building on existing literature and the authors' experiences at different institutions, the authors propose a 5-point inclusive recruitment framework for diversifying GME training programs. This article details each of the 5 steps of the framework, which begins with strong institutional support by setting diversity as a priority. Forming a cycle, the other 4 steps are seeking out candidates, implementing inclusive recruitment practices, investing in trainee success, and building the pipeline. Practical strategies for each step and recommendations for measurable outcomes for continued support for this work are provided. The proposed framework may better equip colleagues and leaders in academic medicine to prioritize and effectively promote diversity and inclusion in GME at their respective institutions.

Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines.

INTRODUCTION: Little is known about what motivates residents to report adverse events. The goals of the qualitative study were to: (1) better understand facilitators to residents' event reporting and (2) identify effective interventions that encourage residents to report. METHODS: The authors conducted focus groups of upper-level residents from 4 training programs (2 internal medicine, a pediatric, and a combined medicine-pediatric) who rotated at 3 institutions within a large healthcare system in 2016. Quantitative data on reporting experience were gathered. Focus groups were audio recorded and transcribed. Two coders reviewed transcripts using the editing approach and organized codes into themes. RESULTS: Sixty-four residents participated in 8 focus groups. Residents were universally exposed to reportable events and knew how to report. Residents' reporting behavior varied by site according to local culture, with residents filing more reports at the pediatric hospital compared to other sites, but all groups expressed similar general views about facilitators to reporting. Facilitators included familiarity with the investigation process, reporting via telephone, and routine safety educational sessions with safety administrators. Residents identified specific interventions that encouraged reporting at the pediatric hospital, including incorporating an attending physician review of events into sign-out and training on error disclosure. CONCLUSIONS: This study provides insight into what motivates resident event reporting and describes concrete interventions to increase reporting. Our findings are consistent with the Theoretical Domains Framework of behavioral change. These strategies could prove successful at other pediatric hospitals to build a culture that values reporting and prepares residents as patient safety champions.

Financial Attitudes and Behaviors of Internal Medicine and Internal Medicine-Pediatrics Residents.

BACKGROUND: Residents graduate from medical school with increasing levels of debt and also may possess poor financial knowledge and practices. Prior studies have assessed resident financial knowledge and interest in financial education, yet additional information regarding their attitudes about personal finance and financial planning could be essential for the development of relevant curricula. OBJECTIVE: We assessed baseline financial attitudes and planning behaviors of internal medicine and internal medicine-pediatrics residents in 3 geographically diverse academic programs. METHODS: A modified version of the Financial Industry Regulatory Authority National Financial Capability survey was administered anonymously to residents in 3 programs in spring 2017. Outcomes included levels of educational debt, positive financial planning behaviors, perception of finances and debt, and education about personal finance. RESULTS: Response rate was 62% (184 of 298). Rates of educational debt were high, with 81% (149 of 184) of respondents reporting educational debt, and the majority owing more than $100,000. Residents' financial practices were variable, and residents could be grouped into 1 of 3 categories-concerned-engaged, concerned-unengaged, and unconcerned-unengaged-based on their engagement with debt and financial management. Residents with high debt (> $250,000) had a bimodal distribution of respondents who strongly agreed and those who strongly disagreed they were concerned about debt. CONCLUSIONS: Resident financial attitudes and practices are variable, ranging from highly engaged residents actively managing their financial wellness to unengaged residents who have low concern, despite high educational debt.

An Inpatient Patient Safety Curriculum for Pediatric Residents.

Introduction: Patient safety is recognized as an important part of pediatric resident education. There is a lack of published safety curricula targeting pediatric residents. A local needs assessment showed that while residents felt safety was an important part of their current and future jobs, they did not feel prepared to apply safety principles to their future careers or participate in a root cause analysis (RCA). Methods: This curriculum was delivered to senior-level pediatric and multiple-board residents during five monthly, hour-long, multidisciplinary sessions. Sessions covered systems-based thinking, terminology, the second victim phenomenon, RCA, and medication errors, while providing feedback on recent event reports filed by residents. Resident knowledge, attitudes, and reporting behavior were evaluated prior to and following the curriculum. Results: Attendees showed statistically significant improved safety attitudes and preparedness to apply safety to their future endeavors; conversely, there were no significant changes in nonattendees. There were no significant changes in knowledge scores or event reporting. Answers to qualitative questions identified learning about the reporting process, RCAs, and follow-up on filed event reports as valuable parts of the curriculum. Residents desired more time to debrief about safety events. Discussion: The curriculum succeeded in engaging residents in patient safety and making them feel prepared for future practice. Residents showed a dissonance between their intentions to report and their actual reporting behaviors, the reasons for which require further exploration. Residents desired a forum to deal with the emotions involved in errors. This curriculum is easily transferable to other institutions with minor modifications.

Pediatric residents' attitudes and practice patterns regarding transition to adult-oriented care.

