Are residents' decisions influenced more by a decision aid or a specialist's opinion? A randomized controlled trial

BACKGROUND

Physicians are reluctant to use decision aids despite their ability to improve care. A potential reason may be that physicians do not believe decision aid advice.

OBJECTIVE

To determine whether internal medicine residents lend more credence to contradictory decision aid or human advice.

DESIGN

Randomized controlled trial. Residents read a scenario of a patient with community-acquired pneumonia and were asked whether they would admit the patient to the intensive care unit or the floor. Residents were randomized to receive contrary advice from either a referenced decision aid or an anonymous pulmonologist. They were then asked, in light of this new information, where they would admit the patient.

PARTICIPANTS

One hundred eight internal medicine residents.

MEASUREMENTS

The percentage of residents who changed their admission location and the change in confidence in the decision.

MAIN RESULTS

Residents were more likely to change their original admission location (OR 2.3, 95% CI 1.04 to 5.1, P = 0.04) and to reduce their confidence in the decision (adjusted difference between means -12.9%, 95% CI -3.0% to -22.8%, P = 0.011) in response to the referenced decision aid than to the anonymous pulmonologist. Confidence in their decision was more likely to change if they initially chose to admit the patient to the floor.

CONCLUSIONS

In a hypothetical case of community-acquired pneumonia, physicians were influenced more by contrary advice from a referenced decision aid than an anonymous specialist. Whether this holds for advice from a respected specialist or in actual practice remains to be studied.

Adolescent medicine: attitudes, training, and experience of pediatric, family medicine, and obstetric-gynecology residents

PURPOSE

Several studies have documented a deficiency in the delivery of preventive services to adolescents during physician visits in the United States. This study sought to assess and compare pediatric, family medicine (FM), and obstetrics and gynecology (OB/GYN) resident perceptions of their responsibility, training, and experience with providing comprehensive health care services to adolescents.

METHODS

A 57-item, close-ended survey was designed and administered to assess resident perceptions of the scope of their practice, training, and experience with providing adolescent health care across a series of health care categories.

RESULTS

Of the 87 respondents (31 OB/GYN, 29 FM, and 27 pediatric), most residents from all three fields felt that the full range of adolescent preventive and clinical services represented in the survey fell under their scope of practice. Residents from all three fields need more training and experience with mental health issues, referring teenagers to substance abuse treatment programs, and addressing physical and sexual abuse. In addition, OB-GYN residents reported deficiencies in training and experience regarding several preventive counseling and general health services, while pediatric residents reported deficiencies in training and experience regarding sexual health services.

CONCLUSIONS

Our results indicate that at this time, residents from these three specialties are not optimally prepared to provide the full range of recommended preventive and clinical services to adolescents.

Internal medicine resident self-report of factors associated with career decisions

BACKGROUND

Little is known about factors contributing to the career decisions of internal medicine residents.

OBJECTIVE

To evaluate factors self-reported by internal medicine residents nationally as important to their career decisions.

DESIGN

Cross-sectional survey conducted in October of 2005, 2006, and 2007 as part of the national Internal Medicine In-Training Examination (IM-ITE).

PARTICIPANTS

Postgraduate year 3 internal medicine residents taking the IM-ITE.

MEASUREMENTS

Residents rated the importance of nine factors in their career decisions on 5-point Likert scales. Univariate statistics characterized the distribution of responses. Associations between variables were evaluated using Cochran-Mantel-Haenszel statistics for ordinal data. Multivariate analyses were conducted using logistic regression.

RESULTS

Of 17,044 eligible residents taking the IM-ITE, 14,890 (87.4%) completed the career decision survey questions. Overall, time with family was the factor most commonly reported as of high or very high importance to career decisions (69.6%). Women were more likely to assign greatest importance to family time (OR 1.22, 95% confidence interval 1.12-1.31, p < 0.001) and long-term patient relationships (OR 1.34, 95% confidence interval 1.23-1.46, p < 0.001). Across debt levels, financial considerations were of greatest importance more often for residents owing >$150,000 (OR 1.33, 95% confidence interval 1.09-1.62, p < 0.001). Across specialties, mentor specialty was rated lowest in importance by residents pursuing hospitalist and general internal medicine careers.

