Implementation of simulation-based health systems science modules for resident physicians.

BACKGROUND: Health system science (HSS) encompasses both core and cross-cutting domains that emphasize the complex interplay of care delivery, finances, teamwork, and clinical practice that impact care quality and safety in health care. Although HSS skills are required during residency training for physicians, current HSS didactics have less emphasis on hands-on practice and experiential learning. Medical simulation can allow for experiential participation and reflection in a controlled environment. Our goal was to develop and pilot three simulation scenarios as part of an educational module for resident physicians that incorporated core and cross-cutting HSS domains.  METHODS: Each scenario included a brief didactic, an interactive simulation in small-group breakout rooms, and a structured debriefing. The case scenario topics consisted of educational leadership, quality and safety, and implementation science. Learners from four residency programs (psychiatry, emergency medicine, orthopedics, ophthalmology) participated January - March 2021. RESULTS: A total of 95 resident physicians received our curricular module, and nearly all (95%) participants who completed a post-session survey reported perceived learning gains. Emotional reactions to the session were positive especially regarding the interactive role-play format. Recommendations for improvement included participation from non-physician professions and tailoring of scenarios for specific disciplines/role. Knowledge transfer included use of multiple stakeholder perspectives and effective negotiation by considering power/social structures. CONCLUSIONS: The simulation-based scenarios can be feasibly applied for learner groups across different residency training programs. Simulations were conducted in a virtual learning environment, but future work can include in-person and actor-based simulations to further enhance emotional reactions and the reality of the case scenarios.

Proxy Detection of Resident Burnout by Program Directors and Domestic Partners.

BACKGROUND: Resident burnout is associated with increased incidence of depression, suicide, and poor patient outcomes, yet identification of it is difficult. This study was designed to compare how well program directors (directors) and a resident's spouse or domestic partner (partner) can serve as a proxy to identify burnout in the resident. STUDY DESIGN: An electronic survey, including the Maslach Burnout Inventory, was distributed to residents, their partners, and directors of all ACGME-accredited residencies at a single university-affiliated hospital. Burnout rates were compared with McNemar's test. Emotional exhaustion and depersonalization rates were compared with Spearman's correlation. RESULTS: The response rate by respondent type was 33% (292 of 876) for residents, 48% (55 of 114) for partners, and 57% (13 of 23) for directors. Residents' self-reported burnout rate was 51% (148 of 292), while partners' proxy predicted burnout rate was 25% (14 of 55), and directors' was 5% (9 of 174). There was moderate correlation of partners' prediction of resident emotional exhaustion (ρ = 0.537, p < 0.01), depersonalization (ρ = 0.501, p < 0.01), and personal accomplishment (ρ = 0.416, p < 0.01). There was poor correlation of directors' prediction of residents' emotional exhaustion (ρ = 0.361, p < 0.01) and depersonalization (ρ = 0.223, p < 0.01). Partners had a 50% sensitivity, 94% specificity, 86% positive predictive value, and 71% negative predictive value in predicting resident burnout. Directors had a 6% sensitivity, 96% specificity, 56% positive predictive value, and 54% negative predictive value in predicting resident burnout. CONCLUSIONS: Directors are not skilled in detecting burnout in their trainees. Partners are an underused group for detecting burnout and may represent an important target audience for awareness of available resources to benefit residents.

Burnout and Perception of Medical School Learning Environments Among Gay, Lesbian, and Bisexual Medical Students.

