Association of Interview and Holistic Review Metrics With Resident Performance-Related Difficulties in an Internal Medicine Residency Program.

Background The utility of traditional academic factors to predict residency candidates' performance is unclear. Many programs utilize holistic review processes assessing applicants on an expanded range of application and interview characteristics. Determining which characteristics might predict performance-related difficulty in residency is needed. Objective We aim to elucidate factors associated with residency performance-related difficulty in a large academic internal medicine residency program. Methods In 2022, we conducted a retrospective cohort study of Electronic Residency Application Service and interview data for residents matriculating between 2018 and 2020. The primary outcome was a composite of performance-related difficulty during residency (referral to the Clinical Competency Committee; any rotation evaluation score of 2 out of 5 or lower; and/or a confidential "comment of concern" to the program director). Logistic regression models were fit to assess associations between resident characteristics and the composite outcome. Results Thirty-eight of 117 residents met the composite outcome. Gold Humanism Honor Society (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.16-0.87) or Alpha Omega Alpha (OR 0.36, 95% CI 0.14-0.99) members were less likely to have performance-related difficulty, as were residents with higher United States Medical Licensing Examination Step 2 Clinical Knowledge scores (OR 0.97, 95% CI 0.47-1.00). One-point increases in general faculty overall interview score, leadership competency score, and leadership overall score were associated with 41% to 63% lower odds of meeting the composite outcome. Interview or file review "flags" had an OR of 2.82 (95% CI 1.37-5.80) for the composite outcome. Conclusions Seven metrics were associated with the composite outcome of resident performance-related difficulty.

Disseminated Peritoneal Tuberculosis Initially Misdiagnosed as Nephrogenic Ascites.

A middle-aged immigrant male from a region with endemic tuberculosis who had a history of end-stage kidney disease presented to the emergency room for routine hemodialysis and abdominal swelling. He was admitted to the medicine service for suggested daily dialysis to improve his volume overload, which was attributed to nephrogenic ascites. He was found to have several findings concerning for systemic illness, including fevers, night sweats, hypercalcemia, lymphadenopathy, omental thickening, ascitic fluid with a serum ascites albumin gradient of less than 1.1 gm/dL, and exudative pleural effusions. Our suspicion for hematologic malignancy versus disseminated infection was high. During admission, there were many diagnostic challenges in obtaining histologic and bacteriologic confirmation of our leading suspected diagnosis, disseminated tuberculosis. Ultimately, tuberculosis infection was confirmed with histologic evidence of granulomatous inflammation of cervical lymph node and sputum culture positive for Mycobacterium tuberculosis. This case highlights the necessity for every patient presenting with new ascites to undergo diagnostic paracentesis. Nephrogenic ascites is a rare syndrome that is possible in volume overloaded states but is a diagnosis of exclusion that should be supported by an exudative serum ascites albumin gradient and no evidence of an alternate etiology.

Preparing Residents for Fellowship: A Novel Mock Interview Program.

OBJECTIVES: Although high-stakes interviews are critically important for residents to obtain competitive fellowships, few formalized programs targeting interviewing skills exist. Previous studies demonstrate that mock interviews increase medical students' and healthcare professionals' confidence and improve match rates, but little research has been conducted among medical residents. The objective of our study was to increase trainees' confidence entering fellowship interviews and prepare them for commonly encountered questions via a mock interview program. METHODS: Emory Internal Medicine residency leaders designed a voluntary mock interview program focused on 103 residents (64% of the overall cohort) pursuing fellowship training (median 36, range 30-37/year) from 2018 to 2020. Administrative staff scheduled eight associate program director interviewers for 75 hours of interviews for 3 years (mean 3.6 hours per interviewer per year), ensuring program feasibility. Interviewers underwent faculty development and used a standardized tool with commonly asked interview questions to conduct mock interviews. Interviewers provided feedback on verbal communication, nonverbal communication, professionalism, and, given recent shifts to virtual interviews, camera readiness. We conducted resident surveys to understand their perceptions of mock interview program experiences. RESULTS: Ninety-nine residents pursuing fellowship (96%) enrolled. Fifty (51%) completed the survey (median 20, range 14-22/year); 46 (92%) reported that the mock interviews were helpful or increased their confidence for interview season. CONCLUSIONS: Residents perceived that this high-fidelity mock interview program successfully prepared them at a critical career juncture. This program is feasible, sustainable, adaptable, and scalable, and may be adopted to benefit trainees in any graduate medical education program.

