Cerebrovascular complications of coccidioidomycosis meningitis: Case report and systematic review.

Coccidioidomycosis exposure is common in the southwest United States and northern Mexico. Dissemination to the meninges is the most severe form of progression. Although ischemic strokes are well-reported in these patients, other cerebrovascular complications of coccidioidomycosis meningitis (CM), as well as their treatment options and outcomes, have not been systematically studied. We present a uniquely severe case of CM with several cerebrovascular complications. We also systematically queried PubMed and EMBASE databases, including articles published before April 2020 reporting human patients with CM-induced cerebrovascular pathology other than ischemic infarcts. Sixteen articles met inclusion criteria, which describe 6 patients with aneurysmal hemorrhage, 10 with non-aneurysmal hemorrhage, one with vasospasm, and one with transient ischemic attacks. CM-associated aneurysms invariably presented with hemorrhage. These were universally fatal until the past decade, when advances in surgical clipping and/or combined surgical and endovascular treatment have improved outcomes. We found that non-aneurysmal intracranial hemorrhages were limited to male patients, involved a diverse set of intracranial vasculature, and had a mortality rate surpassing 80%. Vasospasm was reported once, and was treated with percutaneous transluminal angioplasty. Transient ischemic attacks were reported once, and were successfully treated with fluconazole and dexamethasone. This review suggests that CM can present with a wide array of cerebrovascular complications, including ischemic infarcts, aneurysmogenesis, non-aneurysmal intracranial hemorrhage, vasospasm, and transient ischemic attacks. Mortality has improved over time due to advances in surgical and endovascular treatment modalities. The exception is non-aneurysmal intracranial hemorrhage, which remains associated with high mortality rates and few targeted therapeutic options.

Whither the Pulmonary Ward Attending? Preserving Subspecialty Exposure in United States Internal Medicine Residency Training.

Twenty years ago, the term "hospitalist" was coined at the University of California-San Francisco (San Francisco, CA), heralding a new specialty focused on the care of inpatients. There are now more than 50,000 hospitalists practicing in the United States. At many academic medical centers, hospitalists are largely replacing subspecialists as attendings on the inpatient medicine wards. At University of California-San Francisco, this has been accompanied by declining percentages of residency graduates who enter subspecialty training in internal medicine. The decline in subspecialty medicine interest can be attributed to many factors, including differences in compensation, decreased subspecialist exposure, and a changing research funding landscape. Although there has not been systematic documentation of this trend in pulmonary and critical care medicine, we have noted previously pulmonary and critical care-bound trainees switching to hospital medicine instead. With our broad, multiorgan system perspective, pulmonary and critical care faculty should embrace teaching general medicine. Residency programs have instituted creative solutions to encourage more internal medicine residents to pursue careers in subspecialty medicine. Some solutions include creating rotations that promote more contact with subspecialists and physician-scientists, creating clinician-educator tracks within fellowship programs, and appointing subspecialists to internal medicine residency leadership positions. We need more rigorous research to track the trends and implications of the generalist-specialist balance of inpatient ward teams on resident career choices, and learn what interventions affect those choices.

Does Research Training During Residency Promote Scholarship and Influence Career Choice? A Cross-Sectional Analysis of a 10-Year Cohort of the UCSF-PRIME Internal Medicine Residency Program.

PROBLEM: The Association of Program Directors in Internal Medicine, the Accreditation Council for Graduate Medical Education, the Alliance for Academic Internal Medicine, and the Carnegie Foundation report on medical education recommend creating individualized learning pathways during medical training so that learners can experience broader professional roles beyond patient care. Little data exist to support the success of these specialized pathways in graduate medical education. INTERVENTION: We present the 10-year experience of the Primary Care Medicine Education (PRIME) track, a clinical-outcomes research pathway for internal medicine residents at the University of California San Francisco (UCSF). We hypothesized that participation in an individualized learning track, PRIME, would lead to a greater likelihood of publishing research from residency and accessing adequate career mentorship and would be influential on subsequent alumni careers. CONTEXT: We performed a cross-sectional survey of internal medicine residency alumni from UCSF who graduated in 2001 through 2010. We compared responses of PRIME and non-PRIME categorical alumni. We used Pearson's chi-square and Student's t test to compare PRIME and non-PRIME alumni on categorical and continuous variables. OUTCOME: Sixty-six percent (211/319) of alumni responded to the survey. A higher percentage of PRIME alumni published residency research projects compared to non-PRIME alumni (64% vs. 40%; p = .002). The number of PRIME alumni identifying research as their primary career role was not significantly different from non-PRIME internal medicine residency graduates (35% of PRIME vs. 29% non-PRIME). Process measures that could explain these findings include adequate access to mentors (M 4.4 for PRIME vs. 3.6 for non-PRIME alumni, p < .001, on a 5-point Likert scale) and agreeing that mentoring relationships affected career choice (M 4.2 for PRIME vs. 3.7 for categorical alumni, p = .001). Finally, 63% of PRIME alumni agreed that their research experience during residency influenced their subsequent career choice versus 46% of non-PRIME alumni (p = .023). LESSONS LEARNED: Our results support the concept that providing residents with an individualized learning pathway focusing on clinical outcomes research during residency enables them to successfully publish manuscripts and access mentorship, and may influence subsequent career choice. Implementation of individualized residency program tracks that nurture academic interests along with clinical skills can support career development within medicine residency programs.

