Predictive value of letters of recommendation vs questionnaires for emergency medicine resident performance

OBJECTIVE: To evaluate the predictive value of standard letters of recommendation (LORs) vs preprinted questionnaires (PPQs) for resident performance at one emergency medicine (EM) residency program. METHODS: A retrospective association of LORs and PPQs with in-training residents performance ratings was done at one EM residency program. The residency application files of EM residents who completed the program were reviewed to locate files that had LORs and PPQs written by the same author. Seventeen resident files contained 32 LOR/PPQ pairs. These LORs and PPQs were submitted in a blinded fashion to 3 outside EM residency directors. Each LOR and PPQ was evaluated for the applicant's suitability for the specialty of EM, medical knowledge, procedural skills, interpersonal skills, motivation, and overall rank. The scores given by the outside reviewers were compared with resident performance ratings determined by 5 EM attending physicians who evaluated the residents along the same 6 dimensional ratings. RESULTS: Statistically, no differences were found between the LORs and PPQs in predicting resident performance. CONCLUSIONS: PPQs may substitute for LORs in the evaluation of resident applicants.     

A strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study

PURPOSE: To use a controlled, randomized design to assess the effect on patient satisfaction of an intensive psychosocial training program for residents. METHOD: Twenty-six first-year residents, in two internal medicine and family practice community-based programs affiliated with the Michigan State University College of Human Medicine, were randomly assigned during 1991 and 1992 to a control group or a one-month intensive training program. Experiential teaching focused on many psychosocial skills required in primary care. A 29-item questionnaire administered before and after the residents' training evaluated their patients' satisfaction regarding patient disclosure, physician empathy, confidence in physician, general satisfaction, and comparison of the physician with other physicians. Analyses of covariance with groups and gender as factors and pre-training patient satisfaction scores as the covariate evaluated the effect of the training. RESULTS: The patients of the trained residents expressed more confidence in their physicians (p = .01) and more general satisfaction (p = .02) than did the patients of controls. The effect of training on patient satisfaction with patient disclosure (p < .01) and physician empathy (p < .05) was greater for female than for male residents. CONCLUSION: The intensive psychosocial training program for residents improved their patients' satisfaction.     

Employment-seeking experiences of resident physicians completing training during 1996

CONTEXT: Studies analyzing the physician workforce have concluded that the United States is verging on a physician oversupply, yet we lack persuasive evidence that this is resulting in physician underemployment and/or unemployment. OBJECTIVE: To determine the degree to which graduating residents have difficulty finding or are unable to find employment in their primary career choices. DESIGN: Two 1-page surveys sent separately to residents and to program directors to collect information on the employment status of residents who were completing a graduate medical education program at the end of the 1995-1996 academic year. SETTING: A total of 25 067 resident physicians scheduled in the spring of 1996 to complete a residency program accredited by the Accreditation Council on Graduate Medical Education, and 4569 program directors in 31 specialties and subspecialties. MAIN OUTCOME MEASURE: Both the graduates' employment status and the degree of difficulty they experienced securing a practice position, as reported by resident physicians and program directors. RESULTS: After 6 months of data collection, 12135 (48.4%) of 25 067 resident physicians responded to the survey. Of the respondents, 11 200 had completed their training, and 7628 (68.1%) were attempting to enter the workforce, 28.4% were seeking additional training, and 3.5% were fulfilling their military obligations. Of the 7628 resident physicians who sought employment, 67.3% obtained clinical practice positions in their specialties, 15.5% took academic positions, 5.0% found clinical positions in other specialties, 5.1% had other plans, and 7.1% did not yet have positions but were actively looking. In addition, 22.4% of resident physicians who found clinical positions reported significant difficulty finding them. The subgroup reporting greater difficulty finding clinical positions included international medical graduates (more than 40%),those completing programs in the Pacific or East North Central region, and those in several specialties. The 1996 graduating residents reported significantly higher rates of difficulty finding suitable employment than program directors reported for their graduates (22.4% vs 6.0%); however, the percentage of graduates reported by both groups as entering the workforce was the same (68.1%). Program directors reported an unemployment rate of only 1.2%, for their 1996 graduates, which was less than the rate reported by the resident physicians (7.1%). CONCLUSIONS: Resident physicians' direct reports of their employment-seeking experiences differ from what program directors report. Program directors accurately determined the number of residents pursuing further training; however, they did not have complete information about the employment difficulties experienced by their graduates. Based on graduates' reports, we conclude that employment difficulties are greatest among international medical graduates and vary by specialty and geographic region.     

