A Qualitative Study of Internal Medicine Subspecialty Fellowship Program Directors' Perspectives on Short-Term Hospitalist Employment Prior to Fellowship.

Background Some internal medicine (IM) residents pursuing subspecialty training choose short-term hospitalist employment prior to fellowship, or "pre-fellowship hospitalist years." Residency and fellowship program directors (PDs) advise residents on this decision, but PD experience with fellows pursuing pre-fellowship hospitalist years and the impact on fellowship applications is unknown. Objective We aimed to explore perceptions of fellowship PDs regarding experience with fellows who pursued pre-fellowship hospitalist years, including perceived effects on how such years affect fellowship application candidacy. Methods A purposive sample of 20 fellowship PDs in the most highly competitive and commonly selected IM fellowships (cardiology, pulmonology/critical care medicine, hematology/oncology, gastroenterology) from 5 academic institutions were approached for participation in fall 2021. Interviews included semi-structured questions about pre-fellowship hospitalist employment. Utilizing rapid qualitative analysis, interview transcripts were summarized and reviewed to identify themes and subthemes describing fellowship PDs' perspectives of pre-fellowship hospitalist years. Results Sixteen fellowship PDs (80%) participated. PDs identified 4 major themes as important for trainees considering pre-fellowship hospitalist years: (1) Explain the "Why"-why the year was pursued; (2) Characteristics of the Hospitalist Position-what type of employment; (3) The Challenges-potential concerns faced with pre-fellowship hospitalist years; and (4) Describe the "What"-the experience's contribution to resident professional development. Conclusions Fellowship PDs in 4 competitive IM subspecialities placed a strong emphasis on explaining a clear, logical reason for seeking short-term hospitalist employment prior to fellowship, describing how it fits into the overall career trajectory, and selecting activities that demonstrate continued commitment to the subspecialty.

Resident Burnout, Wellness, Professional Development, and Engagement Before and After New Training Schedule Implementation.

Importance: Burnout is a work-related syndrome of depersonalization (DP), emotional exhaustion (EE), and low personal achievement (PA) that is prevalent among internal medicine resident trainees. Prior interventions have had modest effects on resident burnout. The association of a new 4 + 4 block schedule (4 inpatient weeks plus 4 outpatient weeks) with resident burnout has not previously been evaluated. Objective: To evaluate the association of a 4 + 4 block schedule, compared with a 4 + 1 schedule, with burnout, wellness, and self-reported professional engagement and clinical preparedness among resident physicians. Design, Setting, and Participants: This nonrandomized preintervention and postintervention survey study was conducted in a single academic-based internal medicine residency program from June 2019 to June 2021. The study included residents in the categorical, hospitalist, and primary care tracks in postgraduate years 1 and 2 (PGY1 and PGY2). Data analysis was conducted from October to December 2022. Intervention: In the 4 + 4 structure, resident schedules alternated between 4-week inpatient call-based rotations and 4-week ambulatory non-call-based rotations. Main Outcomes and Measures: The primary outcome was burnout, assessed using the Maslach Burnout Inventory subcategories of EE (range, 0-54), DP (range, 0-30), and PA (range, 0-48), adjusted for sex and PGY. Secondary outcomes included In-Training Examination (ITE) scores and a questionnaire on professional, educational, and health outcomes. Multivariable logistic regression was used to assess the primary outcome, 1-way analysis of variance was used to compare ITE percentiles, and a Bonferroni-adjusted Kruskal Wallis test was used for the remaining secondary outcomes. The findings were reexamined with several sensitivity analyses, and Cohen's D was used to estimate standardized mean differences (SMDs). Results: Of the 313 eligible residents, 216 completed the surveys. A total of 107 respondents (49.5%) were women and 109 (50.5%) were men; 119 (55.1%) were PGY1 residents. The survey response rates were 78.0% (85 of 109) in the preintervention cohort and 60.6% (63 of 104) and 68.0% (68 of 100) in the 2 postintervention cohorts. The PGY1 residents had higher response rates than the PGY2 residents (119 of 152 [78.2%] vs 97 of 161 [60.2%]; P < .001). Adjusted EE scores (mean difference [MD], -6.78 [95% CI, -9.24 to -4.32]) and adjusted DP scores (MD, -3.81 [95% CI, -5.29 to -2.34]) were lower in the combined postintervention cohort. The change in PA scores was not statistically significant (MD, 1.4 [95% CI, -0.49 to 3.29]). Of the 15 items exploring professional, educational, and health outcomes, a large positive association was observed for 11 items (SMDs >1.0). No statistically significant change in ITE percentile ranks was noted. Conclusions and Relevance: In this survey study of internal medicine resident physicians, a positive association was observed between a 4 + 4 block training schedule and internal medicine resident burnout scores and improved self-reported professional, educational, and health outcomes. These results suggest that specific 4 + 4 block combinations may better improve resident burnout than a 4 + 1 combination used previously.