CONCLUSIONS

Greater attention to factors reported by residents as important to their career decisions may assist efforts to optimize the distribution of physicians across disciplines. In addition to lifestyle and practice considerations, these factors may include mentor specialty. As this factor is less commonly reported as important by residents planning careers in generalist fields, attention to effective mentoring may be an important element of efforts to increase interest in these areas.

Scholarship opportunities for trainees and clinician educators: learning outcomes from a case report writing workshop

INTRODUCTION

Publishing a case report demonstrates scholarly productivity for trainees and clinician-educators.

AIM

To assess the learning outcomes from a case report writing workshop.

SETTING

Medical students, residents, fellows and clinician-educators attending a workshop.

PROGRAM DESCRIPTION

Case report writing workshop conducted nine times at different venues.

PROGRAM EVALUATION

Before and after each workshop, participants self-rated their perceived competence to write a case report, likelihood of submitting a case report to a meeting or for publication in the next 6-12 months, and perceived career benefit of writing a case report (on a five-point Likert scale). The 214 participants were from 3 countries and 27 states or provinces; most participants were trainees (64.5 %). Self-rated competence for writing a case report improved from a mean of 2.5 to 3.5 (a 0.99 increase; 95% CI, 0.88-1.12, p < 0.001). The perceived likelihood of submitting a case report, and the perceived career benefit of writing one, also showed statistically significant improvements (p = 0.002, p = 0.001; respectively). Nine of 98 participants published a case report 16-41 months after workshop completion.

DISCUSSION

The workshop increased participants' perception that they could present or publish a case report.

The postgraduate hospital educational environment measure (PHEEM) questionnaire identifies quality of instruction as a key factor predicting academic achievement

OBJECTIVE

This study analyzes the reliability of the PHEEM questionnaire translated into Portuguese. We present the results of PHEEM following distribution to doctors in three different medical residency programs at a university hospital in Brazil.

INTRODUCTION

Efforts to understand environmental factors that foster effective learning resulted in the development of a questionnaire to measure medical residents' perceptions of the level of autonomy, teaching quality and social support in their programs.

METHODS

The questionnaire was translated using the modified Brislin back-translation technique. Cronbach's alpha test was used to ensure good reliability and ANOVA was used to compare PHEEM results among residents from the Surgery, Anesthesiology and Internal Medicine departments. The Kappa coefficient was used as a measure of agreement, and factor analysis was employed to evaluate the construct strength of the three domains suggested by the original PHEEM questionnaire.

RESULTS

The PHEEM survey was completed by 306 medical residents and the resulting Cronbach's alpha was 0.899. The weighted Kappa was showed excellent reliability. Autonomy was rated most highly by Internal Medicine residents (63.7% +/- 13.6%). Teaching was rated highest in Anesthesiology (66.7% +/- 15.4%). Residents across the three areas had similar perceptions of social support (59.0% +/- 13.3% for Surgery; 60.5% +/- 13.6% for Internal Medicine; 61.4% +/- 14.4% for Anesthesiology). Factor analysis suggested that nine factors explained 58.9% of the variance.

CONCLUSIONS

This study indicates that PHEEM is a reliable instrument for measuring the quality of medical residency programs at a Brazilian teaching hospital. The results suggest that quality of teaching was the best indicator of overall response to the questionnaire.

Real-time EBM: from bed board to keyboard and back

BACKGROUND

To practice Evidence-Based Medicine (EBM), physicians must quickly retrieve evidence to inform medical decisions. Internal Medicine (IM) residents receive little formal education in electronic database searching, and have identified poor searching skills as a barrier to practicing EBM.

OBJECTIVE

To design and implement a database searching tutorial for IM residents on inpatient rotations and to evaluate its impact on residents' skill and comfort searching MEDLINE and filtered EBM resources.