Utilization of outpatient diagnostic imaging. Does the physician's gender play a role?

OBJECTIVE: To examine physician and patient characteristics related to the ordering of imaging studies in a general medicine practice and to determine whether physician gender influences ordering patterns. DESIGN: Retrospective cohort study. SETTING: Hospital-based academic general medicine practice of 29 attending physicians. PATIENTS: All 8,203 visits by 5,011 patients during a 6-month period. METHODS: For each visit the following variables were abstracted from the electronic patient record: patient age, patient gender, visit urgency, visit type, and physician seen. All diagnostic imaging studies performed within 30 days of each outpatient visit were identified from the hospital's Radiology Information System. Screening mammography was not included in the analysis. Physician variables included gender and years since medical school graduation. Logistic regression analysis was used to evaluate the effect of various patient, physician, and visit characteristics on the probability of a diagnostic imaging study being ordered. RESULTS: Patient age, urgent visits, visit frequency, and the gender of the physician were all significantly related to the ordering of an imaging study. Correcting for all other factors, the ordering of an imaging study during an outpatient medical visit was 40% more likely if the physician was female (odds ratio = 1.40; 95% confidence interval [CI] 1.01, 1.95). Female physicians were 62% more likely (95% CI 0.99, 2.64) than male physicians to order an imaging study for a male patient and 21% more likely (95% CI 0.87, 1.69) to order an imaging study for a female patient. CONCLUSIONS: Physician gender is a predictor of whether an outpatient medical visit generates an imaging study. Reasons for this observation are unclear, but may be the result of different practice styles of male and female physicians or unmeasured patient characteristics.     

Instructional intranets in graduate medical education

Changes in medicine, medical education, and technology have influenced graduate medical education (GME) and have altered many traditional concepts of resident training. Three issues in particular have led to changes. The first is the shortage of time that academic and community physicians have to devote to medical teaching because of the demands to bring in revenue through clinical practice. The second is the limited exposure that residents have to various medical conditions due to a shift in training venues from hospitals to ambulatory care settings. Last is residents' lack of training in using information technologies. The resultant deficits the exist in GME make it more difficult for residents to practice medicine in the most efficient manner. Hence, there is a need for health care professionals' education to address the coming demands of the 21st century. Instructional computer technology can be useful in bridging this gap. Intranets, internal organizational networks, are private versions of the World Wide Web that are often available only to members of a particular organization. This paper reviews changes in medicine and medical education, describes how instructional intranets can be incorporated into GME, and discusses the impact intranet and Internet technologies can have on GME.     

Residents' experiences of abuse, discrimination and sexual harassment during residency training. McMaster University Residency Training Programs

