Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors.

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

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.

Hazard pay for internal medicine resident physicians during the COVID-19 pandemic: A national survey of program directors.

BACKGROUND: Hazard pay for resident physicians has been controversial in the COVID-19 pandemic. Program director (PD) beliefs about hazard pay and the extent of provision to internal medicine (IM) residents are unknown. OBJECTIVE: To evaluate hazard pay provision to residents early in the COVID-19 pandemic and pandemic and residency program characteristics associated with hazard pay. DESIGN, SETTING, AND PARTICIPANTS: A nationally representative survey was conducted of 429 US/US territory-based IM PDs from August to December 2020. MAIN OUTCOME AND MEASURES: Hazard pay provision and PD beliefs about hazard pay were tested for association with factors related to the pandemic surge and program characteristics. RESULTS: Response rate was 61.5% (264/429); 19.5% of PDs reported hazard pay provision. PD belief about hazard pay was equivocal: 33.2% agreed, 43.1% disagreed, and 23.7% were uncertain. Hazard pay occurred more commonly in the Middle-Atlantic Census Division (including New York City) and with earlier surges and greater resident participation in COVID-19 patient care. Hazard pay occurred more commonly where PDs supported hazard pay (74.5% vs. 22.1%, p = .018). Reasons most frequently given in support of hazard pay were essential worker status, equity, and schedule disruption. Those opposed cited professional obligation and equity. CONCLUSION: Hazard pay for IM residents early in the COVID-19 pandemic was nominal but more commonly associated with heavily impacted institutions. Although PD beliefs were mixed, positive belief was associated with provision. The unique role of residents as both essential workers and trainees might explain our varied results. Further investigation may inform future policy, especially in times of crisis.

Re-thinking morbidity and mortality.

Despite the breadth of patient safety initiatives, physicians talking about their mistakes to other physicians is a difficult thing to do. This difficulty may be exacerbated by a limited exposure to how to analyze and discuss mistakes and respond in a productive way. At the University of Virginia, we recognized the importance of understanding cognitive biases for residents in both their clinical and personal professional development. We re-designed our resident led morbidity and mortality (M&M) conference using a model that integrates dual-process theory and metacognition to promote informed reflection and analysis of cognitive diagnostic errors. We believe that structuring M&M in this way builds a culture that encourages reflection together to learn our most difficult diagnostic errors and to engage in where our thought processes went wrong. In slowly building this culture, we hope to inoculate residents with the habits of mind that can best protect them from harmful biases in their clinical reasoning while instilling a culture of self-reflection.

An unusual presentation of Ehlers-Danlos syndrome vascular type with deep vein thrombosis: a case for multidisciplinary management.

Ehlers-Danlos syndrome (EDS) vascular type typically presents with significant vascular complications such as rupture of blood vessels, gravid uterus, or intestinal perforation. We report on a 24-year-old female that presents with deep vein thrombosis found to be due to compression by a large posterior tibial artery pseudoaneurysm which ultimately leads to the patient's diagnosis. This case highlights the need for a multidisciplinary approach involving vascular surgery, internal medicine, genetics, and other health care providers for patients with vascular type EDS.