DESIGN

Randomized controlled trial. Residents randomized to the searching tutorial met for up to 6 1-hour small group sessions to search for answers to questions about current hospitalized patients.

PARTICIPANTS

Second- and 3rd-year IM residents.

MEASUREMENTS

Residents in both groups completed an Objective Structured Searching Evaluation (OSSE), searching for primary evidence to answer 5 clinical questions. OSSE outcomes were the number of successful searches, search times, and techniques utilized. Participants also completed self-assessment surveys measuring frequency and comfort using EBM databases.

RESULTS

During the OSSE, residents who participated in the intervention utilized more searching techniques overall (p < .01) and used PubMed's Clinical Queries more often (p < .001) than control residents. Searching "success" and time per completed search did not differ between groups. Compared with controls, intervention residents reported greater comfort using MEDLINE (p < .05) and the Cochrane Library (p < .05) on post-intervention surveys. The groups did not differ in comfort using ACP Journal Club, or in self-reported frequency of use of any databases.

CONCLUSIONS

An inpatient EBM searching tutorial improved searching techniques of IM residents and resulted in increased comfort with MEDLINE and the Cochrane Library, but did not impact overall searching success.

Reduction and management of no-shows by family medicine residency practice exemplars

PURPOSE

We wanted to describe the methods used by family medicine residency practices with low no-show rates (rate exemplars) and those able to keep visit rates high despite no-shows (management exemplars).

METHODS

Program directors of US family medicine residency programs were asked to respond to a survey questionnaire. Telephone interviews were conducted with the administrators of rate exemplars (no-show rates of 10% or less) and management exemplars (average of 8 to 10 patient visits per half-day plus high administrator satisfaction with no-show management strategies).

RESULTS

Directors of 14 rate and 8 management exemplars, identified from among the 141 practices (31.5%) that returned the initial survey instrument, were interviewed and subsequently resurveyed. All of the rate exemplars used multiple strategies, including patient education, patient reminders, patient sanctions, and some degree of open-access scheduling. Practices that managed no-shows well encouraged walk-ins and work-ins and overbooked resident schedules either equally or based upon individual no-show rates. Practice exemplars of both types were highly committed to addressing the no-shows problem and were diligent about following their policies and procedures regarding no-shows.

CONCLUSION

Some family medicine residency practices are able to achieve low no-show rates or keep them from affecting practice volume. Those that do use combinations of well-established methods.

Do our newly graduated medical doctors have adequate knowledge about neonatal resuscitation?

CONTEXT AND OBJECTIVE

Neonatal resuscitation should be part of medical school curriculums. We aimed to evaluate medical school graduates' knowledge of neonatal resuscitation.

DESIGN AND SETTING

Cross-sectional study on the performance of candidates sitting a medical residency exam at Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, in 2004.

METHODS

There were two questions on neonatal resuscitation. One question in the theory test aimed at evaluating basic knowledge on the initial approach towards newly born infants. The question in the practical exam was designed to evaluate the candidate's ability to perform the initial steps of resuscitation and to establish bag-mask ventilation.

RESULTS

Out of 642 candidates from 74 medical schools, 151 (23.5%) answered the theory question correctly. Significantly more physicians from public medical schools in the State of São Paulo answered correctly than did those from other schools in Brazil (52.5% versus 9.2%; p < 0.05). A total of 436 candidates did the practical exam. The grades among graduates from medical schools belonging to the State of São Paulo were significantly higher than among those from other schools (5.9 +/- 2.6 versus 4.1 +/- 2.1; p < 0.001). The grades for the practical question among candidates who had answered the theory question correctly were significantly higher than those obtained by candidates who had given wrong answers (p < 0.05).

CONCLUSION

Medical school graduates' knowledge of neonate resuscitation in the delivery room is quite precarious. Emphasis on neonatal resuscitation training is urgently needed in medical schools.

The United States physician workforce and international medical graduates: trends and characteristics

BACKGROUND

International medical graduates (IMGs) have been a valuable resource for the United States physician workforce, and their contribution to the United States workforce is likely to increase.