OBJECTIVE: To assess the prevalence of psychological abuse, physical assault, and discrimination on the basis of gender and sexual orientation, and to examine the prevalence and impact of sexual harassment in residency training programs. DESIGN: Self-administered questionnaire. SETTING: McMaster University, Hamilton, Ont. PARTICIPANTS: Residents in seven residency training programs during the academic year from July 1993 to June 1994. Of 225 residents 186 (82.7%) returned a completed questionnaire, and 50% of the respondents were women. OUTCOME MEASURES: Prevalence of psychological abuse, physical assault and discrimination on the basis of gender and sexual orientation experienced by residents during medical training, prevalence and residents' perceived frequency of sexual harassment. RESULTS: Psychological abuse was reported by 50% of the residents. Some of the respondents reported physical assault, mostly by patients and their family members (14.7% reported assaults by male patients and family members, 9.8% reported assaults by female patients and family members), 5.4% of the female respondents reported assault by male supervising physicians. Discrimination on the basis of gender was reported to be common and was experienced significantly more often by female residents than by male residents (p < 0.01). Ten respondents, all female, reported having experienced discrimination on the basis of their sexual orientation. Most of the respondents experienced sexual harassment, especially in the form of sexist jokes, flirtation and unwanted compliments on their dress or figure. On average, 40% of the respondents, especially women (p < 0.01), reported experiencing offensive body language and receiving sexist teaching material and unwanted compliments on their dress. Significantly more female respondents than male respondents stated that they had reported events of sexual harassment to someone (p < 0.001). The most frequent emotional reactions to sexual harassment were embarassment (reported by 24.0%), anger (by 23.4%) and frustration (20.8%). CONCLUSION: Psychological abuse, discrimination on the basis of gender and sexual harassment are commonly experienced by residents in training programs. A direct, progressive, multidisciplinary approach is needed to label and address these problems.     

Palmitoylation of the rat mu opioid receptor

We describe a structured and uniform resident experience in operative endoscopy and analyze the costs of implementing such a program at an urban academic medical center. The residency curriculum at Northwestern Memorial Hospital incorporates a five-part approach to endoscopy training: weekly endoscopy rounds, an annual animal laboratory for residents, an individual animal laboratory, supervision by skilled endoscopic surgeons, and a laparoscopic training facility. Thirty-two residents have completed the training over 4 years. The annual cost of the entire program is $34,500, which can be offset partially by vendor support. A comprehensive and continuous endoscopic training program is an important and affordable part of resident education.     

Internal medicine training in ambulatory gynecology. A house of staff survey

OBJECTIVES: Practicing internists commonly provide gynecologic care, yet internists receive little formal training in ambulatory gynecology. To evaluate current residency training, we surveyed house staff perceptions of their training in gynecology. METHODS: Data were collected from house staff at five Portland, Ore, internal medicine training programs by questionnaire using a Likert scale about training in 24 gynecologic and five nongynecologic internal medicine problems. Responses were compared by level of training, institution, and gender. RESULTS: Responses were received from 195 (89%) of 221 residents. House staff reported less than adequate training in gynecology, particularly in the areas of family planning and medical complications of pregnancy, while reporting much superior training in the traditional medicine problems. CONCLUSIONS: House staff in internal medicine report little training in the diagnosis and treatment of gynecologic problems. Training in family planning may be particularly deficient. Residency programs must seek effective teaching strategies to address this deficiency.     

Factors associated with family physicians' involvement in research in Israel

OBJECTIVES: To identify the factors that encourage or deter family medicine physicians and residents in Israel from participating in research. METHOD: In October 1995, a questionnaire containing items on demographic variables, research attitudes, and academic and research activities in primary care settings was mailed to a random sample of 200 family medicine physicians and residents (out of approximately 600) employed by the General Sick Fund, the largest health maintenance organization in Israel. The questionnaire also contained items regarding difficulties in participating in research and asked for opinions about several general statements about research in family practice. RESULTS: In all, 190 physicians responded, for a response rate of 95%. Based on their responses, the respondents were divided into four groups by amount of research involvement. Univariate analysis using the chi-square test was used for the comparison of variables among the four groups. The respondents reporting greater knowledge of and involvement in research were, by and large, men (p = .01) who were qualified specialists with academic status (p < .00001). They also taught students (p = .0005) and residents (p < .0005), participated in more conferences (p < .0005), and while in residency training had had a mentor who encouraged involvement in research (p = .0001). CONCLUSION: Research is essential to family medicine with regard to both primary care practice and academic activities, its development, however, has been inhibited. Given the results of this preliminary study, family medicine residency programs would be well advised to assign a research mentor to every resident; also, time and resources should be devoted to research in postgraduate training programs. Perhaps more important, women physicians in Israel should be encouraged to participate more actively in research, and support for them in their special needs should be made available.     