Importance: The perspectives of gay, lesbian, bisexual (sexual minority [SM]) students about their medical school learning environment and how they relate to burnout is poorly understood. Objective: To understand SM medical students' perceptions of the medical school learning environment and how this is associated with reported burnout. Design, Setting, and Participants: This cross-sectional study included medical students graduating from Association of American Medical Colleges (AAMC)-accredited allopathic US medical schools in 2016 and 2017 and responding to the AAMC Graduation Questionnaire. Data analysis was conducted from June 2021 to March 2022. Exposures: Sexual orientation, based on self-identification, and categorized as bisexual, gay or lesbian, or heterosexual or straight. Main Outcomes and Measures: Primary outcomes included burnout as measured by Oldenburg Burnout Inventory for Medical Students (OLBI-MS; two 24-point scales [range, 0-48], with higher scores indicating greater burnout) and student perceptions of the medical school learning environment (0-5-point scales for emotional climate [range, 0-20] and student-faculty interactions [range, 0-15], with higher scores indicating more positive perceptions). Logistic regression was used to model the association between burnout, SM status, and learning environment while controlling for demographic characteristics. Results: A total of 25 757 respondents (12 527 [48.6%] women; 5347 [20.8%] Asian; 2255 [8.8%] underrepresented in medicine; 15 651 [60.8%] White; 10 726 [41.6%] aged ≤26 years) were included in the analysis: 568 (2.2%) self-identified as bisexual, 854 (3.3%) as gay or lesbian, and 24 335 (94.5%) as heterosexual or straight. Both bisexual students and gay or lesbian students reported less favorable perceptions of their learning environments than heterosexual students (mean [SD] emotional climate score, bisexual students: 8.56 [3.29]; gay or lesbian students: 9.22 [3.33]; heterosexual or straight students: 9.71 [3.20]; P < .001; mean [SD] faculty-student interaction score, bisexual students: 13.46 [3.69]; gay or lesbian students: 14.07 [3.45]; heterosexual or straight students: 14.32 [3.37]; P < .001). Bisexual and gay or lesbian students were more likely to be in the top quartile for burnout scores (bisexual: odds ratio [OR], 1.71; 95% CI, 1.42-2.07; P < .001; gay or lesbian: OR, 1.53; 95% CI, 1.31-1.79; P < .001). This association was attenuated when accounting for student perceptions of the learning environment (bisexual: OR, 1.37; 95% CI, 1.11-1.67; P < .001; gay or lesbian: OR, 1.42; 95% CI, 1.19-1.68; P < .001), with poorer perceptions of the medical school learning environment associated with higher burnout symptoms. Conclusions and Relevance: In this cross-sectional study, SM students had less favorable perceptions of the medical school learning environment compared with heterosexual students. Results suggest the medical school environment may be associated with higher rates of burnout in SM students. Future research should explore interventions to improve the learning environment for SM students.

What's it Worth?: The Costs and Benefits of an Initiative to Decrease Post-Call Fatigued Driving Among Surgery Residents.

BACKGROUND: In 2017 the ACGME enacted new regulations requiring sponsoring institutions to ensure "safe transportation options for residents who may be too fatigued to safely return home." We investigate here the impact of a pilot "Safe Ride" program designed to mitigate the risks of fatigued driving. METHODS: During a 2-month pilot period at a single university-affiliated general surgery residency with four urban clinical sites, all residents (n = 72) were encouraged to hire a rideshare (e.g., Uber, Lyft) to and from 24-h clinical shifts if they felt too fatigued to drive safely. The cost of the rideshare was fully reimbursed to the resident. The impact of this intervention was evaluated using utilization data and a post-intervention resident survey. RESULTS: A total of 16.6% of trainees utilized a rideshare at least one time. Sixty-three post-call rides were taken, predominantly by junior residents (92.4%) and for commutes greater than 15 miles (91%). The cost for the 60-day pilot was $3030. Comparing pre-intervention to post-intervention data, there was a significant improvement in the reported frequency of falling asleep or nearly asleep while driving (P < 0.001). Trainees nearly unanimously (98%) supported efforts to make the program permanent. DISCUSSION: Driving while fatigued is common among surgical residents, with increased risk among junior residents, during longer commutes and following longer shifts. A reimbursed rideshare program effectively targets these risk factors and was associated with a significant decrease in rates of self-reported fatigued driving. Future efforts should focus on strategies to promote use of reimbursed rideshare programs while remaining cost efficient.

Structured interdisciplinary bedside rounds improve interprofessional communication and workplace efficiency among residents and nurses on an inpatient internal medicine unit.

Structured Interdisciplinary Bedside Rounds (SIBR) is a standardized, team-based intervention for hospitals to deliver high quality interprofessional care. Despite its potential for improving IPC and the workplace environment, relatively little is known about SIBR's effect on these outcomes. Our study aimed to assess the fidelity of SIBR implementation on an inpatient medicine teaching unit and its effects on perceived IPC and workplace efficiency. We conducted a quasi-experimental study with 88 residents and 44 nurses at a large academic medical center and observed 1308 SIBR encounters over 24 weeks. Of these 1308 encounters, the bedside nurse was present for 96.7%, physician for 97.6%, and care manager for 94.7, and 64.7% occurred at the bedside. Following SIBR implementation, perceived IPC improved significantly among residents (93.3% versus 67.9%, p < .024) and nurses (73.7% versus 36.0%, p < .008) compared to before implementation. Moreover, residents perceived greater workplace efficiency operationalized as being paged less frequently with questions by nurses (20.0% versus 49.1%, p = .01). No statistically significant improvements were reported regarding burnout, meaning at work, and workplace satisfaction. Our implementation of SIBR significantly improved perceived IPC and workplace efficiency, which are two important domains of healthcare quality. Future work should examine the impact of SIBR on patient-centered outcomes such as patient experience.