OBJECTIVE

To describe the historical trends and compare the characteristics of IMGs to United States medical graduates (USMGs) in the United States.

DESIGN

Longitudinal analysis of the American Medical Association Physicians' Professional Data (AMA-PPD) database using the 1978-2004 files and a comparative analysis of the characteristics of a random sample of 1,000 IMGs and a random sample of 1,000 USMGs using the 2004 file.

MEASUREMENTS

Historical trends and characteristics of IMGs in the United States.

RESULTS

Over the last 26 years, the number of IMGs in the United States grew by 4,873 per year reaching a total of 215,576 in 2004, about 2.4 times its size in 1978. The proportion of IMGs increased 0.12% per year, from 22.2% in 1978 to 25.6% in 2004. In 2004, compared with USMGs, IMGs were older, less likely to be board certified [Odds ratio (OR), 0.68; 95% CI, 0.53 to 0.86], less likely to work in group practice (OR, 0.60; 95% CI, 0.37 to 0.98), more likely to have Internal Medicine as practice specialty (OR, 2.10; 95% CI, 1.62 to 2.71) and more likely to be residents (OR, 1.52; 95% CI, 1.07 to 2.16).

CONCLUSIONS

Over the last quarter century, the IMGs provided a significant and steady supply for the United States physician workforce that continues to grow. Policymakers should consider the consequences for both the United States and source countries.

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.

Preparing fourth-year medical students to teach during internship

Interns are expected to teach medical students, yet there is little formal training in medical school to prepare them for this role. To enhance the teaching skills of our graduating students we initiated a 4-hour "teaching to teach" course as part of the end of the fourth-year curriculum. Course evaluations demonstrate that students strongly support this program (overall ratings 2000 to 2005: mean=4.4 [scale 1 to 5], n=224). When 2004 course participants were surveyed during the last month of their internship, 84%"agree" or "strongly agree" with the statement: "The teaching to teach course helped prepare me for my role as a teacher during internship" (2005: mean 4.2 [scale 1 to 5], n=45, response rate 60%). A course preparing fourth-year students to teach during internship is both feasible and reproducible, with a minimal commitment of faculty and resident time. Participants identify it as an important addition to their education and as useful during internship.

Perceived, actual, and desired knowledge regarding Medicare billing and reimbursement. A national needs assessment survey of internal medicine residents

BACKGROUND

Economics and reimbursement have become a daily part of practicing physicians' lives. Yet, few internal medicine (IM) programs have offered formal curricula during residency about practice management or economics.

OBJECTIVE

To determine perceived, desired, and actual knowledge of Medicare billing and reimbursement among residents compared with community-based General Internists.

DESIGN AND PARTICIPANTS

Cross-sectional needs assessment survey of community and university-based second-year IM residents from 4 geographic regions of the United States.

RESULTS

One hundred and thirty-three second-year IM residents completed the questionnaire. Residents rated their level of knowledge about Medicare as a 2.0 (SD=0.9) on a Likert scale (1="very low," 5="very high"). Residents agreed that Medicare reimbursement should be taught in residency with a score of 4.0 (SD=1.1; 1="strongly disagree," 5="strongly agree" SD=1.1). On the knowledge assessment portion of the questionnaire, residents scored significantly lower than a group of general IM physicians who completed the same questions (percent correct=41.8% vs 59.0%, P<.001). Residents' scores correlated with their self-assessed level of knowledge (P=.007).

CONCLUSIONS

Our study demonstrates that second year IM residents feel they have a low level of knowledge regarding outpatient Medicare billing, and have a lower test score than practicing Internists to back up their feelings. The residents also strongly agree that they do not receive enough education about Medicare reimbursement, and believe it should be a requirement in residency training.