Provider training for patient-centered alcohol counseling in a primary care setting

OBJECTIVE: To assess the impact of a brief training program on primary care providers' skills, attitudes, and knowledge regarding high-risk and problem drinking. DESIGN: Training plus pretesting and posttesting for program efficacy. SETTING: Ambulatory primary care clinic; academic medical center. PARTICIPANTS: Fourteen attending physicians, 12 residents, and 5 nurse practitioners were randomized by clinical team affiliation to a Special Intervention or usual care condition of a larger study. We report the results of the training program for the Special Intervention providers. INTERVENTION: Providers received a 2-hour group training session plus a 10- to 20-minute individual tutorial session 2 to 6 weeks after the group session. The training focused on teaching providers how to perform patient-centered counseling for high-risk and problem drinkers. MAIN OUTCOME MEASURES: Alcohol counseling skills; attitudes regarding preparedness to intervene and perceived importance and usefulness of intervening with high-risk and problem drinkers; and knowledge of the nature, prevalence, and appropriate treatment of alcohol abuse in primary care populations. RESULTS: After training, providers scored significantly higher on measures of counseling skills, preparedness to intervene, perceived usefulness and importance of intervening, and knowledge. CONCLUSION: A group training program plus brief individual feedback can significantly improve primary care providers' counseling skills, attitudes, and knowledge regarding high-risk and problem drinkers.     

A randomized study of a pH sensor feeding tube vs a standard feeding tube in patients requiring enteral nutrition

RATIONALE AND OBJECTIVES: A survey of chief residents of academic radiology programs is conducted annually on behalf of the American Association of Academic Chief Residents in Radiology (A3CR2). Data are obtained to improve the training of diagnostic radiology residents and to increase the understanding of radiologists and their associates about issues of interest to radiologists in training. METHODS: Questionnaires were mailed to 133 accredited programs in the United States and Canada. A wide variety of demographic and common interest questions were asked. The analysis took into account geographic location of the responders and the size of the residency program. Comparisons were made to the data from prior years. RESULTS: Completed surveys from 93 programs (70%) were returned. The percentage of women residents is increasing. Important regional and size variations exist in several areas including salary, workload, prior clinical training, resident/fellow ratios, post residency plans, and call schedules. Although many chief residents feel knowledgeable about the health care system, opinions about the future of radiology and medical care are tentative. CONCLUSIONS: This survey provides important demographic information about academic radiology residency programs. The summary information regarding plans for fellowship training, resident call schedules, and opinions about socioeconomic issues may be useful for chief residents, program directors, and departmental chairmen.     

Elevated soluble fas production in SLE correlates with HLA status not with disease activity

CONTEXT: Medical educators have had a growing sense that proficiency in physical diagnostic skills is waning, but few data have examined the question critically. OBJECTIVE, DESIGN, AND SETTING: To compare the cardiac auscultatory proficiency of medical students and physicians in training. A multicenter cross-sectional assessment of students and house staff. A total of 8 internal medicine and 23 family practice programs of the mid-Atlantic area. PARTICIPANTS: A total of 453 physicians in training and 88 medical students. INTERVENTIONS: All participants listened to 12 cardiac events directly recorded from patients, which they identified by completing a multiple-choice questionnaire. MAIN OUTCOME MEASURES: scores were expressed as the percentage of participants, for year and type of training, who correctly identified each event. Cumulative scores were expressed as the total number of events correctly recognized. An adjusted score was calculated whenever participants selected not only the correct finding but also findings that are acoustically similar and yet absent. RESULTS: Trainees' cumulative scores ranged between 0 and 7 for both internal medicine and family practice residents (median, 2.5 and 2.0, respectively). Internal medicine residents had the highest cumulative adjusted scores for the 6 extra sounds and for all 12 cardiac events tested (P=.01 and .02, respectively). On average, internal medicine and family practice residents recognized 20% of all cardiac events; the number of correct identifications improved little with year of training and was not significantly higher than the number identified by medical students. CONCLUSIONS: Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events. This study suggests a need to improve the teaching and assessment of cardiac auscultation during generalists' training, particularly with the advent of managed care and its search for more cost-effective uses of technology.     

