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.

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.

The impact of a "low-intensity" versus "high-intensity" medical intensive care unit on patient outcomes in critically ill veterans.

OBJECTIVE: To determine whether a low-intensity versus high-intensity medical intensive care unit (MICU) format in a Veterans Affairs (VA) hospital setting improves patient outcomes, as measured by duration of mechanical ventilation (MV), ventilator-free days (VFDs), and hospital mortality. DESIGN: Retrospective cohort study. SETTING: Medical intensive care unit at the San Francisco Veterans Affairs Medical Center (SFVAMC). PATIENTS: On July 1, 2004, the SFVAMC transitioned from a low-intensity MICU to a high-intensity MICU. All patients admitted to the MICU who required MV for 18 months before (n = 96) and 18 months after (n = 131) the transition were included in the analysis. MEASUREMENTS: We prospectively defined the primary outcome measure as the difference in the median duration of MV between groups. Secondary outcomes included VFDs and hospital mortality. Continuous variables were compared using the Wilcoxon rank sum test; dichotomous variables were compared using Fisher exact test. MAIN RESULTS: The low-intensity and high-intensity MICU groups were similar in age, gender, weight, and admitting diagnosis (P > .27 in all cases). Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were 22.0 in the low-intensity era and 20.0 in the high-intensity era (P = .048). Median duration of MV was significantly lower in the high-intensity MICU format compared to the low-intensity MICU format (102 vs 61 hours, P for log-rank test = .0052). After controlling for covariates, there were 4.2 more VFDs in the high-intensity era (95% CI 1.9 to 6.6 days). The high-intensity era was associated with a reduced hospital mortality rate (27% vs 40%) and an adjusted odds ratio of 0.34 (95% CI 0.15 to 0.74). CONCLUSIONS: For critically ill veterans admitted to an MICU requiring MV, a high-intensity ICU structure is associated with more favorable mechanical ventilatory outcomes and lower mortality.

Supervising the supervisors--procedural training and supervision in internal medicine residency.

BACKGROUND: At teaching hospitals, bedside procedures (paracentesis, thoracentesis, lumbar puncture, arthrocentesis and central venous catheter insertion) are performed by junior residents and supervised by senior peers. Residents' perceptions about supervision or how often peer supervision produces unsafe clinical situations are unknown. OBJECTIVE: To examine the experience and practice patterns of residents performing bedside procedures. DESIGN AND PARTICIPANTS: Cross-sectional e-mail survey of 653 internal medicine (IM) residents at seven California teaching hospitals. MEASUREMENTS: Surveys asked questions in three areas: (1) resident experience performing procedures: numbers of procedures performed and whether they received other (e.g., simulator) training; (2) resident comfort performing and supervising procedures; (3) resident reports of their current level of supervision doing procedures, experience with complications as well as perceptions of factors that may have contributed to complications. RESULTS: Three hundred sixty-seven (56%) of the residents responded. Most PGY1 residents had performed fewer than five of any of the procedures, but most PGY-3 residents had performed at least ten by the end of their training. Resident comfort for each procedure increased with the number of procedures performed (p < 0.001). Although residents reported that peer supervision happened often, they also reported high rates of supervising a procedure before feeling comfortable with proper technique. The majority of residents (64%) reported at least one complication and did not feel supervision would have prevented complications, even though many reported complications represented technique- or preparation-related problems. CONCLUSIONS: Residents report low levels of comfort and experience with procedures, and frequently report supervising prior to feeling comfortable. Our findings suggest a need to examine best practices for procedural supervision of trainees.

Using the american board of internal medicine practice improvement modules to teach internal medicine residents practice improvement.

BACKGROUND: Although residency programs must prepare physicians who can analyze and improve their practice, practice improvement (PI) is new for many faculty preceptors. We describe the pilot of a PI curriculum incorporating a practice improvement module (PIM) from the American Board of Internal Medicine for residents and their faculty preceptors. METHODS: Residents attended PI didactics and completed a PIM during continuity clinic and outpatient months working in groups under committed faculty. RESULTS: All residents participated in PI group projects. Residents agreed or strongly agreed that the projects and the curriculum benefited their learning and patient care. A self-assessment revealed significant improvement in PI competencies, but residents were just reaching a "somewhat confident" level. CONCLUSION: A PI curriculum incorporating PIMs is an effective way to teach PI to both residents and faculty preceptors. We recommend the team approach and use of the PIM tutorial approach especially for faculty.

