A Multicenter Curricular Intervention to Address Resident Knowledge and Perceptions of Personal Finance.

OBJECTIVES: We evaluated internal medicine residents' confidence and knowledge of personal finance, perceptions of burnout, and relations between these issues before and after an educational intervention. METHODS: We surveyed internal medicine residents at two university-based training programs in 2018. We developed and implemented a curriculum at both sites, covering topics of budgeting, saving for retirement, investment options, and the costs of investing. Each site used the same content but different strategies for dissemination. One used a condensed-form lecture series (two 1-hour sessions) and the other used a microlecture series (four 30-minute sessions) series. Residents were resurveyed following the intervention for comparison. RESULTS: The preintervention survey response rate was 41.2% (122/296) and the postintervention response rate was 44.3% (120/271). Postintervention mean scores for personal finance knowledge improved for basic concepts (52.6% vs 39.4%, P < 0.001), mutual fund elements (30.8% vs 19.7%, P < 0.001), investment plans (68.5% vs. 49.2%, P < 0.001), and overall knowledge (50.1% vs 36.1%, P < 0.001). A significantly smaller proportion of residents reported feelings of burnout following the intervention (23.3% vs 36.9%, P = 0.022). CONCLUSIONS: Our findings show that residents want to learn about finances. Our brief educational intervention is a practical way to improve overall knowledge. Our intervention suggests that improving knowledge of finance may be associated with decreased feelings of burnout.

Telehealth for the internal medicine resident: A 3-year longitudinal curriculum.

AIMS: Across the United States of America, patients are increasingly receiving healthcare using innovative telehealth technologies. As healthcare continues to shift away from traditional office-based visits, providers face new challenges. Telehealth champions are needed to adapt technologies to meet the needs of patients, providers and communities, especially within the realm of primary care specialties. Given these challenges, this intervention aimed to incorporate telemedicine into internal medicine resident training across multiple training years to prepare them for practice in the current and changing healthcare system. METHODS: Education and telehealth leaders at the Medical University of South Carolina identified key topics relevant to telehealth and the provision of general internal medicine services. With this as a framework, we developed a 3-year longitudinal telehealth curriculum for internal medicine resident physicians, consisting of an introduction to telemedicine equipment in the first year, didactic learning through in-person education and online modules in the second year and experiential learning through remote monitoring of chronic disease in the third year. Participants included approximately 100 internal medicine residents per year (2016-2019). Self-perceived knowledge, comfort and ability to provide telehealth services was assessed via a survey completed before and after participation in the curriculum. RESULTS: Resident physicians' self-reported knowledge of telehealth history, access to care, contributions of telehealth applications and quality of care and communication each improved after completion of the online curriculum. There were also significant improvements in resident comfort and perceived ability to provide telehealth services after participation in the curriculum, as assessed via a survey. Overall, 41% of residents felt their ability to utilize telehealth as part of their current or future practice was greater than average after completion of the online modules compared to only 2% at baseline (p<0.01). Results also show residents accurately identify barriers to telehealth adoption at the healthcare system level, including the lack of clinical time to implement services (67% post- vs 47% pre-curriculum, p = 0.02), unfamiliarity with concepts (65% post- vs 21% pre-curriculum, p<-0.01) and concerns about consistent provider reimbursement (74% post- vs 39% pre-curriculum, p < 0.01). CONCLUSION: Telemedicine and remote patient monitoring are an increasingly prevalent form of healthcare delivery. Internal medicine residents must be adept in caring for patients utilizing this technology. This curriculum was effective in improving resident comfort and self-efficacy in providing care through telehealth and provided residents with hands-on opportunities through supervised inclusion in remote patient-monitoring services. This curriculum model could be employed and evaluated within other internal medicine residency programmes to determine the feasibility at institutions with and without advanced telehealth centres.

Self-Directed Learning among Internal Medicine Residents in the Information Age.