Interventions to Reduce Inappropriate Physical Therapy Consultation in the Inpatient Setting: A Quality Improvement Initiative.

ABSTRACT: Physical therapy (PT) in inpatient settings is a limited and valuable resource. Inappropriate PT consultation is costly and can lead to delays in care and discharge planning. Baseline data at an academic hospital revealed that approximately one in four PT consults were inappropriate (n = 29,230) across all services, as defined by an activity measure post-acute care "6-Clicks" basic mobility score of >22. Our interdisciplinary quality improvement team used the Six Sigma methodology to address this problem. We performed a root-cause analysis that identified high-impact root causes and implemented two targeted interventions: (1) A modified electronic health record PT order with clinical-decision support, and (2) nursing role change to assume PT-ordering responsibility. The rate of inappropriate PT consults decreased from 23.9% to <10% postintervention across all inpatient units, with the nursing role change reaching statistical significance (p < .0019). Our multifaceted intervention contributed to a significant reduction in unnecessary PT consults, expediting evaluation of patients qualifying for skilled inpatient therapy.

A Novel Hospital Medicine Training Track for Internal Medicine Residents: Description and Program Evaluation of the First 15 Years.

Background: The growth of hospital medicine has resulted in a parallel growth of hospital medicine training within internal medicine residency programs (IMRPs), but the experience and outcomes of these training offerings have not yet been described. Objective: To describe the first dedicated hospitalist track and the program evaluation data. Methods: The University of Colorado Hospitalist Training Track (HTT) is a 3-year track within the IMRP with robust inpatient clinical training, specialized didactics, experiential improvement work, and career mentorship. We collected data on graduates' current practices and board certification pass rates. To further evaluate the track, we electronically sent a cross-sectional survey to 124 graduates from 2005 to 2019 to identify current practice settings, graduate roles, and assessment of the training track. Results: Among 124 graduates, 97 (78.2%) practice hospital medicine, and the board certification pass rate was slightly higher than the overall IMRP pass rate for those graduating classes. Sixty-two (50%) graduates responded to the survey. Among respondents, 50 (80.6%) currently practice hospital medicine and 34 (54.8%) practice in an academic setting. The majority (50, 80.6%) hold leadership roles and are involved in a variety of scholarship, educational, and operational projects. Dedicated clinical training, didactics, and mentorship were valued by respondents. Conclusions: This represents the first description and program evaluation of a HTT for IM residents. A dedicated HTT produces graduates who choose hospital medicine careers at high rates and participate in a wide variety of leadership and nonclinical roles.

COVID-19's impact on faculty and staff at a School of Medicine in the US: what is the blueprint for the future?

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) caused unprecedented challenges within medical centers, revealing inequities embedded in the medical community and exposing fragile social support systems. While faculty and staff faced extraordinary demands in workplace duties, personal responsibilities also increased. The goal of this study was to understand the impact of the COVID-19 pandemic on personal and professional activities of faculty and staff in order to illuminate current challenges and explore solutions. METHODS: Qualitative, semi-structured group interviews involved faculty and staff at four affiliate sites within the Department of Medicine at the University of Colorado, School of Medicine. Focus groups addressed the impact of COVID-19 on (1) Changes to roles and responsibilities at work and at home, (2) Resources utilized to manage these changes and, (3) Potential strategies for how the Department could assist faculty and staff. Thematic analysis was conducted using an inductive method at the semantic level to form themes and subthemes. RESULTS: Qualitative analysis of focus group transcripts revealed themes of: (1) Challenges and disparities experienced during the pandemic, (2) Disproportionate impact on women personally and professionally, (3) Institutional factors that contributed to wellness and burnout, and (4) Solutions and strategies to support faculty and staff. Within each of these themes were multiple subthemes including increased professional and personal demands, concern for personal safety, a sense of internal guilt, financial uncertainty, missed professional opportunities, and a negative impact on mentoring. Solutions were offered and included an emphasis on addressing preexisting inequities, the importance of community, and workplace flexibility. CONCLUSIONS: The COVID-19 pandemic created burdens for already challenged faculty and staff in both their personal and professional lives. Swift action and advocacy by academic institutions is needed to support the lives and careers of our colleagues now and in the future.

