Multicenter Study of Optional In-Person Visits to Residency Programs After Virtual Interviews.

Background Compared to in-person recruitment, virtual interviewing reduces costs and promotes equity. However, many residency applicants believe that visiting programs helps inform their rank decisions. Objective We assessed the feasibility of and stakeholder opinions about optional in-person visits after virtual interviewing and program rank list finalization. Methods Six internal medicine residency programs conducted virtual recruitment in 2022-2023 and finalized their rank lists 4 weeks before the deadline. Applicants were invited for optional in-person visits after program rank list finalization. Interviewed applicants, program directors, and program administrators were given surveys that included 7-17 questions and employed "skip logic," discrete answers (eg, "yes/no/unsure" or multiple choice), and open-ended questions. Survey questions assessed stakeholders' opinions about the value, equity, and potential downsides of this recruitment process. Results Participating programs interviewed an average of 379 applicants (range 205-534) with 39 (10.3% [39 of 379], range 7.9%-12.8% [33 of 420-51 of 397]) applicants completing in-person visits. Of 1808 interviewed applicants, 464 responded to the survey (26%); 88% (407 of 464) believe a similar optional in-person visit should be offered next year, 75% (347 of 464) found this process equitable, but only 56% (258 of 464) trusted programs not to change their rank lists. Nearly all who attended an in-person visit (96.5%, 109 of 113) found it valuable. All program directors liked the optional in-person visit and believe future applicants should be offered similar in-person visits. Conclusions A large majority of participating applicants and program directors believe that in-person visits should be offered after program rank list finalization. The majority of respondents felt this recruitment process was equitable.

Internal Medicine Resident Perspectives on Virtual Recruitment.

This survey study describes the perceived implications of virtual-only recruitment and the preferred application process for residents and fellows.

Forum theatre for training residents to be allies.

BACKGROUND: Residents are commonly targets and bystanders of workplace discrimination, yet little is known about how best to train residents to manage these incidents. We sought to train residents to respond effectively to being a target or bystander of discrimination. APPROACH: We used a novel, 75-min theatrical role-playing intervention called Theatre for Healthcare Equity (T.H.E.) to teach 71 internal medicine residents between December 2017 and February 2018. In T.H.E. residents took turns acting as either a 'resident' target or a 'student' bystander in a simulated scenario of discrimination. A facilitator led follow-up discussions including group reflection and development of learning scripts to help with difficult situations. A post-graduation survey was sent in November 2021 to assess residents' retention of knowledge, attitudes and potential application in practice. EVALUATION: T.H.E. was well received by residents, though survey response rates were low. All respondents to a post-session survey reported having acquired knowledge and skills to help them respond to incidents of bias and discrimination. Most respondents to the post-graduation survey nearly 4 years later remembered T.H.E.; seven wrote reflective narrative responses indicating that T.H.E. had raised awareness of these issues, empowered them to speak up on behalf of colleagues and validated their emotional reactions to hurtful speech from patients. We describe an incident in which a former resident attributed his ability to serve as an effective bystander ally to participating in T.H.E. years earlier. IMPLICATIONS: T.H.E. was an efficient, well-received intervention that some of our residents found to have been helpful years later. We continue to use T.H.E. as the basis for periodic ongoing allyship training for residents and teaching faculty to improve the inclusiveness of our clinical learning environment.

Internal Medicine Residency Program Director Support and Burnout During the COVID-19 Pandemic: Results of a National Survey.

Background: Burnout is common among physicians and physician leaders, including residency program directors (PDs). The effects of the COVID-19 pandemic and other stressors in 2020 on PDs is unknown. Objective: To measure the prevalence of burnout among internal medicine (IM) residency PDs 6 months into the COVID-19 pandemic. Methods: A total of 429 IM PDs, representing 83% of accredited residency programs, were surveyed from August to December 2020. Burnout, using a 2-item screening tool, and self-reported consideration of resigning in 2020, were compared to their annual prevalence since 2012 and tested for possible associations with pandemic stressors and program characteristics. Results: The survey response rate was 61.5% (264 of 429). One-third (33.6%, 87 of 259) of PD respondents met burnout criteria, and 45.1% (110 of 244) reported considering resigning in the past year, which were within the range of preceding years. PDs who reported feeling highly supported by institutional leadership were less likely to meet burnout criteria and to have considered resigning. There were no associations between burnout or consideration of resigning and the amount of clinical time PDs spent in their roles, duration of maximum stress on programs, budget cuts to programs, or geographic region. Conclusions: The prevalence of burnout among PDs in fall 2020 was similar to the prevalence of burnout in pre-pandemic years despite uniquely extreme stressors. PDs' perception of being highly supported by institutional leadership was associated with lower prevalence of burnout and consideration of resigning. Perceived leadership support may be a protective factor against burnout during periods of high stress.

Benefit-risk assessment and reporting in clinical trials of chronic pain treatments: IMMPACT recommendations.

ABSTRACT: Chronic pain clinical trials have historically assessed benefit and risk outcomes separately. However, a growing body of research suggests that a composite metric that accounts for benefit and risk in relation to each other can provide valuable insights into the effects of different treatments. Researchers and regulators have developed a variety of benefit-risk composite metrics, although the extent to which these methods apply to randomized clinical trials (RCTs) of chronic pain has not been evaluated in the published literature. This article was motivated by an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting and is based on the expert opinion of those who attended. In addition, a review of the benefit-risk assessment tools used in published chronic pain RCTs or highlighted by key professional organizations (ie, Cochrane, European Medicines Agency, Outcome Measures in Rheumatology, and U.S. Food and Drug Administration) was completed. Overall, the review found that benefit-risk metrics are not commonly used in RCTs of chronic pain despite the availability of published methods. A primary recommendation is that composite metrics of benefit-risk should be combined at the level of the individual patient, when possible, in addition to the benefit-risk assessment at the treatment group level. Both levels of analysis (individual and group) can provide valuable insights into the relationship between benefits and risks associated with specific treatments across different patient subpopulations. The systematic assessment of benefit-risk in clinical trials has the potential to enhance the clinical meaningfulness of RCT results.