How Residents Develop Trust in Interns: A Multi-Institutional Mixed-Methods Study.

PURPOSE: Although residents trust interns to provide patient care, little is known about how trust forms. METHOD: Using a multi-institutional mixed-methods study design, the authors interviewed (March-September 2014) internal medicine (IM) residents in their second or third postgraduate year at a single institution to address how they develop trust in interns. Transcript analysis using grounded theory yielded a model for resident trust. Authors tested (January-March 2015) the model with residents from five IM programs using a two-section quantitative survey (38 items; 31 rated 0 = not at all to 100 = very much; 7 rated 0 = strongly disagree to 100 = strongly agree) to identify influences on how residents form trust. RESULTS: Qualitative analysis of 29 interviews yielded 14 themes within five previously identified factors of trust (resident, intern, relationship, task, and context). Of 478 residents, 376 (78.7%) completed the survey. Factor analysis yielded 11 factors that influence trust. Respondents rated interns' characteristics (reliability, competence, and propensity to make errors) highest when indicating importance to trust (respective means 86.3 [standard deviation = 9.7], 76.4 [12.9], and 75.8 [20.0]). They also rated contextual factors highly as influencing trust (access to an electronic medical record, duty hours, and patient characteristics; respective means 79.8 [15.3], 73.1 [14.4], and 71.9 [20.0]). CONCLUSIONS: Residents form trust based on primarily intern- and context-specific factors. Residents appear to consider trust in a way that prioritizes interns' execution of essential patient care tasks safely within the complexities and constraints of the hospital environment.

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine?

PURPOSE: Professional and governmental organizations recommend an ideal US physician workforce composed of at least 40 % primary care physicians. They also support primary care residencies to promote careers in primary care. Our study examines the relationship between graduation from a primary care or categorical internal medicine residency program and subsequent career choice. METHODS: We conducted a cross-sectional electronic survey of a cohort of internal medicine residency alumni who graduated between 2001 and 2010 from a large academic center. Our primary predictor was graduation from a primary care versus a categorical internal medicine program and our primary outcome is current career role. We performed chi-square analysis comparing responses of primary care and categorical residents. RESULTS: We contacted 481 out of 513 alumni, of whom 322 responded (67 %). We compared 106 responses from primary care alumni to 169 responses from categorical alumni. Fifty-four percent of primary care alumni agreed that the majority of their current clinical work is in outpatient primary care vs. 20 % of categorical alumni (p < 0.001). While 92.5 % of primary-care alumni were interested in a primary care career prior to residency, only 63 % remained interested after residency. Thirty of the 34 primary care alumni (88 %) who lost interest in a primary care career during residency agreed that their ambulatory experience during residency influenced their subsequent career choice. CONCLUSIONS: A higher percentage of primary care alumni practice outpatient primary care as compared to categorical alumni. Some alumni lost interest in primary care during residency. The outpatient clinic experience may impact interest in primary care.

The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement.

BACKGROUND: Quality improvement has become increasingly important in the practice of medicine; however, engaging residents in meaningful projects within the demanding training environment remains challenging. METHODS: We conducted a year-long quality improvement project involving internal medicine residents at an academic medical centre. Resident champions designed and implemented a discharge summary improvement bundle, which employed an educational curriculum, an electronic discharge summary template, regular data feedback and a financial incentive. The timeliness and quality of discharge summaries were measured before and after the intervention. Residents and faculty were surveyed about their perceptions of the project; primary care providers were surveyed about their satisfaction with hospital provider communication. RESULTS: With implementation of the bundle, the average time from patient discharge to completion of the discharge summary fell from 3.5 to 0.61 days (p<0.001). The percentage of summaries completed on the day of discharge rose from 38% to 83% (p<0.001) and this improvement was sustained for 6 months following the end of the project. The percentage of summaries that included all recommended elements increased from 5% to 88% (p<0.001). Primary care providers reported a lower likelihood of discharge summaries being unavailable at the time of outpatient follow-up (38% to 4%, p<0.001). Residents reported that the systems changes, more than the financial incentive, accounted for their behaviour change. CONCLUSIONS: Our discharge summary improvement project provides an instructive example of how residents can lead clinically meaningful quality improvement projects.