BACKGROUND: Most youth with chronic illness will survive into adulthood. The complexity of the medical history and care in these patients necessitates a well-planned and coordinated transition over several years as they move from pediatric to adult-oriented health care. METHODS: We assessed pediatric residents' practice patterns and attitudes regarding transition communication by administering a survey about transition to pediatric, combined internal medicine-pediatrics, pediatric neurology, and combined psychiatry-child psychiatry-pediatric residents. RESULTS: Among 110 residents who were contacted, 66 completed the survey, for a response rate of 61%. Surveyed residents report discussing transition with their patients when their patients are age 18 or older, when guidelines suggest a discussion should begin around age 12. Most residents felt that transition should be initially addressed one year prior to transfer. Residents also reported barriers such as lack of experience with transition and lack of role modeling by supervisors as barriers to providing transitional care. CONCLUSIONS: The practice patterns and attitudes of pediatric residents in this study do not reflect the recommendations that have been published regarding transitional care services to prepare patients and families for transfer from pediatric to adult-oriented care. In particular, most residents report that they start transition discussions when a patient is near the age of 18, rather than the age of 12 as guidelines suggest and as families would prefer. Pediatric residents need further education regarding transition, with particular emphasis on the need for early and frequent discussions with patients and families regarding transition.

The practice patterns of recently graduated internal medicine-pediatric hospitalists.

OBJECTIVES: To identify the current practice patterns and professional activities of internal medicine-pediatrics (med-peds) hospitalists who have graduated in the past 5 years (June 2009-June 2013). METHODS: The national Medicine-Pediatrics Program Directors Association (MPPDA) conducted a cross-sectional survey study of the 79 residency program directors who are members of the MPPDA regarding the practice patterns of recent graduates (from 2009-2013) currently practicing as hospitalists. The survey was distributed in the spring of 2014 on the MPPDA listserv. The survey inquired about time spent caring for hospitalized adults and children, medical school appointments, practice in freestanding children's hospitals, and completion of hospital medicine (HM) fellowships. RESULTS: Forty-nine program directors (62%) completed the survey and provided data on 1042 graduates from 46 programs. Of those graduates, 26.4% (n=275) practice as hospitalists, and none had completed an HM fellowship. Approximately two-thirds (65%) of med-peds hospitalists provide care to hospitalized children and adults, with one-third providing care solely to hospitalized adults. Approximately one-half (53.5%) have an appointment with a medical school and roughly one-quarter (28%) practice in a freestanding children's hospital. CONCLUSIONS: An increasing percentage of recent med-peds graduates are pursuing careers in HM, and two-thirds are providing care to hospitalized children. As consideration for an accredited pediatric HM fellowship continues, certifying and accrediting bodies should consider how this will impact the med-peds workforce and allow med-peds graduates flexibility in their training requirements that will permit them to acquire the necessary skills to care for hospitalized children and adults.

Addressing health literacy through clear health communication: a training program for internal medicine residents.

OBJECTIVE: To develop, pilot, and test the effectiveness of a clear health communication curriculum to improve resident knowledge, attitudes, and skills regarding health literacy. METHODS: Thirty-one internal medicine residents participated in a small group curriculum that included didactic teaching, practice with a standardized patient, and individualized feedback on videotaped encounters with real patients. Outcomes were assessed using a pre-post survey and a communication skills checklist. RESULTS: Mean knowledge scores increased significantly from 60.3% to 77.6% (p<0.001). Residents also reported increased familiarity with the concept of health literacy (mean response 3.2 vs. 4.5 on a 5 point scale), importance placed on health literacy (4.2 vs. 4.9), frequency of considering health literacy in patient care (3.3 vs. 4.0), and confidence in communicating with low literacy patients (3.3 vs. 4.1) (all p<0.001). Use of plain language increased significantly from 33% to 86% (p=0.023). There were nonsignificant increases in the use of teach-back (0-36%, p=0.116) and encouraging questions (0-14%, p=0.502). CONCLUSION: Training in clear health communication improves resident knowledge, attitudes, and skills regarding health literacy. PRACTICE IMPLICATIONS: The increased use of clear health communication techniques can significantly improve the care and outcomes of vulnerable patients with limited health literacy.

Giving residents tools to talk about behavior change: a motivational interviewing curriculum description and evaluation.

OBJECTIVE: To determine whether a motivational interviewing (MI) curriculum is effective in teaching internal medicine residents core MI skills and the empathic, nonjudgmental MI style. METHODS: Nineteen third-year residents met for 12 h with a faculty instructor. Teaching methods included lecture, written exercises, a simulated patient exercise, and discussion of residents' behavior change issues. RESULTS: Residents' adoption of MI skills was evaluated before and after the course with the Helpful Responses Questionnaire. Residents decreased use of closed-ended questions (from a score of 1.13 to 0.37, p=0.036) and MI roadblocks (4.00-1.08, p<0.001), and increased the use of reflections (1.87-4.87, p<0.001), and use of MI strategies (0.45-0.97, p=0.017). Residents' use of open-ended questions decreased from 1.97 to a mean of 1.05, p=0.023. Residents' ratings of the course on a 5-point scale varied from 3.7 for written exercises to 4.6/5 for the simulated patient exercise. After the course, residents rated behavior change counseling skills as more important. DISCUSSION AND CONCLUSION: A 12-h course increased residents' use of core MI communication skills in a written measure, and was highly rated. PRACTICE IMPLICATIONS: Future work should examine whether teaching of the empathic, collaborative MI stance impacts patient outcomes.