A resident's reflections on becoming an agent of curricular change.
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Attitude of Health Personnel↗
Biomedical subjects
Scott M Wright
Publications and source records attributed to Scott M Wright.
Insufficient treatment of hypercholesterolemia among patients hospitalized with chest pain.
BACKGROUND: Although morbidity and mortality from coronary artery disease can be improved with a variety of pharmacologic interventions, many patients remain undertreated. HYPOTHESIS: This study sought to assess whether hospitalization for possible coronary artery disease would prompt initiation of appropriate lipid-lowering therapy. METHODS: This prospective, observational study was conducted on consecutive patients with active chest pain admitted to the Emergency Department of the hospital for suspected myocardial ischemia. Elevated cholesterol, defined as low-density lipoprotein (LDL), was >100 mg/dl with a prior history or a new diagnosis of coronary artery disease, or an LDL >130 mg/dl without known coronary artery disease. Data were recorded at the time of admission, discharge, and at 4-month follow-up. RESULTS: Of the patients with hyperlipidemia, 65% men and 55% women were on medication at the time of admission (p = 0.30), while at discharge, 79% men and 60% women were on treatment (p = 0.002), with similar rates of treatment at 4-month follow-up (p = 0.030). At discharge, two variables were independently associated with patients receiving lipid-lowering therapy: age > or =65 years (odds ratio = 2.3; 95% confidence interval 1.2-4.5) and male gender (2.7; 15-5.0). CONCLUSIONS: In patients hospitalized with chest pain, particularly in women, the initiation of treatment of hyperlipidemia frequently does not happen. This oversight represents a lost opportunity for making an impact on the health of this population.
Adult↗
Facing the malpractice crisis: academic physicians' willingness to accept quick fix solutions.
BACKGROUND: We sought to determine the willingness of academic physicians to accept strategies to contain institutional malpractice costs. METHODS: We surveyed all 270 Department of Medicine physicians at a large academic center. Respondents were asked about their knowledge regarding malpractice premiums, willingness to reduce patient-care activities and accept decreases in compensation. RESULTS: The response rate was 80%. Respondents estimated the annual increase in malpractice premiums from 2004 to 2005 to be 29%. The true increase was 28% (P = 0.55). Almost all opposed eliminating patient care (95%) or providing patient care every other year at double effort and withdrawing from patient care on alternate years (97%). Seventy percent would limit their clinical procedures. Most physicians opposed salary reduction (97%) or decreases in fringe benefits (99%). CONCLUSIONS: Few academic physicians are willing to limit patient care or accept decreases in compensation to recoup institutional malpractice costs.
Academic Medical Centers↗
Personal growth and its correlates during residency training.
OBJECTIVES: To explore the characteristics of and factors associated with personal growth during residency training. METHODS: In 2003, 359 house officers on 7 internal medicine residency training programmes in the USA were surveyed about their training experiences and issues related to their personal growth. Factor analysis and internal reliability testing were used to develop a 'personal growth scale'. Logistic regression models were then used to identify independent associations between individual variables and 'high' versus 'low' personal growth scores. RESULTS: A total of 281 house officers (80%) responded. The personal growth scale had a Cronbach's alpha of 0.81. Factors that were independently associated with achieving high amounts of personal growth during residency training included: agreeing that reflection is important during residency training (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.1-7.4); being male (OR 2.6, 95% CI 1.4-4.5); being non-white (OR 2.2, 95% CI 1.3-3.9); having a strong desire to develop personally and professionally (OR 2.2, 95% CI 1.1-4.1), and feeling highly supported by one's programme director (OR 2.1, 95% CI 1.2-3.9). Independent predictors of scoring below the median on the personal growth scale included feeling emotionally isolated at work (OR 0.4, 95% CI 0.2-0.7) and noting that negative or disappointing experiences had been powerful (OR 0.4, 95% CI 0.2-0.9). CONCLUSIONS: Disparate amounts of personal growth occur among trainees during residency training. Residency programmes interested in promoting personal growth among their trainees may wish to focus on modifiable factors that are associated with personal growth, such as fostering supportive relationships and encouraging reflection.