The Experience of Women in Hospital Medicine Leadership: a Qualitative Study.

BACKGROUND: Since 2017, women have made up over 50% of medical school matriculants; however, only 16% of department chairs are women-a number that has remained stagnant and demonstrates the underrepresentation of women in leadership positions in medicine. OBJECTIVE: To better understand the challenges women face in leadership positions and to inform how best to advance women leaders in Hospital Medicine. DESIGN, SETTING, AND PARTICIPANTS: Using hermeneutical phenomenological methods, we performed semi-structured qualitative interviews of ten female division heads from hospital medicine groups in the USA, transcribed verbatim, and coded for thematic saturation using Atlas.ti software. MEASUREMENTS: Qualitative themes and subthemes. KEY RESULTS: Ten women hospitalist leaders were interviewed from September through November 2019. Participants identified four key challenges in their leadership journeys: lack of support to pursue leadership training, bullying, a sense of sacrifice in order to achieve balance, and the need for internal and external validation. Participants also suggested key interventions in order to support women leaders in the future: recommending a platform to share experiences, combat bullying, advocate for themselves, and bolster each other in sponsorship and mentorship roles. Finally, participants identified how they have unique strengths as women in leadership, and are transforming the culture of medicine with a focus on diversity and flexibility. CONCLUSION: Women in leadership positions face unique challenges, but also have a unique perspective as to how to support the next generation of leaders.

Teaching Students to Transform: The Health Innovations Scholars Program 6 Years Later.

Training in leadership and health system transformation is increasingly important in undergraduate medical education in order to develop a pipeline of engaged physicians dedicated to transforming health care. Despite this growing need, it is unclear whether current leadership training methods have long-term impact on students' career trajectory. The authors analyzed career outcomes from 6 years of the Health Innovations Scholars Program (HISP) to better understand how the program affected the 46 graduates' future involvement in health system transformation and leadership. Eighty-eight percent of the graduates remained involved in quality improvement, 70% held leadership positions, 31% participated in health innovation, and 15% participated in patient safety initiatives. Project involvement of the graduates represented both primary and secondary catalysts for health system change, leading to 28 unique catalyst events. HISP is a model for directing trainees' career trajectory toward engagement in health system leadership and redesign.

Expanding Training in Quality Improvement and Patient Safety Through a Multispecialty Graduate Medical Education Curriculum Designed for Fellows.

Introduction: Although the Accreditation Council for Graduate Medical Education requires quality improvement and patient safety (QIPS) training for fellow-level trainees, this experience is often insufficient due to lack of faculty time and expertise within fellowship training programs. We developed a centralized GME curriculum targeted to an integrated, multispecialty audience of fellow-level trainees with the goal of promoting leadership and scholarship in QIPS. Methods: The University of Colorado implemented the Fellows' Quality and Safety Academy, a three-seminar curriculum in patient safety and health systems improvement. As most participants had prior training in QIPS during medical school or residency, educational strategies emphasized application of QIPS concepts through focused didactic content review paired with small-group case-based exercises and coaching of experiential project work to promote content mastery as well as practice of leadership and scholarship strategies. Results: Since the curriculum's inception in 2017, there have been 106 participants in the Foundations in Patient Safety seminar, 49 participants in the Adverse Events Into Quality Improvement seminar, and 48 participants in the Quality in Academics seminar. These participants represented 44 separate fellowship disciplines from both adult and pediatric subspecialties. Learners reported improved attitudes and confidence and demonstrated objective knowledge acquisition across QIPS content domains. Discussion: Our pedagogical approach of centralizing QIPS training and harnessing faculty expertise to teach fellow-level trainees across specialties through interdisciplinary collaboration and interactive project-based work is an effective strategy to promote development of QIPS competencies during fellowship training.

Parental Leave for Residents at Programs Affiliated With the Top 50 Medical Schools.