Hypertensive Urgency: An Emergency Department Pipeline to Primary Care Pilot Study.

BACKGROUND: Optimal triage of patients with hypertensive urgency (HU) in the emergency department (ED) is not well established. 2017 ACC/AHA hypertension (HTN) guidelines recommend treatment initiation and follow-up within 1 week. Objectives of our pilot study were to evaluate feasibility and impact of directly connecting ED patients with HU to outpatient HTN management on blood pressure (BP) control and ED utilization. METHODS: ED patients with HU and no primary care physician were scheduled by a referral coordinator for an initial appointment in a HTN clinic embedded within a primary care practice. BP control and ED utilization over the subsequent 90 days were tracked and compared with BP at time of the referral ED visit, and ED utilization in the 90 days preceding referral. RESULTS: Data are reported for the first 40 referred patients. Average time to first visit was 7.8 days. Mean age was 51 years (range 28-76), 75% were African-American, and mean pooled 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 20.8%. Mean BP declined from 198/116 mm Hg at ED visit to 167/98 mm Hg at HTN clinic visit 1 to 136/83 by 6 weeks and was sustained at 90 days. Total ED visits for the group decreased from 61 in the 90 days prior to referral, to 18 in the 90 days after the first HTN clinic visit. CONCLUSIONS: In this pilot study, coordinated referral between the ED and primary care provides safe, timely care for this high ASCVD risk population and leads to sustained reductions in BP and ED utilization.

Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation.

Importance: Previous studies have shown that medical student mistreatment is common. However, few data exist to date describing how the prevalence of medical student mistreatment varies by student sex, race/ethnicity, and sexual orientation. Objective: To examine the association between mistreatment and medical student sex, race/ethnicity, and sexual orientation. Design, Setting, and Participants: This cohort study analyzed data from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The questionnaire annually surveys graduating students at all 140 accredited allopathic US medical schools. Participants were graduates from allopathic US medical schools in 2016 and 2017. Data were analyzed between April 1 and December 31, 2019. Main Outcomes and Measures: Prevalence of self-reported medical student mistreatment by sex, race/ethnicity, and sexual orientation. Results: A total of 27 504 unique student surveys were analyzed, representing 72.1% of graduating US medical students in 2016 and 2017. The sample included the following: 13 351 female respondents (48.5%), 16 521 white (60.1%), 5641 Asian (20.5%), 2433 underrepresented minority (URM) (8.8%), and 2376 multiracial respondents (8.6%); and 25 763 heterosexual (93.7%) and 1463 lesbian, gay, or bisexual (LGB) respondents (5.3%). At least 1 episode of mistreatment was reported by a greater proportion of female students compared with male students (40.9% vs 25.2%, P < .001); Asian, URM, and multiracial students compared with white students (31.9%, 38.0%, 32.9%, and 24.0%, respectively; P < .001); and LGB students compared with heterosexual students (43.5% vs 23.6%, P < .001). A higher percentage of female students compared with male students reported discrimination based on gender (28.2% vs 9.4%, P < .001); a greater proportion of Asian, URM, and multiracial students compared with white students reported discrimination based on race/ethnicity (15.7%, 23.3%, 11.8%, and 3.8%, respectively; P < .001), and LGB students reported a higher prevalence of discrimination based on sexual orientation than heterosexual students (23.1% vs 1.0%, P < .001). Moreover, higher proportions of female (17.8% vs 7.0%), URM, Asian, and multiracial (4.9% white, 10.7% Asian, 16.3% URM, and 11.3% multiracial), and LGB (16.4% vs 3.6%) students reported 2 or more types of mistreatment compared with their male, white, and heterosexual counterparts (P < .001). Conclusions and Relevance: Female, URM, Asian, multiracial, and LGB students seem to bear a disproportionate burden of the mistreatment reported in medical schools. It appears that addressing the disparate mistreatment reported will be an important step to promote diversity, equity, and inclusion in medical education.

The Changing Face of HIV Care: Expanding HIV Training in an Internal Medicine Residency Program.