The prognosis and treatment of acquired hemophilia: a systematic review and meta-analysis.

The inhibition of factor VIII by autoantibody development, or acquired hemophilia, occurs in approximately one person per million each year and can cause life-threatening bleeding. Due to the disease rarity, there are no randomized studies addressing prognostic features and treatment. The goal of this study is to identify prognostic indictors in acquired hemophilia to guide treatment choices. MEDLINE and EMBASE search from 1985-2008 retrieved 32 studies with detailed clinical information on five or more patients with acquired hemophilia. Univariate and multivariate analysis of the effects of age, sex, underlying condition, inhibitor titer, and treatment regimen were evaluated with regards to complete remission and death. A total of 32 studies containing 359 patients with acquired hemophilia were included in the analysis. The all-cause mortality rate in this cohort was 21%. Multivariate analyses revealed that patients more likely to die are the elderly [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.32-4.36] and those with underlying malignancy (OR 2.76, CI 1.38-5.50). Early achievement of complete remission resulted in improved survival. Complete remission occurred in 94% of patients receiving combination chemotherapy, 82% receiving dual therapy, and 68% receiving steroids alone. Patients receiving immunosuppression had reduced odds of persistent hemophilia, with combination chemotherapy being the most efficacious (OR 0.04, CI 0.01-0.23) and steroid therapy alone being the least (OR 0.38, CI 0.14-0.94). In acquired hemophilia, increased age, underlying malignancy, and lack of complete remission are risk factors for death. Although the included studies were not randomized, patients treated with combination chemotherapy had the greatest odds of remission and the lowest odds of death.

Does this adult patient have septic arthritis?

CONTEXT: In patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality. OBJECTIVE: To review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis. DATA SOURCES: Structured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity. STUDY SELECTION: Studies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis. DATA EXTRACTION: Three authors independently abstracted data from the included studies. DATA SYNTHESIS: Fourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts <25,000/microL: LR, 0.32; 95% CI, 0.23-0.43; for counts > or =25,000/microL: LR, 2.9; 95% CI, 2.5-3.4; for counts >50,000/microL: LR, 7.7; 95% CI, 5.7-11.0; and for counts >100,000/microL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47). CONCLUSIONS: Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.

Test characteristics of alpha-fetoprotein for detecting hepatocellular carcinoma in patients with hepatitis C. A systematic review and critical analysis.

BACKGROUND: Patients with hepatitis C virus (HCV) are at increased risk for hepatocellular carcinoma. Although serum alpha-fetoprotein (AFP) is often used to detect hepatocellular carcinoma in HCV-infected individuals, its utility is unclear. PURPOSE: To define the test characteristics of AFP for the diagnosis of hepatocellular carcinoma in patients with HCV. DATA SOURCES: MEDLINE search from 1966 to December 2002 for English- and non-English-language articles examining the test characteristics of AFP for identifying hepatocellular carcinoma. STUDY SELECTION: Articles were included if they reported the sensitivity and specificity of AFP for detecting hepatocellular carcinoma in patients with HCV. Articles were excluded if the cause of hepatitis was ambiguous or if 50% or more of the study patients did not have HCV. DATA EXTRACTION: Relevant articles were evaluated for quality of evidence; test characteristics were abstracted and calculated. DATA SYNTHESIS: Five studies met all inclusion criteria and were analyzed. The overall quality of evidence was limited; only one study universally applied an acceptable gold standard test, and three of five studies used a case-control design that potentially overestimates diagnostic accuracy. By using the most commonly reported cutoff value of a positive test result for hepatocellular carcinoma (AFP level > 20 microg/L), the ranges of test characteristics were as follows: sensitivity, 41% to 65%; specificity, 80% to 94%; positive likelihood ratios, 3.1 to 6.8; and negative likelihood ratios, 0.4 to 0.6. CONCLUSIONS: The paucity of high-quality data calls for more rigorous study of AFP and other diagnostic tests for detecting hepatocellular carcinoma in HCV-infected patients with an accepted gold standard applied to the entire cohort. Even if the "best-case" estimates of AFP sensitivity and specificity are accurate, AFP has limited utility for detecting hepatocellular carcinoma.