Beyond journal clubs. Moving toward an integrated evidence-based medicine curriculum

Incorporating evidence-based medicine (EBM) into clinical practice is an important competency that residency training must address. Residency program directors, and the clinical educators who work with them, should develop curricula to enhance residents' capacity for independent evidence-based practice. In this article, the authors argue that residency programs must move beyond journal club formats to promote the practice of EBM by trainees. The authors highlight the limitations of journal club, and suggest additional curricular approaches for an integrated EBM curriculum. Helping residents become effective evidence users will require a sustained effort on the part of residents, faculty, and their educational institutions.

What do attending physicians contribute in a house officer-based ambulatory continuity clinic?

OBJECTIVE

To study the educational contributions of attending physicians in an internal medicine house staff ambulatory clinic.

DESIGN

Cross-sectional, self-administered survey.

SETTING

University-affiliated general internal medicine practice.

PATIENTS/PARTICIPANTS

Internal medicine residents and attendings.

MEASUREMENTS AND MAIN RESULTS

Attending and resident perceptions of whether attendings made contributions to teaching points, diagnosis (DX), therapy (RX), and health care maintenance (HCM) were assessed in 428 patient encounters. Resident assessments significantly exceeded attending self-assessments of contributions to teaching points (82% vs 74%, P=.001), DX (44% vs 34%, P=.001), RX (61% vs 55%, P=.02), and HCM (19% vs 15%, P=.04). Both residents and attendings perceived that contributions declined progressively with increasing resident year (P<.05). Primary care and categorical residents assessed attending contributions comparably. However, attendings perceived contributing more to RX and HCM for categorical residents than primary care (P<.05). Male and female residents assessed attending contributions comparably. However, attendings perceived contributing generally more to DX in male residents than female (P=.003). In 8% of encounters, either residents or attendings felt that patient evaluation by the attending was needed. In these encounters with personal patient evaluation by attendings, both residents and attendings felt that attendings made more contributions to DX (P=.001) and teaching points than in other encounters.

CONCLUSIONS

Attending physicians consistently underestimate their perceived contributions to house officer ambulatory teaching. Their personal patient evaluation increases assistance with DX and teaching points. Given perceived declining contributions by training year, attendings may need to identify other teaching strategies for interactions with senior residents.

Brief report: Brief instrument to assess geriatrics knowledge of surgical and medical subspecialty house officers

PROBLEM

Initiatives are underway to increase geriatrics training in nonprimary care disciplines. However, no validated instrument exists to measure geriatrics knowledge of house officers in surgical specialties and medical subspecialties.

METHODS

A 23-item multiple-choice test emphasizing inpatient care and common geriatric syndromes was developed through expert panels and pilot testing, and administered to 305 residents and fellows at 4 institutions in surgical disciplines (25% of respondents), emergency medicine (29%), medicine subspecialties (19%), internal medicine (12%), and other disciplines (15%).

RESULTS

Three items decreased internal reliability. The remaining 20 items covered 17 topic areas. Residents averaged 62% correct on the test. Internal consistency was appropriate (Cronbach's alpha coefficient=0.60). Validity was supported by the use of expert panels to develop content, and by overall differences in scores by level of training (P<.0001) and graded improvement in test performance, with 58%, 63%, 62%, and 69% correct responses among HO1, HO2, HO3, and HO4s, respectively.

CONCLUSIONS

This reliable, valid measure of clinical geriatrics knowledge can be used by a wide variety of surgical and medical graduate medical education programs to guide curriculum reform or evaluate program performance to meet certification requirements. The instrument is now available on the web.

Brief report: Housestaff adherence to cervical cancer screening recommendations

BACKGROUND

Postgraduate training involves intensive clinical education characterized by long work hours with minimal flexibility. Time demands may be a barrier to obtaining preventive care for housestaff during postgraduate training.

OBJECTIVE

Assess adherence to United States Preventive Services Task Force (USPSTF) cervical cancer screening recommendations.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Convenience sample of female housestaff at 1 university hospital.

MEASUREMENTS

Primary outcomes included (1) adherence to USPSTF recommendations, (2) perception of adherence to recommendations, and (3) barriers to obtaining preventive care.