OBJECTIVES: The revolution in information technology and a rapidly expanding evidence base are changing residency training. Understanding the habits and preferences of trainees' self-directed learning (SDL) has never been more important. Our goal was to provide a contemporary description of residents' SDL practices. METHODS: Internal medicine residents at four university-affiliated programs were surveyed in Spring 2017. Residents estimated the number of hours in their typical week spent in SDL on service and after hours when on inpatient and noninpatient rotations, how often they used specific educational resources for SDL, and the percentage of time that they used four different modes to access resources. RESULTS: Of 384 residents, a total of 254 (66%) responded. Residents spent more total hours in SDL on noninpatient services (median 11, interquartile range 8-17) than on inpatient services (median 7, interquartile range 4-10) and the same median number of hours in SDL on clinical duty as off hours for both inpatient (median 3 hours) and noninpatient (median 5 hours) rotations. Nearly all of the respondents (99%) reported using online point-of-care resources for SDL at least once per week. Most (77%) never used printed textbooks. Desktop/laptop was the most commonly used (47% of the time) medium to access resources. CONCLUSIONS: Although the resident learning environment and resource use are changing, residents engage in as much or more time in SDL as in previous studies, with a large proportion occurring during clinical service. Understanding residents' current SDL habits will better prepare educators to support and guide our trainees.

Effects of an Academic Half Day in a Residency Program on Perceived Educational Value, Resident Satisfaction and Wellness.

BACKGROUND: The academic half day (AHD) has emerged in recent years as an alternative to the traditional noon conference model of didactic teaching in graduate medical education. However, the effects of this change on learners are not fully understood. This study aimed to assess the effects of the AHD on attendance, satisfaction, perceived value and wellness of resident physicians. METHODS: A survey aimed to assess housestaff satisfaction, perceived value and relevance to medical literature of the core educational curriculum was developed and validated. This, along with a wellness assessment survey, was distributed to residents electronically prior to the implementation of the AHD and again at the end of the academic year. Attendance was tracked for all conferences. RESULTS: The survey was administered to residents before and after implementation of the AHD (response rates were 100% and 83%, respectively at these time points [n = 95]). Implementation of the AHD lead to a significant increase in average time spent in the core conference series per week (29.7 versus 64.8 minutes). It additionally led to a statistically significant improvement of resident satisfaction with the core curriculum, perceived value of the core conference series, understanding of medical literature and promotion of reading outside of work. CONCLUSIONS: The AHD significantly improved resident time in conference, resident satisfaction and perceived educational value of the core conference series compared to a noon conference model. While challenges will exist with any educational conference model, the AHD appears to be a highly attractive approach to medical resident education.

Porphyria Cutanea Tarda Associated With Acute Hemorrhagic Pancreatitis.

Porphyria cutanea tarda (PCT) is a condition of dysregulated heme synthesis that leads to accumulation of photosensitizing precursors with resultant fragility and blistering of the skin. It can be hereditary or acquired and has been known to be associated with hepatic C virus, alcohol, HIV, and estrogen. In this article, we report an unusual presentation of PCT associated with acute hemorrhagic pancreatitis in a 57-year-old man. He presented initially to a community hospital with acute onset of epigastric abdominal pain and new-onset ascites. Lipase was elevated. Diagnostic paracentesis was grossly bloody. He was then transferred to our institution for concern for acute hemorrhagic pancreatitis. On arrival, physical examination demonstrated vesicles and bullae with erythematous bases, in different stages of healing seen over the dorsal aspects of both hands with scaling, scarring, and hypopigmentation and hyperpigmentation of the skin. Laboratory evaluation and skin biopsy confirmed the diagnosis of PCT. Search for an underlying etiology failed to reveal typical predisposing factors. This report illustrates that acute hemorrhagic pancreatitis may be an underlying etiology for PCT.

Antibiotic Use and Respiratory Pathogens in Adults With Sickle Cell Disease and Acute Chest Syndrome.

Background: Acute chest syndrome (ACS) is an acute complication of sickle cell disease (SCD). Historically, the most common pathogens were Chlamydophila pneumoniae, Mycoplasma pneumoniae, and respiratory syncytial virus. Pediatric patients receiving guideline-adherent therapy experienced fewer ACS-related and all-cause 30-day readmissions compared with those receiving nonadherent therapy. This has not been evaluated in adults. Objectives: The primary objectives were to characterize antibiotic use and pathogens. The secondary objective was to assess the occurrence of readmissions associated with guideline-adherent and clinically appropriate treatment compared with regimens that did not meet those criteria. Methods: A retrospective cohort analysis was conducted for adults with SCD hospitalized between August 1, 2014, and July 31, 2017, with pneumonia (PNA) or ACS. The study was approved by the institutional review board. Results: A total of 139 patients with 255 hospitalizations were reviewed. Among 41 respiratory cultures, 3 organisms were isolated: Cryptococcus neoformans, Pseudomonas aeruginosa, and budding yeast. Respiratory panels were collected on 121 admissions, with 17 positive for 1 virus; all were negative for Chlamydophila pneumoniae and M pneumoniae. There were significantly more ACS-/PNA-related 7-day readmissions from patients on guideline-adherent regimens compared with nonadherent regimens (3.7% vs 0%; P = 0.04). Conclusion and Relevance: These findings challenge existing knowledge regarding the most common pathogens in adults with SCD with ACS or PNA. Routine inclusion of a macrolide may not be necessary. Future studies focused on pathogen characterization with standardized assessment are necessary to determine appropriate empirical therapy in this population.