Barriers to Accessing Nighttime Supervisors: a National Survey of Internal Medicine Residents.

BACKGROUND: Single-center studies have reported residents experience barriers to accessing supervising physicians overnight, but no national dataset has described barriers perceived by residents or the association between supervision models and perceived barriers. OBJECTIVE: To explore residents' perception of barriers to accessing overnight supervision. DESIGN: Questions about overnight supervision and barriers to accessing it were included on the American College of Physicians Internal Medicine In-Training Examination® (IM-ITE®) Resident Survey in Fall 2017. PARTICIPANTS: All US-based internal medicine residents who completed the 2017 IM-ITE®. Responses from 20,744 residents (84%) were analyzed. MAIN MEASURES: For our main outcome, we calculated percentages of responses for eight barriers and tested for association with the presence or absence of nocturnists. For our secondary outcome, we categorized free-text responses enumerating barriers from all residents into the five Systems Engineering Initiative for Patient Safety (SEIPS) categories to elucidate future areas for study or intervention. KEY RESULTS: Internal medicine residents working in hospitals without nocturnists more commonly reported having at least one barrier to accessing a supervising physician "always" or "most of the time" (5075/9842, 51.6%) compared to residents in hospitals with nocturnists (3074/10,902, 28.2%, p < 0.001). Among residents in hospitals without nocturnists, the most frequently reported barrier to accessing attending supervision was attendings not being present in the hospital (30.4% "always" or "most of the time"); residents in hospitals with nocturnists most frequently reported desire to make their own decisions as a barrier to contacting attendings (15.7% "always" or "most of the time"). Free-text responses from residents with and without nocturnists most commonly revealed organization (47%) barriers to accessing supervision; 28% cited person barriers, and 23% cited tools/technology barriers. CONCLUSIONS: Presence of nocturnists is associated with fewer reported barriers to contacting supervising physicians overnight. Organizational culture, work schedules, desire for independence, interpersonal interactions, and technology may present important barriers.

Interpretation of chronic pain clinical trial outcomes: IMMPACT recommended considerations.

Interpreting randomized clinical trials (RCTs) is crucial to making decisions regarding the use of analgesic treatments in clinical practice. In this article, we report on an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, the purpose of which was to recommend approaches that facilitate interpretation of analgesic RCTs. We review issues to consider when drawing conclusions from RCTs, as well as common methods for reporting RCT results and the limitations of each method. These issues include the type of trial, study design, statistical analysis methods, magnitude of the estimated beneficial and harmful effects and associated precision, availability of alternative treatments and their benefit-risk profile, clinical importance of the change from baseline both within and between groups, presentation of the outcome data, and the limitations of the approaches used.

The Procedure Coordinator: A Resident-Driven Initiative to Increase Opportunity for Inpatient Procedures.

BACKGROUND: Training residents to become competent in common bedside procedures can be challenging. Some hospitals have attending physician-led procedure teams with oversight of all procedures to improve procedural training, but these teams require significant resources to establish and maintain. OBJECTIVE: We sought to improve resident procedural training by implementing a resident-run procedure team without routine attending involvement. METHODS: We created the role of a resident procedure coordinator (RPC). Interested residents on less time-intensive rotations voluntarily served as RPC. Medical providers in the hospital contacted the RPC through a designated pager when a bedside procedure was needed. A structured credentialing process, using direct observation and a procedure-specific checklist, was developed to determine residents' competence for completing procedures independently. Checklists were developed by the residency program and approved by institutional subspecialists. The service was implemented in June 2016 at an 850-bed academic medical center with 70 internal medicine and 32 medicine-pediatrics residents. The procedure service functioned without routine attending involvement. The impact was evaluated through resident procedure logs and surveys of residents and attending physicians. RESULTS: Compared with preimplementation procedure logs, there were substantial increases postimplementation in resident-performed procedures and the number of residents credentialed in paracenteses, thoracenteses, and lumbar punctures. Fifty-nine of 102 (58%) residents responded to the survey, with 42 (71%) reporting the initiative increased their ability to obtain procedural experience. Thirty-one of 36 (86%) attending respondents reported preferentially using the service. CONCLUSIONS: The RPC model increased resident procedural training opportunities using a structured sign-off process and an operationalized service.

Problematic communications during 2016 fellowship recruitment in internal medicine.

Some internal medicine residency program directors have expressed concerns that their third-year residents may have been subjected to inappropriate communication during the 2016 fellowship recruitment season. The authors sought to study applicants' interpersonal communication experiences with fellowship programs. Many respondents indicated that they had been asked questions that would constitute violations of the National Residency Matching Program (NRMP) Communications Code of Conduct agreement, including how they plan to rank specific programs. Moreover, female respondents were more likely to have been asked questions during interview experiences about other programs to which they applied, and about their family plans. Post-interview communication policies were not made clear to most applicants. These results suggest ongoing challenges for the internal medicine community to improve communication with applicants and uniform compliance with the NRMP communications code of conduct during the fellowship recruitment process.