Developing entrustable professional activities as the basis for assessment of competence in an internal medicine residency: a feasibility study.

BACKGROUND: Graduate medical education programs assess trainees' performance to determine readiness for unsupervised practice. Entrustable professional activities (EPAs) are a novel approach for assessing performance of core professional tasks. AIM: To describe a pilot and feasibility evaluation of two EPAs for competency-based assessment in internal medicine (IM) residency. SETTING/PARTICIPANTS: Post-graduate year-1 interns (PGY-1s) and attendings at a large internal medicine (IM) residency program. PROGRAM DESCRIPTION: Two Entrustable professional activities (EPA) assessments (Discharge, Family Meeting) were piloted. PROGRAM FEASIBILITY EVALUATION: Twenty-eight out of 43 (65.1 %) PGY-1 s and 32/43 (74.4 %) attendings completed surveys about the Discharge EPA experience. Most who completed the EPA assessment (10/12, 83.8 %, PGY-1s; 9/11, 83.3 %, attendings) agreed it facilitated useful feedback discussions. For the Family Meeting EPA, 16/26 (61.5 %) PGY-1s completed surveys, and most who participated (9/12 PGY1s, 75 %) reported it improved attention to family meeting education, although only half recommended continuing the EPA assessment. DISCUSSION: From piloting two EPA assessments in a large IM residency, we recognized our reminder systems and time dedicated for completing EPA requirements as inadequate. Collaboration around patient safety and palliative care with relevant clinical services has enhanced implementation and buy-in. We will evaluate how well EPA-based assessment serves the intended purpose of capturing trainees' trustworthiness to conduct activities unsupervised.

The effect of a resident-led quality improvement project on improving communication between hospital-based and outpatient physicians.

This article reports on a resident-led quality improvement program to improve communication between inpatient internal medicine residents and their patients' primary care physicians (PCPs). The program included education on care transitions, standardization of documentation, audit and feedback of documented PCP communication rates with public reporting of performance, rapid-cycle data analysis and improvement projects, and a financial incentive. At baseline, PCP communication was documented in 55% of patients; after implementation of the intervention, communication was documented in 89.3% (2477 of 2772) of discharges during the program period. The program was associated with a significant increase in referring PCP satisfaction with communication at hospital admission (baseline, 27.7% "satisfied" or "very satisfied"; postintervention, 58.2%; P < .01) but not at discharge (baseline, 14.9%; postintervention, 21.8%; P = .41). Residents cited the importance of PCP communication for patient care and audit and feedback of their performance as the principal drivers of their engagement in the project.

Identifying entrustable professional activities in internal medicine training.

BACKGROUND: Entrustable professional activities (EPAs) can form the foundation of competency-based assessment in medical training, focused on performance of discipline-specific core clinical activities. OBJECTIVE: To identify EPAs for the Internal Medicine (IM) Educational Milestones to operationalize competency-based assessment of residents using EPAs. METHODS: We used a modified Delphi approach to conduct a 2-step cross-sectional survey of IM educators at a 3-hospital IM residency program; residents also completed a survey. Participants rated the importance and appropriate year of training to reach competence for 30 proposed IM EPAs. Content validity indices identified essential EPAs. We conducted independent sample t tests to determine IM educator-resident agreement and calculated effect sizes. Finally, we determined the effect of different physician roles on ratings. RESULTS: Thirty-six IM educators participated; 22 completed both surveys. Twelve residents participated. Seventeen EPAs had a content validity index of 100%; 10 additional EPAs exceeded 80%. Educators and residents rated the importance of 27 of 30 EPAs similarly. Residents felt that 10 EPAs could be met at least 1 year earlier than educators had specified. CONCLUSIONS: Internal medicine educators had a stable opinion of EPAs developed through this study, and residents generally agreed. Using this approach, programs could identify EPAs for resident evaluation, building on the initial list created via our study.

Shifting indirect patient care duties to after hours in the era of work hours restrictions.