BACKGROUND: Of the top 15 medical schools with affiliated graduate medical education (GME) programs, 8 offer paid parental leave, with an average duration of 6.6 weeks. It is not known how other GME programs approach parental leave. OBJECTIVE: We searched for the parental leave policies for residents in programs affiliated with the top 50 medical schools. METHODS: In 2019, we identified the top 50 medical schools designated by US News & World Report in the research and primary care categories (totaling 59 schools), and identified the associated GME programs. For each school, we accessed its website and searched for "GME Policies and Procedures" to find language related to maternity, paternity, or parental leave, or the Family Medical Leave Act. If unavailable, we e-mailed the GME office to identify the policy. RESULTS: Of 59 schools, 25 (42%) described paid parental leave policies with an average of 5.1 weeks paid leave; 11 of those (44%) offer ≤ 4 weeks paid parental leave. Twenty-five of 59 (42%) programs did not have paid parental leave, but 13 of these specify that residents can use sick or vacation time to pay for part of their parental leave. Finally, 13 of 59 (22%) offered state mandated partial paid leave. One school did not have any description of parental leave. CONCLUSIONS: While paid parental leave for residents has been adopted by many of the GME programs affiliated with the top 50 medical schools, it is not yet a standard benefit offered to the majority of residents.

Learning Together: Integration of Advanced Practice Providers into a General Medicine Ward Team.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) demands that physicians should be trained to engage in clinical activities with other health profession providers. Incorporation of advanced practice providers (APPs) into medicine ward teams has not yet been described. AIM: To describe a pilot and feasibility evaluation of an interprofessional general medicine ward team with internal medicine residents and APPs to encourage resident leadership development, enhance service to education balance, and promote interprofessional collaboration. SETTING: University of Colorado, Internal Medicine Residency Program. PARTICIPANTS: Sixteen internal medicine residents, 16 interns, 19 Department of Medicine faculty members, and 8 advanced practice provider fellows in hospital medicine. PROGRAM DESCRIPTION: The authors describe an interprofessional general medicine ward team including team structure, and roles and responsibilities of each team member. PROGRAM EVALUATION: Each team member completed an electronic survey following the rotation and the majority agreed that the pilot team allowed for an enhanced resident leadership role, and helped to restore the service to education balance and interprofessional collaboration. DISCUSSION: An interprofessional general medicine ward team is feasible, has the potential to optimize service to education balance, and exposes learners to a collaborative interprofessional clinical environment.

Clinical Guideline Highlights for the Hospitalist: The Use of Intravenous Fluids in the Hospitalized Adult.

GUIDELINE TITLE: Intravenous Fluid Therapy in Adults in Hospital RELEASE DATE: December, 2013 PRIOR VERSION: Not Applicable DEVELOPER: Multidisciplinary Guideline Development Group within the United Kingdom's National Clinical Guideline Centre FUNDING SOURCE: National Institute for Health and Care Excellence TARGET POPULATION: Hospitalized adult patients.

You Can't Have It All: The Experience of Academic Hospitalists During Pregnancy, Parental Leave, and Return to Work.

BACKGROUND: The United States lags behind most other countries regarding the support for working mothers and parental leave. Data are limited to describe the experience of female hospital medicine physicians during pregnancy, parental leave, and their return to work in academic hospital medicine. METHODS: We conducted a qualitative descriptive study including interviews with 10 female academic hospitalists chosen from institutions across the country that are represented in Society of Hospital Medicine (SHM) Committees. Interview guides were based on the following domains: experience in pregnancy, parental leave, and return to work. Interviews were recorded, transcribed verbatim, and analyzed using a general inductive approach to theme analysis using the ATLAS.ti software (Scientific Software Development GmbH, Berlin, Germany). PRIMARY OUTCOME: Women in hospital medicine experience the following six common challenges in their experience as new parents, each of which has the potential to impact their career trajectory, wellness, and are associated with areas for institutional improvement: (1) access to paid parental leave, (2) physical challenges, (3) breastfeeding, (4) career opportunities, (5) colleague responses, and (6) empathy in patient care.

Isolation Precautions in the Inpatient Setting.

This article provides an overview of the use of standard and isolation precautions in the hospital setting, including droplet, airborne, and contact precautions. The article includes the indications for use, guidance for appropriate discontinuation of precautions, and the effect of precaution use on infection control measures, patient safety and experience, health care costs, and environmental outcomes.