Adult↗
Association between higher mental well-being and residents' capacity for empathy.
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Attitude of Health Personnel↗
Personal growth during internship: a qualitative analysis of interns' responses to key questions.
BACKGROUND: During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship. DESIGN: Prospective qualitative study conducted over the course of internship. PARTICIPANTS: Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs. APPROACH: Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns' writings to identify triggers, facilitators, and barriers related to personal growth. RESULTS: Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs. CONCLUSIONS: Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns' core values especially in association with powerful triggers.
Attitude of Health Personnel↗
Physician characteristics associated with proficiency in feedback skills.
BACKGROUND: Providing and eliciting high-quality feedback is valuable in medical education. Medical learners' attainment of clinical competence and professional growth can be facilitated by reliable feedback. This study's primary objective was to identify characteristics that are associated with physician teachers' proficiency with feedback. METHODS: A cohort of 363 physicians, who were either past participants of the Johns Hopkins Faculty Development Program or members of a comparison group, were surveyed by mail in July 2002. Survey questions focused on personal characteristics, professional characteristics, teaching activities, self-assessed teaching proficiencies and behaviors, and scholarly activity. The feedback scale, a composite feedback variable, was developed using factor analysis. Logistic regression models were then used to determine which faculty characteristics were independently associated with scoring highly on a dichotomized version of the feedback scale. RESULTS: Two hundred and ninety-nine physicians responded (82%) of whom 262 (88%) had taught medical learners in the prior 12 months. Factor analysis revealed that the 7 questions from the survey addressing feedback clustered together to form the "feedback scale" (Cronbach's alpha: 0.76). Six items, representing discrete faculty responses to survey questions, were independently associated with high feedback scores: (i) frequently attempting to detect and discuss the emotional responses of learners (odds ratio [OR]=4.6, 95% confidence interval [CI] 2.2 to 9.6), (ii) proficiency in handling conflict (OR=3.7, 95% CI 1.5 to 9.3), (iii) frequently asking learners what they desire from the teaching interaction (OR=3.5, 95% CI 1.7 to 7.2), (iv) having written down or reviewed professional goals in the prior year (OR=3.2, 95% CI 1.6 to 6.4), (v) frequently working with learners to establish mutually agreed upon goals, objectives, and ground rules (OR=2.2, 95% CI 1.1 to 4.7), and (vi) frequently letting learners figure things out themselves, even if they struggle (OR=2.1, 95% CI 1.1 to 3.9). CONCLUSIONS: Beyond providing training in specific feedback skills, programs that want to improve feedback performance among their faculty may wish to promote the teaching behaviors and proficiencies that are associated with high feedback scores identified in this study.
Adult↗
Morbidity and mortality conference, grand rounds, and the ACGME's core competencies.
Morbidity and Mortality (M&M) Conferences are an Accreditation Council for Graduate Medical Education (ACGME) mandated educational series that occur regularly at all institutions that have residency training programs. The potential for learning from medical errors, complications, and unanticipated outcomes is immense--provided that the focus is on education, as opposed to culpability. The education innovation described in this manuscript is the manner in which we have used the ACGME Outcome Project's 6 core competencies as the structure upon which the cases discussed at our M&M conference are framed. When presented at grand rounds in a novel format, M&M conference has not only maintained support for the quality improvement efforts in the Department, but has served to improve the educational impact of the conference.
Accreditation↗
A time to be promoted. The Prospective Study of Promotion in Academia (Prospective Study of Promotion in Academia).