PURPOSE: Few data describe how often residents defer indirect patient care tasks to after hours or show whether residents report this time in duty hours logs. Thus, the authors examined how often residents perform one such task, discharge dictation, outside scheduled hours. METHOD: The authors tracked all discharge summaries dictated by internal medicine residents at a single teaching hospital from January to June 2009. They determined the length and timing of discharge dictations by querying the hospital voice-dictation system. Definite work hours violations occurred when residents completed dictations on the postcall day after reaching mandated duty hours limits or on scheduled days off. Potential work hours violations arose when residents dictated after 6 pm or during the month subsequent to their rotation. The authors compared the number of residents they determined to have incurred duty hours violations with the number self-reporting violations. RESULTS: The authors obtained data on 1,152 dictations performed by 39 residents. Residents spent a mean 6.5 hours dictating per month, averaging 13 minutes per dictation. Using objective criteria, the authors determined that the majority of residents (32; 82%) incurred definite duty hours violations. Far fewer (2; 5%) self-reported violations. Team census, total time spent dictating, and dictation length were associated with dictating during restricted hours. CONCLUSIONS: Indirect patient care tasks, such as dictating discharge summaries, may contribute substantially to unrecognized duty hours violations. Accurate and objective ways to assess resident workflow can help create effective solutions for resident efficiency and inform changes to resident schedules.

Educating generalists: factors of resident continuity clinic associated with perceived impact on choosing a generalist career.

BACKGROUND: Fewer residents are choosing general internal medicine (GIM) careers, and their choice 5 be influenced by the continuity clinic experience during residency. We sought to explore the relationship between resident satisfaction with the continuity clinic experience and expressed interest in pursuing a GIM career. METHODS: We surveyed internal medicine residents by using the Veterans Health Administration Office of Academic Affiliations Learners' Perceptions Survey-a 76-item instrument with established reliability and validity that measures satisfaction with faculty interactions, and learning, working, clinical, and physical environments, and personal experience. We identified 15 reliable subscales within the survey and asked participants whether their experience would prompt them to consider future employment opportunities in GIM. We examined the association between satisfaction measures and future GIM interest with 1-way analyses of variance followed by Student-Newman-Keuls post hoc tests. RESULTS: Of 217 residents, 90 (41%) completed the survey. Residents felt continuity clinic influenced career choice, with 22% more likely to choose a GIM career and 43% less likely. Those more likely to choose a GIM career had higher satisfaction with the learning (P  =  .001) and clinical (P  =  .002) environments and personal experience (P < .001). They also had higher satisfaction with learning processes (P  =  .002), patient diversity (P < .001), coordination of care (P  =  .009), workflow (P  =  .001), professional/personal satisfaction (P < .001), and work/life balance (P < .001). CONCLUSIONS: The continuity clinic experience 5 influence residents' GIM career choice. Residents who indicate they are more likely to pursue GIM based on that clinical experience have higher levels of satisfaction. Further prospective data are needed to assess if changes in continuity clinic toward these particular factors can enhance career choice.

Developing educators, investigators, and leaders during internal medicine residency: the area of distinction program.

BACKGROUND: Professional organizations have called for individualized training approaches, as well as for opportunities for resident scholarship, to ensure that internal medicine residents have sufficient knowledge and experience to make informed career choices. CONTEXT AND PURPOSE: To address these training issues within the University of California, San Francisco, internal medicine program, we created the Areas of Distinction (AoD) program to supplement regular clinical duties with specialized curricula designed to engage residents in clinical research, global health, health equities, medical education, molecular medicine, or physician leadership. We describe our AoD program and present this initiative's evaluation data. METHODS AND PROGRAM EVALUATION: We evaluated features of our AoD program, including program enrollment, resident satisfaction, recruitment surveys, quantity of scholarly products, and the results of our resident's certifying examination scores. Finally, we described the costs of implementing and maintaining the AoDs. RESULTS: AoD enrollment increased from 81% to 98% during the past 5 years. Both quantitative and qualitative data demonstrated a positive effect on recruitment and improved resident satisfaction with the program, and the number and breadth of scholarly presentations have increased without an adverse effect on our board certification pass rate. CONCLUSIONS: The AoD system led to favorable outcomes in the domains of resident recruitment, satisfaction, scholarship, and board performance. Our intervention showed that residents can successfully obtain clinical training while engaging in specialized education beyond the bounds of core medicine training. Nurturing these interests 5 empower residents to better shape their careers by providing earlier insight into internist roles that transcend classic internal medicine training.