Nurse-physician collaboration in an academic medical centre: The influence of organisational and individual factors.

Ineffective physician-nurse collaboration has been recognised to adversely impact patient and organisational outcomes, and some studies suggest an underlying factor may be that nurses and physicians have different perceptions of interprofessional collaboration (IPC). The objectives of this study were to evaluate for a difference in the perception of IPC between physicians and nurses and to explore potential contributing factors at the individual and organisational levels to any observed difference. Data including measures of perceptions of IPC were collected from a convenience sample of resident physicians (n = 47), attending physicians (n = 18), and nurses (n = 54) providing care for internal medicine patients in a large tertiary care academic medical centre. Regression analysis revealed significantly lower perceptions of IPC scores for nurses in comparison to the scores of both the resident and attending physician groups (p = .0001 for both). Although demographic and workload factors also differed by profession, only profession and workload remained significant in regression analysis. Given the known relationships between effective physician-nurse collaboration and superior patient and organisational outcomes, better defining the individual and organisational predictors of IPC scores may support development of more effective interventions targeting improvements in IPC.

Comparing the accumulation of active- and nonactive-site mutations in the HIV-1 protease.

Protease inhibitor resistance still poses one of the greatest challenges in treating HIV. To better design inhibitors able to target resistant proteases, a deeper understanding is needed of the effects of accumulating mutations and the contributions of active- and nonactive-site mutations to the resistance. We have engineered a series of variants containing the nonactive-site mutations M46I and I54V and the active-site mutation I84V. These mutations were added to a protease clone (V6) isolated from a pediatric patient on ritonavir therapy. This variant possessed the ritonavir-resistance-associated mutations in the active-site (V32I and V82A) and nonactive-site mutations (K20R, L33F, M36I, L63P, A71V, and L90M). The I84V mutation had the greatest effect on decreasing catalytic efficiency, 10-fold when compared to the pretherapy clone LAI. The decrease in catalytic efficiency was partially recovered by the addition of mutations M46I and I54V. The M46I and I54V were just as effective at decreasing inhibitor binding as the I84V mutation when compared to V6 and LAI. The V6(54/84) variant showed over 1000-fold decrease in inhibitor-binding strength to ritonavir, indinavir, and nelfinavir when compared to LAI and V6. Crystal-structure analysis of the V6(54/84) variant bound to ritonavir and indinavir shows structural changes in the 80's loops and active site, which lead to an enlarged binding cavity when compared to pretherapy structures in the Protein Data Bank. Structural changes are also seen in the 10's and 30's loops, which suggest possible changes in the dynamics of flap opening and closing.

Secondary mutations M36I and A71V in the human immunodeficiency virus type 1 protease can provide an advantage for the emergence of the primary mutation D30N.

Development of resistance mutations in enzymatic targets of human immunodeficiency virus 1 (HIV-1) hampers the ability to provide adequate therapy. Of special interest is the effect mutations outside the active site of HIV-1 protease have on inhibitor binding and virus viability. We engineered protease mutants containing the active site mutation D30N alone and with the nonactive site polymorphisms M36I and/or A71V. We determined the K(i) values for the inhibitors nelfinavir, ritonavir, indinavir, KNI272, and AG1776 as well as the catalytic efficiency of the mutants. Single and double mutation combinations exhibited a decrease in catalytic efficiency, while the triple mutant displayed catalytic efficiency greater than that of the wild type. Variants containing M36I or A71V alone did not display a significant change in binding affinities to the inhibitors tested. The variant containing mutation D30N displayed a 2-6-fold increase in K(i) for all inhibitors tested, with nelfinavir showing the greatest increase. The double mutants containing a combination of mutations D30N, M36I, and A71V displayed -0.5-fold to +6-fold changes in the K(i) of all inhibitors tested, with ritonavir and nelfinavir most affected. Only the triple mutant showed a significant increase (>10-fold) in K(i) for inhibitor nelfinavir, ritonavir, or AG-1776 displaying 22-, 19-, or 15-fold increases, respectively. Our study shows that the M36I and A71V mutations provide a greater level of inhibitor cross-resistance combined with active site mutation D30N. M36I and A71V, when present as natural polymorphisms, could aid the virus in developing active site mutations to escape inhibitor binding while maintaining catalytic efficiency.