OBJECTIVE: The study's objectives were to determine (1) the rate at which department of medicine faculty in the United States are promoted, (2) if clinician-educators (CEs) are promoted to Associate Professor at the same rate as clinician-investigators (CIs), and (3) the variables that predict promotion. METHODS: The Prospective Study of Promotion in Academia was a part-retrospective, part-prospective (from 2000 to 2003) cohort study. Six-hundred and four Internal Medicine junior faculty across the United States who had been registered as new appointees with the Association of American Medical Colleges in 1995 were invited to participate. Twenty-one percent of these had already left their institution when the study began. One hundred and eighty-three Internal Medicine faculty from 87 institutions in 35 states enrolled. The main outcome measure was the time from appointment as Assistant Professor to promotion to Associate Professor. RESULTS: Follow-up was complete for all 183 faculty. Among the faculty that achieved promotion, the estimated median time to promotion was 6.0 years (95% Conf. Int.=5.8 to 6.2). The unadjusted sixth-year promotion rate for CEs was 16%, while for CIs it was 26% (P=.002). Independent negative predictors of promotion included low amount of research time (Hazard Ratio [HR] =0.3, 95% Conf. Int.=0.2 to 0.5), having a manuscript review service (HR=0.4, 95% Conf. Int.=0.2 to 0.7), never meeting with Chairman/Chief about promotion (HR=0.4, 95% Conf. Int.=0.2 to 0.7), low job satisfaction (HR=0.5, 95% Conf. Int.=0.3 to 0.9), and working in the Northeast (HR=0.6, 95% Conf. Int.=0.4 to 1.1). Positive predictors included making between 130 dollars and 149,000 dollars per year (HR=1.9, 95% Conf. Int.=1.1 to 3.4), working more than 60 h/wk (HR=1.9, 95% Conf. Int.=1.1 to 3.0), having a career mentor available (HR=1.8, 95% Conf. Int.=1.1 to 2.9), and having access to a grant office (HR=1.6, 95% Conf. Int.=1.0 to 2.6). CONCLUSION: CEs and CIs appear to be promoted at different rates. The characteristics that are independently associated with earlier promotion may be helpful for institutions and individual faculty that are committed to achieving promotion efficiently.
Adult↗
Costs and funding for published medical education research.
CONTEXT: The Institute of Medicine has called for increased rigor of education research and funding to support educational innovation. However, funding for medical education research is scarce. The costs of conducting studies in medical education and how such research is currently funded have not been systematically evaluated. OBJECTIVES: To determine how medical education research studies that were recently published were funded and to approximate the costs of conducting these studies. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional survey of first authors of medical education studies published from September 1, 2002, to December 31, 2003. Original medical education research studies conducted at US institutions and published in 13 prominent peer-reviewed journals were included. MAIN OUTCOME MEASURES: For each study we measured duration, percentage of the authors' total work commitment ("percentage effort") devoted to the study, resources used and their costs, attainment of funding, and the first author's estimated cost of conducting the study. The cost of each study was calculated by multiplying the percentage effort of each author for the duration of the study by the national median salary for each author, according to specialty and academic rank, and then adding the costs of resources used. RESULTS: Responses were received from authors of 243 (84%) of 290 identified medical education studies. The median calculated cost of conducting the 243 studies was 24,471 dollars (interquartile range [IQR], 11,531 dollars-63 808 dollars). The median authors' estimate of study cost was 10,000 dollars (IQR, 4000 dollars-25 000 dollars). Some funding was obtained for 72 (29.6%) of the studies. Of studies that were funded, the median amount of funding was 15,000 dollars (IQR, 5000 dollars-66,500 dollars). The median calculated cost of funded studies was 37,315 dollars (IQR, 18,731 dollars-82,393 dollars). Private foundation grants were the most common funding source (n = 30 [41.7%]). Factors independently associated with attaining funding were training in grant writing (odds ratio, 2.05; 95% confidence interval, 1.11-3.79) and number of medical education studies published by the first author (odds ratio, 2.4; 95% confidence interval, 1.24-4.63). CONCLUSIONS: The majority of published medical education research is not formally funded, and the studies that do receive support are substantially underfunded. To realize the Institute of Medicine's directive and to improve the quality of medical research, policy reform that increases funding for medical education scholarship will likely be required.
Costs and Cost Analysis↗
Challenges in systematic reviews of educational intervention studies.
Educators have recognized the need to apply evidence-based approaches to medical training. To do so, medical educators must have access to reliable evidence on the impact of educational interventions. This paper describes 5 methodologic challenges to performing systematic reviews of educational interventions for health care professionals: finding reports of medical education interventions, assessing quality of study designs, assessing the scope of interventions, assessing the evaluation of interventions, and synthesizing the results of educational interventions. We offer suggestions for addressing these challenges and make recommendations for reporting, reviewing, and appraising interventions in medical education.