PROBLEM: People with HIV/AIDS are living longer and are at an increased risk of comorbidities. A qualified physician workforce is needed to care for this growing population. APPROACH: In 2012, a novel three-year HIV training track (HIV TT) was implemented as part of the Yale Primary Care Residency Program. To prepare for the implementation of this program, a needs assessment was performed, a web-based curriculum and 12 HIV-specific entrustable professional activities (EPAs) were created, and adequate clinical training opportunities in HIV and primary care were established. Program evaluation included process, learner, and outcome evaluations from 2012 to 2017. OUTCOMES: Since its inception, the HIV TT has enrolled a total of 11 residents (6-7 at a time), with 5 graduating to date. Residents delivered high-quality HIV and primary care for a diverse panel of patients; improved their knowledge and performance in HIV care, including according to the HIV-specific EPAs; and were highly satisfied with the program. All faculty remained with the program, and patients indicated satisfaction. NEXT STEPS: Next steps include enhanced coordination of residents' schedules, improved EPA documentation, evaluation of residents' HIV and non-HIV competence beyond residency, and monitoring graduates' career trajectories. Expanding HIV training within internal medicine residency programs is feasible and effective and has the potential to alleviate the shortage of physicians trained to provide HIV care and primary care in a single setting.

Minority Resident Physicians' Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace.

Importance: Black, Hispanic, and Native American physicians remain underrepresented in medicine despite national efforts to increase diversity in the health care workforce. Understanding the unique workplace experiences of minority physicians is essential to inform strategies to create a diverse and inclusive workforce. While prior research has explored the influence of race/ethnicity on the experiences of minority faculty and medical students, there is a paucity of literature investigating how race/ethnicity affects the training experiences of resident physicians in graduate medical education. Objective: To characterize how black, Hispanic, and Native American resident physicians experience race/ethnicity in the workplace. Design, Setting, and Participants: Semistructured, in-depth qualitative interviews of black, Hispanic, and Native American residents were performed in this qualitative study. Interviews took place at the 2017 Annual Medical Education Conference (April 12-17, 2017, in Atlanta, Georgia), sponsored by the Student National Medical Association. Interviews were conducted with 27 residents from 21 residency programs representing a diverse range of medical specialties and geographic locations. Main Outcomes and Measures: The workplace experiences of black, Hispanic, and Native American resident physicians in graduate medical education. Results: Among 27 participants, races/ethnicities were 19 (70%) black, 3 (11%) Hispanic, 1 (4%) Native American, and 4 (15%) mixed race/ethnicity; 15 (56%) were female. Participants described the following 3 major themes in their training experiences in the workplace: a daily barrage of microaggressions and bias, minority residents tasked as race/ethnicity ambassadors, and challenges negotiating professional and personal identity while seen as "other." Conclusions and Relevance: Graduate medical education is an emotionally and physically demanding period for all physicians. Black, Hispanic, and Native American residents experience additional burdens secondary to race/ethnicity. Addressing these unique challenges related to race/ethnicity is crucial to creating a diverse and inclusive work environment.

Personal and Professional Well-Being of Surgical Residents in New England.

BACKGROUND: Although there is increasing literature about burnout and attrition among surgeons, little is known about personal and professional well-being of surgical trainees. STUDY DESIGN: General surgery residents from the 6 New England states participated in a cross-sectional, qualitative, self-reported survey to assess the domains of personal health maintenance, personal finance, work environment, and fatigue management as they relate to surgical training. RESULTS: All surgical residency programs in the New England region were invited to participate. Of these 19 programs, 10 elected to participate in the study. Three hundred and sixty-three total trainees were contacted with requests to participate, and 166 completed responses to the survey, resulting in a response rate of 44.9%. Ninety percent of respondents identified their programs as "university or academic." Substantial cohorts reported that during training they lacked basic healthcare maintenance visits (54%) and had undesired weight gain (44%). Although most found their stipends adequate, three-quarters worried about their finances (75%) and reported substantial educational debt (45%). Most residents enjoyed coming to work; however, the vast majority reported that work-related stress is moderate to extreme (92%). Most also reported that work-related stress negatively affects their overall well-being (72%). The mean Epworth Sleepiness Scale score among respondents was 14, consistent with moderate excessive daytime sleepiness. CONCLUSIONS: Surgical trainee well-being is critical to optimal patient care, career development, and burnout reduction. Surgical residents attend to their own preventive health maintenance, finances, sleep, and stress reduction with variable success. Residency programs should make modest programmatic accommodations to allow trainees to tend to various aspects of their personal well-being.

Why Aren't More Primary Care Residents Going into Primary Care? A Qualitative Study.