Physical diagnosis skills of physicians in training: a focused assessment

OBJECTIVE: To assess the proficiency of emergency medicine (EM) trainees in the recognition of physical findings pertinent to the care of the critically ill patient. METHODS: Fourteen medical students, 63 internal medicine (IM) residents, and 47 EM residents from three university-affiliated programs in Philadelphia were tested. Proficiency in physical diagnosis was assessed by a multimedia questionnaire targeting findings useful in emergencies or related to diseases frequently encountered in the ED. Attitudes toward diagnosis not based on technology, teaching practices of physical examination during EM training, and self-motivated learning of physical diagnosis also were assessed for all the EM trainees. RESULTS: With the exception of ophthalmology, the EM trainees were never significantly better than the senior students or the IM residents. They were less proficient than the IM residents in cardiology, and not significantly different from the IM residents in all other areas. For no organ system tested, however, did they achieve less than a 42.9% error rate (range: 42.9-72.3%, median = 54.8%). There was no significant improvement in proficiency over the three years of customary EM training. The EM residents who had received supervised teaching in physical diagnosis during training achieved a significantly higher cumulative score. The EM residents attributed great clinical importance to physical diagnosis and wished for more time devoted to its teaching. CONCLUSIONS: These data confirm the recently reported deficiencies of physical diagnosis skills among physicians in training. The results are particularly disturbing because they relate to EM trainees and concern skills useful in the ED. Physical diagnosis should gain more attention in both medical schools and residency programs.     

Decrease of insulin resistance after splenectomy in a diabetic patient with liver cirrhosis and portal hypertension. Physiopathologic evaluation

OBJECTIVE: To evaluate the effects of a course in physical diagnosis on the knowledge, skills, and attitudes of internal medicine trainees. DESIGN: A controlled, prospective assignment of housestaff to a year-long curricular program, linked to a set of pre- and posttests. Houseofficers who could not attend the teaching sessions functioned as control subjects. SETTING: An internal medicine training program at an urban medical school. SUBJECTS: 56 (86.1%) of 65 eligible internal medicine housestaff (post-graduate years 1 through 3) participated in the intervention and assessment. A comparison group of 14 senior medical students participated in the pretest. INTERVENTION: 12 monthly lectures emphasizing skills useful in emergencies or validated by the literature. MEASUREMENTS: The pre- and posttests included: 1) a multiple-choice questionnaire to assess knowledge; 2) professional standardized patients to assess selected skills; and 3) Likert-type questionnaires to assess self-motivated learning and attitude toward diagnosis not based on technology. MAIN RESULTS: The residents expressed interest in the program and on a six-point scale rated the usefulness of lectures and standardized patients as 3.5 +/- 1.3 and 4.3 +/- 1, respectively. For no system tested, however, did they achieve more than 55.2% correct answers (range: 24.2%-55.2%, median = 41.04), and their performance did not differ from that of the fourth-year medical students. There was no significant difference in pre/posttest improvement between the control and intervention groups. CONCLUSIONS: These data confirm the deficiencies of physical diagnostic skills and knowledge among physicians in training. These deficiencies were not corrected by the classroom lecture series. Improvement in these skills may require a more intense experiential program made part of residency requirements.     

Female medical leadership: cross sectional study

OBJECTIVE: To assess the relation between male and female medical leadership. DESIGN: Cross sectional study on predictive factors for female medical leadership with data on sex, age, specialty, and occupational status of Norwegian physicians. SETTING: Oslo, Norway. SUBJECTS: 13 844 non-retired Norwegian physicians. MAIN OUTCOME MEASURE: Medical leaders, defined as physicians holding a leading position in hospital medicine, public health, academic medicine, or private health care. RESULTS: 14.6% (95% confidence interval 14.0% to 15.4%) of the men were leaders compared with 5.1% (4.4% to 5.9%) of the women. Adjusted for age men had a higher estimated probability of leadership in all categories of age and job, the highest being in academic medicine with 0.57 (0.42 to 0.72) for men aged over 54 years compared with 0.39 (0.21 to 0.63) for women in the same category. Among female hospital physicians there was a positive relation between the proportion of women in their specialty and the probability of leadership. CONCLUSION: Women do not reach senior positions as easily as men. Medical specialties with high proportions of women have more female leaders.     