RESULTS

Surveys were completed by 204 housestaff. Overall, 81% of housestaff were adherent to USPSTF screening recommendations. Housestaff requiring screening in the past year were less likely to be adherent when compared with housestaff requiring screening in the past 3 years. Overall, 84% accurately perceived their screening behavior as adherent or nonadherent (kappa=0.58). Of the 43% who identified a barrier to obtaining preventive care, not having time to schedule or keep appointments was reported most frequently (n=72).

CONCLUSIONS

Housestaff accurately perceived their need for cervical cancer screening and were generally adherent to USPSTF recommendations, even though lack of time during postgraduate training was frequently reported as a barrier to obtaining preventive care. However, we found lower adherence among a small subgroup of housestaff at a slightly greater risk for cervical disease and most likely to benefit from screening.

Differences in preventive health quality by residency year. Is seniority better?

BACKGROUND

It is assumed that the performance of more senior residents is superior to that of interns, but this has not been assessed objectively.

OBJECTIVE

To determine whether adherence to national guidelines for outpatient preventive health services differs by year of residency training.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred twenty Internal Medicine residents, postgraduate year (PGY)- 1 and PGY -2, attending a University Internal Medicine teaching clinic between June 2000 and May 2003.

MEASUREMENTS

We studied 6 preventive health care services offered or received by patients by abstracting data from 1,017 patient records. We examined the differences in performance between PGY-1 and PGY-2 residents.

RESULTS

Postgraduate year-2 residents did not statistically outperform PGY-1 residents on any measure. The overall proportion of patients receiving appropriate preventive health services for pneumococcal vaccination, advising tobacco cessation, breast and colon cancer screening, and lipid screening was similar across levels of training. PGY-1s outperformed PGY-2s for tobacco use screening (58%, 51%, P = .03). These results were consistent after accounting for clustering of patients within provider and adjusting for patient age, gender, race and insurance, resident gender, and number of visits during the measurement year.

CONCLUSIONS

Overall, patients cared for by PGY-2 residents did not receive more outpatient preventive health services than those cared for by PGY-1 residents. Efforts should be made to ensure quality patient care in the outpatient setting for all levels of training.

Brief report: Physician discomfort and variability with disability assessments

BACKGROUND

Completing a disability assessment is a common physician task; yet, little formal training is available.

OBJECTIVE

To assess physician comfort with disability assessments, and evaluate their consistency.

DESIGN

We conducted 2 separate surveys. The "Comfort" survey asked physicians to rate their comfort (1 = very uncomfortable to 10 = very comfortable) with 12 potentially uncomfortable tasks, including disability assessment. The second survey described 2 different patients requesting disability assessment, 1 with acute and the other with chronic back pain; participants assigned each a level of disability.

PARTICIPANTS

Resident and staff physicians at an urban county hospital.

RESULTS

For 54 physicians returning "Comfort" surveys, disability assessment had the lowest average comfort rating (4.3, SD 1.9) compared with all other tasks (mean ratings ranged from 4.8 to 8.0). For the 73 physicians returning the "Disability Cases" survey, 88% found Case 1 qualified for limited employment, but varied on the types of limitations imposed. For Case 2, 39% assigned no disability, 39% limited employment, and 22% full disability.

CONCLUSIONS

Our pilot studies support the hypothesis that physicians are not comfortable with disability assessment, and their assessments can be highly variable. Physician discomfort and lack of training may contribute to variability in disability assessments.

THE BEHAVIORAL INTERVIEW, A METHOD TO EVALUATE ACGME COMPETENCIES IN RESIDENT SELECTION: A PILOT PROJECT

Interviews are a key part of the recruiting process in resident selection. Most programs use an unstructured resume-based interview. In 1999, the ACGME endorsed six competencies including behaviors as well as knowledge. Studies of interviews in the business community which use structured, behavioral interviews show more validity in future job success when essential job related behaviors are required. The premise of the behavioral interview is that past behavior is predictive of future behavior For this reason we introduced in the 2003-2004 recruiting season a behavioral interview to assess four ACGME competencies in the resident candidate- Professionalism, Patient Care, Communication Skills and System Based Practice. Provided in this report is a description of the process used to create the interview questions, the rating system, how it was introduced to candidates and faculty and its acceptance in the recruiting process for anesthesiology residents.