BACKGROUND: Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. OBJECTIVE: We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. DESIGN: This was a qualitative study based on semi-structured, in-person interviews. PARTICIPANTS: Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. APPROACH: We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. KEY RESULTS: We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. CONCLUSIONS: Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

The residency application abyss: insights and advice.

Most medical students apply for residency training upon completion of medical school. The choice of specialty is one of a student's first major career decisions, and the application process often results in considerable anxiety, as it is competitive, unpredictable, and requires a significant investment of time and money. This article, which addresses several important facets of the residency application using both experiential and evidence-based data, is organized chronologically into sections that describe a logical approach to applying for residency: choice of a specialty, the personal statement, the interview day, and developing a rank list. A list of relevant websites is also included. This paper is a resource that provides timely and tangible guidance to medical students applying for residency training.

The association of faculty and residents' gender on faculty evaluations of internal medicine residents in 16 residencies.

PURPOSE: Previous studies have found gender bias in the global evaluations of trainees. The purpose of this study was to investigate the association of faculty and residents' gender on the evaluation of residents' specific clinical skills, using direct observation. METHOD: In 2001-2002, 40 clinician-educators from 16 internal medicine residency programs viewed a series of nine scripted videotapes depicting varying levels of residents' clinical performance in medical interviewing, physical examination, and counseling. Differences in the ratings of women versus men faculty, in relation to differences in the residents' gender, were compared using random-effects regression analysis. RESULTS: There were no statistically or educationally significant differences in the rating of clinical skills attributable to faculty or residents' gender for medical interviewing, physical examination, or counseling. CONCLUSIONS: This study suggests that gender bias may be less prevalent in the current era of evaluation of clinical skills, particularly when specific skills are directly observed by faculty. Further work is needed to examine whether the findings of this study translate to the actual training setting.

Middle manager role of the chief medical resident: an organizational psychologist's perspective.

The role of the chief resident in internal medicine is examined through the eyes of an organizational psychologist who, over a 3-year period, met with each of 6 groups of chief residents for an average of 1 hour a week over the 12 months of the job. Based on this experience, the chief resident job is conceptualized as a middle management role with 4 distinct types of tasks: up work, down work, lateral work, and internal work. Core challenges facing the chief residents at each stage of the chief resident year are also identified. The paper concludes with a description of "lessons" learned in 5 areas (sliding up or sliding down, losing contact, splitting, scapegoating, and losing sight of the system) for improving the effectiveness of the chief resident role.

Medicine residents' understanding of the biostatistics and results in the medical literature.

CONTEXT: Physicians depend on the medical literature to keep current with clinical information. Little is known about residents' ability to understand statistical methods or how to appropriately interpret research outcomes. OBJECTIVE: To evaluate residents' understanding of biostatistics and interpretation of research results. DESIGN, SETTING, AND PARTICIPANTS: Multiprogram cross-sectional survey of internal medicine residents. MAIN OUTCOME MEASURE: Percentage of questions correct on a biostatistics/study design multiple-choice knowledge test. RESULTS: The survey was completed by 277 of 367 residents (75.5%) in 11 residency programs. The overall mean percentage correct on statistical knowledge and interpretation of results was 41.4% (95% confidence interval [CI], 39.7%-43.3%) vs 71.5% (95% CI, 57.5%-85.5%) for fellows and general medicine faculty with research training (P < .001). Higher scores in residents were associated with additional advanced degrees (50.0% [95% CI, 44.5%-55.5%] vs 40.1% [95% CI, 38.3%-42.0%]; P < .001); prior biostatistics training (45.2% [95% CI, 42.7%-47.8%] vs 37.9% [95% CI, 35.4%-40.3%]; P = .001); enrollment in a university-based training program (43.0% [95% CI, 41.0%-45.1%] vs 36.3% [95% CI, 32.6%-40.0%]; P = .002); and male sex (44.0% [95% CI, 41.4%-46.7%] vs 38.8% [95% CI, 36.4%-41.1%]; P = .004). On individual knowledge questions, 81.6% correctly interpreted a relative risk. Residents were less likely to know how to interpret an adjusted odds ratio from a multivariate regression analysis (37.4%) or the results of a Kaplan-Meier analysis (10.5%). Seventy-five percent indicated they did not understand all of the statistics they encountered in journal articles, but 95% felt it was important to understand these concepts to be an intelligent reader of the literature. CONCLUSIONS: Most residents in this study lacked the knowledge in biostatistics needed to interpret many of the results in published clinical research. Residency programs should include more effective biostatistics training in their curricula to successfully prepare residents for this important lifelong learning skill.