Oral anticoagulation in dental surgery

STUDY OBJECTIVES: To evaluate whether pediatric or emergency medicine residents exhibit a bias when they select patients from triage based on the chief complaint, ie, medical versus surgical in the pediatric emergency department (PED). DESIGN: A retrospective chart review of a convenience sample of consecutive patients, excluding those seen during times when both pediatric and emergency medicine residents were not simultaneously present. SETTING: Urban Municipal PED with 25,000 visits annually. TYPE OF PARTICIPANTS: Pediatric residents, emergency medicine residents, and medical students rotating through the PED and their supervising attending physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five hundred and ninety-nine charts were included in the study. On the basis of the triage complaint the initial diagnosis was classified as either surgical or medical. Surgical diagnoses were assigned to those patients who required a surgical procedure, involved a surgical subspecialty or were victims of trauma and represented 151 (25.2%) of the patients seen. Medical diagnoses were assigned to the nonsurgical patients and represented 448 (74.8%) of the patients seen. There are roughly three pediatric residents to each emergency resident working in our PED. Of the 367 patients seen by the pediatric residents, 73 (19.9%) had surgical diagnoses, and 294 (80.1%) had medical diagnoses. Of the 158 patients seen by the emergency residents, 59 (37.3%) had surgical diagnoses and 99 (62.7%) had medical diagnoses. chi2 analysis was used to compare categorical variables. The P value was considered significant at <0.05. DISCUSSION: Residents, both pediatric and emergency medicine, were instructed to see patients based upon the severity of the patient illness as judged by the triage nurse unless the patients' illnesses were of equal severity, in which case they were to be seen in the order in which they presented. The null hypothesis was that in the absence of physician bias, both pediatric and emergency medicine residents would see the same proportion of surgical and medical patients. The results showed that a bias exists. Emergency medicine residents saw a greater proportion of surgical patients, and pediatric residents saw a greater proportion of general medical patients. A limitation of this study may be the that the supervising attending physician selected residents to see certain patients to expedite PED flow. CONCLUSIONS: Recognizing that bias in the selection of patients seen exists is important in ensuring a balanced education experience.     

Relation of family responsibilities and gender to the productivity and career satisfaction of medical faculty

BACKGROUND: Studies have found that female faculty publish less, have slower career progress, and generally have a more difficult time in academic careers than male faculty. The relation of family (dependent) responsibilities to gender and academic productivity is unclear. OBJECTIVE: To describe dependent responsibilities by gender and to identify their relation to the aspirations, goals, rate of progress, academic productivity, and career satisfaction of male and female medical school faculty. DESIGN: 177-item survey questionnaire. SETTING: 24 randomly selected medical schools in the contiguous United States. PARTICIPANTS: 1979 respondents from a probability sample of full-time academic medical school faculty. MEASUREMENTS: The main end point for measuring academic productivity was the total number of publications in refereed journals. Perceived career progress and career satisfaction were assessed by using Likert scales. RESULTS: For both male and female faculty, more than 90% of time devoted to family responsibilities was spent on child care. Among faculty with children, women had greater obstacles to academic careers and less institutional support, including research funding from their institutions (46% compared with 57%; P < 0.001) and secretarial support (0.68 full-time equivalents compared with 0.83 full-time equivalents; P = 0.003), than men. Compared with men with children, women with children had fewer publications (18.3 compared with 29.3; P < 0.001), slower self-perceived career progress (2.6 compared with 3.1; P < 0.001), and lower career satisfaction (5.9 compared with 6.6; P < 0.001). However, no significant differences between the sexes were seen for faculty without children. CONCLUSIONS: Compared with female faculty without children and compared with men, female faculty with children face major obstacles in academic careers. Some of these obstacles can be easily modified (for example, by eliminating after-hours meetings and creating part-time career tracks). Medical schools should address these obstacles and provide support for faculty with children.