Ethical and Clinical Considerations in Treating Infections at the End of Life.

Patients often affirm the goal to pursue comfort at the end of life, although clinicians may struggle with how best to provide comfort and face the ethical dilemma of treating or allowing a suspected infection to unfold. Treating an infection at the end of life does not allow for uniform improvement in symptoms and more time with family and friends. Additionally, there is potential for burden to the patient or health care system and treatment may occur to the exclusion of other comfort measures. Currently, the practice of providing or forgoing antibiotics at the end of life is variable, and literature supporting best practices can be contradictory. Data to support the use or withholding of treatment have been scant and vary across settings and patient populations. We review common obstacles providers face, prognostication tools that may assist in clinical decision making, the ethical support for withholding therapy, and how to factor in potential burdens of treatment. We propose that nurses, whether at the bedside in an acute care or nursing facility or in the home setting as a member of the interdisciplinary home hospice team, are uniquely qualified to help patients and families navigate this challenging clinical decision.

The Structure of Medical Intensive Care Units at Training Institutions.

BACKGROUND: As a result of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour guideline implementation, the structure of intensive care unit (ICU) teams at training institutions has been affected. The impact these changes have had on the current work environment has not been well described. METHODS: The authors conducted an online survey of internal medicine program directors in 2016. The survey investigated how training institutions structure their intensive care units in reference to volume, resident housestaff and alternative coverage options, with a focus on changes made after the implementation of the 2011 ACGME duty hour restrictions. RESULTS: Notable differences were found in program director responses to coverage of patients in the ICUs. A total of 62 of the 132 (48%) responding program directors describe coverage of all patients solely by resident housestaff. Since 2011, 54 (41%) programs have increased the number of resident physicians rotating in the ICU per month and initiated or increased the use of nonresident coverage of patients. Use of non-resident providers is not associated with a decrease in the number of total ICU months per resident or a decrease in educational value. CONCLUSIONS: Since the 2011 ACGME duty hour implementation, there is wide variability in the learning environment of medical intensive care units in training institutions.

Appropriateness of direct oral anticoagulant dosing for venous thromboembolism treatment.

Adherence to FDA-approved dosing for the direct oral anticoagulants (DOACs) based on renal function, hepatic function, and concomitant medications in a real-world setting has not been evaluated. The purpose of this retrospective cohort analysis was to determine the prescribing accuracy of DOAC dosing for venous thromboembolism (VTE) treatment compared with enoxaparin. The secondary outcomes were to describe the incidence of in-hospital VTE recurrence and bleeding on DOAC therapy. The study included 168 patients with 261 admissions for the DOAC group and 639 patients with 841 admissions for the enoxaparin group. Dosing was appropriate in 235/261 (90.0%) of patient admissions in the DOAC group. Among the DOAC doses administered, 233/2246 (10.4%) were contraindicated based on renal function, hepatic function, or drug interactions compared with 322/7293 (4.4%) of administered enoxaparin doses evaluated based on renal function, p < 0.001. Three recurrent VTEs, 3 major bleeding events, 1 probable major bleeding event, and 3 clinically relevant non-major bleeding events were observed during the study period. Although a majority of DOAC doses administered were appropriate, further education and close monitoring of these agents are warranted to increase appropriateness of therapy and improve patient safety.

Academic detailing to teach aging and geriatrics.

Geriatric education is a required component of internal medicine training. Work hour rules and hectic schedules have challenged residency training programs to develop and utilize innovative teaching methods. In this study, the authors examined the use of academic detailing as a teaching intervention in their residents' clinic and on the general medicine inpatient wards to improve clinical knowledge and skills in geriatric care. The authors found that this teaching method enables efficient, directed education without disrupting patient care. We were able to show improvements in medical knowledge as well as self-efficacy across multiple geriatric topics.