Internal medicine residents' clinical and didactic experiences after work hour regulation: a survey of chief residents.

BACKGROUND: Work hour regulations for house staff were intended in part to improve resident clinical and educational performance. OBJECTIVE: To characterize the effect of work hour regulation on internal medicine resident inpatient clinical experience and didactic education. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Chief residents at all accredited U.S. internal medicine residency programs outside New York. MEASUREMENTS AND MAIN RESULTS: The response rate was 62% (202/324). Most programs (72%) reported no change in average patient load per intern after work hour regulation. Many programs (48%) redistributed house staff admissions through the call cycle. The number of admissions per intern on long call (the day interns have the most admitting responsibility) decreased in 31% of programs, and the number of admissions on other days increased in 21% of programs. Residents on outpatient rotations were given new ward responsibilities in 36% of programs. Third-year resident ward and float time increased in 34% of programs, while third-year elective time decreased in 22% of programs. The mean weekly hours allotted to educational activities did not change significantly (12.7 vs 12.4, P = .12), but 56% of programs reported a decrease in intern attendance at educational activities. CONCLUSIONS: In response to work hour regulation, many internal medicine programs redistributed rather than reduced residents' inpatient clinical experience. Hours allotted to educational activities did not change; however, most programs saw a decrease in intern attendance at conferences, and many reduced third-year elective time.

Transfers of patient care between house staff on internal medicine wards: a national survey.

BACKGROUND: Transfer of responsibility for patient care between physicians is a key process in the care of hospitalized patients. Systems of transfer management and transfer frequency may affect clinical outcomes. METHODS: To characterize the systems by which patient information is transferred ("signed out") between resident physicians in internal medicine residency programs and to determine the impact of recently enacted resident work-hour regulations on the frequency of transfers, we mailed a self-administered survey to chief residents at 324 accredited US internal medicine residency programs outside of New York State. The main outcome measures were sign-out practices, skills training, and transfer frequency. RESULTS: Surveys were returned from 202 programs (62%). Transfer systems varied among and within institutions: 55% did not consistently require both a written and an oral sign-out at transfers of care, 34% left sign-out to interns alone, and 59% had no means of informing nurses that a transfer had taken place. In addition, 60% of the programs did not provide any lectures or workshops on sign-out skills. After work-hour regulations were instituted, transfers of care for a hypothetical patient increased by a mean of 11% (from 7.0 to 7.8 transfers; P<.001) during a Monday-Friday hospitalization. A member of the primary team was in the hospital for 47% of the hospitalization. CONCLUSION: Although transfers of care are increasingly frequent, few internal medicine residency programs have comprehensive transfer of care systems in place, and most do not provide formal training in sign-out skills to all residents.

Effects of training in direct observation of medical residents' clinical competence: a randomized trial.

BACKGROUND: Faculty observation of residents and students performing clinical skills is essential for reliable and valid evaluation of trainees. OBJECTIVE: To evaluate the efficacy of a new multifaceted method of faculty development called direct observation of competence training. DESIGN: Controlled trial of faculty from 16 internal medicine residency programs using a cluster randomization design. SETTING: Academic medical centers. PARTICIPANTS: 40 internal medicine teaching faculty members: 17 in the intervention group and 23 in the control group. MEASUREMENTS: Changes in faculty comfort performing direct observation, faculty satisfaction with workshop, and changes in faculty rating behaviors 8 months after completing the training. INTERVENTION: The direct observation of competence workshop combines didactic mini-lectures, interactive small group and videotape evaluation exercises, and evaluation skill practice with standardized residents and patients. RESULTS: 37 faculty members (16 in the intervention group and 21 in the control group) completed the study. Most of the faculty in the intervention group (14 [88%]) reported that they felt significantly more comfortable performing direct observation compared with control group faculty (4 [19%]) (P = 0.04), and all intervention faculty rated the training as outstanding. For 9 videotaped clinical encounters, intervention group faculty were more stringent than controls in their evaluations of medical interviewing, physical examination, and counseling; differences in ratings for medical interviewing and physical examination remained statistically significant even after adjustment for baseline rating behavior. LIMITATIONS: The study involved a limited number of residency programs, and faculty did not rate the performance of actual residents. CONCLUSION: Direct observation of competence training, a new multifaceted approach to faculty development, leads to meaningful changes in rating behaviors and in faculty comfort with evaluation of clinical skills.