Bag of worms

In this story, I describe, from my perspective as a resident, working with a surgeon to resuscitate a woman who has suffered an avulsion of her pulmonary artery. The patient, a victim of a collision with an intoxicated driver, arrived at the hospital as I was caring for another patient who was undergoing his tenth admission for detoxification. Having been thrown unexpectedly into the fray, I looked upon a beating heart for the first time.

Teaching and learning in an 80-hour work week: a novel day-float rotation for medical residents

The 80-hour workweek limit for residents provides an opportunity for residency directors to creatively innovate their programs. Our novel day-float rotation augmented both the educational structure within the inpatient team setting and the ability for house staff to complete their work within the mandated limits. Descriptive evaluation of the rotation was performed through an end-of-rotation questionnaire. The average length of the ward residents' work week was quantified before and after the rotation's implementation. Educational portfolios and mentored peer-teaching opportunities enriched the rotation. As measured by our evaluation, this new rotation enhanced learning and patient care while reducing work hours for inpatient ward residents.

Are continuity clinic patients less satisfied when the resident is postcall?

Due to recent public debate and newly imposed resident work hour restrictions, we decided to investigate the relationship of resident call status to their ambulatory patients' satisfaction. Resident continuity clinic patients were asked to rate their level of satisfaction on a 10-point Likert-type scale. Using multiple regression approaches, these data were then assessed as a function of resident call status. We found that in 646 patient encounters, patient satisfaction scores were significantly less when the resident was postcall, 8.99 +/- 1.8, than when not postcall, 9.31 +/- 1.3. We herein discuss etiologies and implications of these findings for both patient care and medical education.

The physician-scientist in Canadian psychiatry

OBJECTIVE

The objective of the study was to determine whether physician-scientists in psychiatry in Canada are in decline, as was reported for medicine overall during the 1990s in the United States.

DESIGN

Federal databases were searched to study grant applications in the area of mental health submitted by physician-scientists compared with PhD-scientists for the period 1985-2001. A survey of Canadian Residency Training Program Directors was carried out for the graduating class of 2000.

SETTING

The Canadian publicly funded university system.

PARTICIPANTS

Applicants to the Medical Research Council of Canada and its successor, the Canadian Institutes of Health Research, for operating grant support and Residency Training Program Directors.

INTERVENTIONS

None.

OUTCOME MEASURES

Comparison over time between MD and PhD applicants regarding the number of grant applications submitted, the proportion of applications funded and the number of new applications submitted, with separation of applications submitted to a predominantly "biomedical" peer review committee and to a predominantly "clinical research" peer review committee. The survey obtained information about a number of variables related to research training.

RESULTS

The situation for physician-scientists in psychiatry in Canada appeared remarkably similar to general findings in US studies. Relative to PhD applicants, fewer grant proposals were being made by physicians (paired t16 = 7.08, p < 0.001) and, in consequence, fewer proposals were funded. The proportion of proposals funded was similar for MD and PhD applicants (paired t16 = 0.27, p = 0.79). Grant applications made to the predominantly biomedical committee were more likely to be funded than applications to the committee with an orientation toward clinical research (paired t7 = 5.53, p < 0.001). Applications by PhD-scientists to the biomedical committee showed the largest increase over time and were the most successful. From the survey of graduating classes, close to one-third of residents had authored or co-authored a publication during residency. Only 7% were proceeding to research fellowship training. The remuneration available for fellowship training was about one-third of what graduating classmates could expect to earn in the first year of practice.

CONCLUSIONS

Quantitative data indicate that physician-scientists in psychiatry in Canada are experiencing the same pressures and challenges as physician-scientists in the United States. A plan of action tailored to the needs of the psychiatric community in Canada needs to be developed.

Medicare financing of graduate medical education

The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.