Education, Medical↗
52 precepts that medical trainees and physicians should consider regularly.
Being a physician is rewarding but also challenging in the complex health care system. As physicians, we are continually trying to deliver more effective and higher quality care to our patients. With improvement in mind, a list of precepts has been generated as a tool to remind all of us in clinical medicine about the exemplary characteristics, behaviors, and attitudes that are expected as the norm in this profession. The list is organized into four categories: promotion of relationships with patients, principles of the effective clinician, growth and improvement, and values to guide one's career in medicine. The list is envisioned as an instrument that may be helpful to medical learners and physicians by promoting reflection about ways to consistently perform at a high level while more fully appreciating the joy of practicing medicine. The list of precepts may also be useful to medical educators who wish to successfully mold the physicians of tomorrow.
Attitude of Health Personnel↗
What interns talk about.
Peer education is an important component of residency training and it generally takes the form of informal discussions. Residents may also prepare more formal presentations for their peers and analysing the topics they choose to address can serve as a form of needs assessment by giving faculty insight into the content they believe should be taught. At our internal medicine residency program, interns participating in an evidence-based medicine rotation make a formal 30-minute presentation on the topic of their choosing. We reviewed the Power Point slides from 88 presentations given over the past 6 years and have characterized the topics that were covered. Many of the talks were innovative and dealt with subject matter not covered elsewhere in the residency curriculum. Providing housestaff with more opportunities to formally teach each other may improve the educational experience of residency training.
Baltimore↗
Long-term follow-up of a longitudinal faculty development program in teaching skills.
BACKGROUND: The long-term impact of longitudinal faculty development programs (FDPs) is not well understood. OBJECTIVE: To follow up past participants in the Johns Hopkins Faculty Development Program in Teaching Skills and members of a comparison group in an effort to describe the long-term impact of the program. DESIGN AND PARTICIPANTS: In July 2002, we surveyed all 242 participants in the program from 1987 through 2000, and 121 members of a comparison group selected by participants as they entered the program from 1988 through 1995. MEASUREMENTS: Professional characteristics, scholarly activity, teaching activity, teaching proficiency, and teaching behaviors. RESULTS: Two hundred participants (83%) and 99 nonparticipants (82%) responded. When participants and nonparticipants from 1988 to 1995 were compared, participants were more likely to have taught medical students and house officers in the last year (both P<.05). Participants rated their proficiency for giving feedback more highly (P<.05). Participants scored higher than nonparticipants for 14 out of 15 behaviors related to being learner centered, building a supportive learning environment, giving and receiving feedback, and being effective leaders, half of which were statistically significant (P<.05). When remote and recent participants from 1987 through 2000 were compared with each other, few differences were found. CONCLUSIONS: Participation in the longitudinal FDP was associated with continued teaching activities, desirable teaching behaviors, and higher self-assessments related to giving feedback and learner centeredness. Institutions should consider supporting faculty wishing to participate in FDPs in teaching skills.
Adult↗
Completing a scholarly project during residency training. Perspectives of residents who have been successful.
BACKGROUND: Resident research has potential benefits and scholarly activity is an internal medicine residency training requirement. This study sought to learn about the resources needed and the barriers to performing scholarly work during residency from residents who had been successful. METHODS: A questionnaire was delivered to 138 internal medicine residents presenting their work at the 2002 American College of Physicians-American Society of Internal Medicine annual session. Residents were asked to comment on why they had participated in a scholarly project, the skills and resources needed to complete the project, as well as the barriers. Comparisons were made between residents who presented a research abstract and those who exhibited a clinical vignette. RESULTS: Seventy-three residents (53%) completed the questionnaire. Thirty-nine residents presented a clinical vignette and 34 displayed a research abstract. Residents participated in research for a variety of reasons, including intellectual curiosity (73%), career development (60%), and to fulfill a mandatory scholarly activity requirement at their residency program (32%). The most common barriers were insufficient time (79%), inadequate research skills (45%), and lack of a research curriculum (44%). Residents who had presented research abstracts devoted more time (median, 200 vs 50 hours; P<.05) to their project than those who exhibited clinical vignettes. Sixty-nine percent of residents thought research should be a residency requirement. CONCLUSIONS: The majority of respondents reported that their scholarly project was a worthwhile experience despite considerable barriers. Teaching research skills more explicitly with a focused curriculum and providing adequate protected time may enable residents to be successful.
Biomedical Research↗
Resident research and scholarly activity in internal medicine residency training programs.
OBJECTIVES: 1) To describe how internal medicine residency programs fulfill the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity training requirement including the current context of resident scholarly work, and 2) to compare findings between university and nonuniversity programs. DESIGN: Cross-sectional mailed survey. SETTING: ACGME-accredited internal medicine residency programs. PARTICIPANTS: Internal medicine residency program directors. MEASUREMENTS: Data were collected on 1) interpretation of the scholarly activity requirement, 2) support for resident scholarship, 3) scholarly activities of residents, 4) attitudes toward resident research, and 5) program characteristics. University and nonuniversity programs were compared. MAIN RESULTS: The response rate was 78%. Most residents completed a topic review with presentation (median, 100%) to fulfill the requirement. Residents at nonuniversity programs were more likely to complete case reports (median, 40% vs 25%; P=.04) and present at local or regional meetings (median, 25% vs 20%; P=.01), and were just as likely to conduct hypothesis-driven research (median, 20% vs 20%; P=.75) and present nationally (median, 10% vs 5%; P=.10) as residents at university programs. Nonuniversity programs were more likely to report lack of faculty mentors (61% vs 31%; P<.001) and resident interest (55% vs 40%; P=.01) as major barriers to resident scholarship. Programs support resident scholarship through research curricula (47%), funding (46%), and protected time (32%). CONCLUSIONS: Internal medicine residents complete a variety of projects to fulfill the scholarly activity requirement. Nonuniversity programs are doing as much as university programs in meeting the requirement and supporting resident scholarship despite reporting significant barriers.
Adult↗
Factors associated with citation of internal medicine residency programs for lack of scholarly activity.
BACKGROUND: The Accreditation Council for Graduate Medical Education requires that residents demonstrate scholarly activity prior to completion of training. PURPOSE: To determine which factors are associated with program citation for failure to comply with the Residency Review Committee (RRC) scholarly activity requirement for internal medicine residencies. METHODS: All 391 internal medicine residency program directors were surveyed in March 2002. Data were collected on program characteristics and factors (research curriculum, research director, faculty mentors, protected time for research, funding, and presence of a mandatory research requirement) that have been associated with successful resident research. Multiple logistic regression analysis identified factors associated with citation. RESULTS: The response rate was 78%. Ten percent of respondents report having been cited for lack of demonstration of scholarly activity. Factors that reduced the odds of citation were being a university-based program, odds ratio (OR) 0.13, 95% confidence interval (CI) 0.03-0.54, p = .005; having a greater number of residents, OR 0.95, 95% CI 0.93-0.98, p = .001; and having funding to support resident scholarship, OR 0.39, 95% CI 0.17-0.91, p = .03. Using multiple logistic regression analysis, having designated funding for resident scholarship was the only factor independently associated with a decreased odds of citation, OR 0.27, 95% CI 0.10-0.72, p = .009. CONCLUSIONS: To improve compliance with the RRC requirement for scholarly activity and avoid citation, residency programs may wish to consider devoting more resources, particularly money, to support resident scholarly activity.
Accreditation↗
Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis.
CONTEXT: Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF). OBJECTIVE: To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs. DATA SOURCES: We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field. STUDY SELECTION: We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age > or =55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome. DATA EXTRACTION: Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner. DATA SYNTHESIS: Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P =.60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P =.01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-359 dollars [95% CI, -763 dollars to 45 dollars]; n = 4, P =.10 for non-US trials and -536 dollars [95% CI, -956 dollars to -115 dollars]; n = 4, P =.03, for US trials). CONCLUSION: Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.
Aged↗