Best Time To Get Sick? Never!

Resident Transition: Chances are, many of us have heard of the saying, “Don’t get sick in July,” which refers to the perceived and possibly real association between the start of a new academic year and worse patient outcomes in teaching hospitals. There’s also literature suggesting that weekend admissions are associated with increased mortality. Add to this the findings of a new study published in this month’s JAMA regarding increased risk of mortality associated with resident service changes, and one is left with no “good time” to get sick. But are these findings valid? In this retrospective study, the authors looked at 230,000+ admissions to internal medicine services at 10 US Veterans Health Administration hospitals and associations between in-hospital, 30-day and 90-day mortality and readmission rates with resident care transitions. After adjusting for important comorbidities, resident transition was associated with a statistically significant increase in risk of mortality (OR 1.21, 95% CI 1.12 – 1.31 for 30-day mortality with intern + resident transition). However, in an alternative analysis that compared patients admitted 2 days prior to resident transitions with those admitted on days not associated with service changes, there was no significant association between resident transition and mortality. This suggests that the increased risk of mortality observed in the original analysis may be due to inadequate adjustment for other important confounding variables in this observational study looking at a complex care delivery system where resident transition is just one small piece of the process. Having said that, given what we know about how important information can be missed during handoffs, this study should make us consider strategies to ensure safety of patients regardless of when they are admitted to the hospital. — Sarang Kim, MD

Chief Resident Commentary:  We asked one of our internal medicine chief residents to comment on this article and to consider the idea of minimizing resident transitions, perhaps by making a service rotation longer than the typical 4 weeks:

While on service as a resident, I noticed that there arises the occasion that you kind of feel like your “wheels are spinning” with a certain patient. You and your team are stuck in a rut, and nothing really gets done for the patient. Often times in those situations, I looked forward to my attending changing out, or even the whole resident team changing out just so that the patient got a fresh perspective of their case. Sometimes that’s exactly what a patient needs to advance in their care.

The obvious downside of being on service longer than 4 weeks would be elimination of the coveted “4+1” block schedule (4 weeks inpatient + 1 week outpatient). I think one might also run into serious burnout possibilities with being on service longer than a month. It’s physically and emotionally draining to be on service for that long without a break. We also have residents doing only 2-week blocks and in some rare cases 1-week blocks, which further increase handoffs. But with the constraints of the rotating 4+1 system and giving residents the ability to choose their own vacation weeks, these shorter rotations seem inevitable from a scheduling perspective. Maybe a good solution would be to change out the senior resident and intern in a “staggered” manner, as is done in some other programs. So when the senior resident switches, the intern stays on the team and vice-versa. This way, there’s always someone who has some degree of knowledge (hopefully) about the patient.

Daniel Schaer, MD, MPH
Chief Resident
Department of Medicine
Rutgers-Robert Wood Johnson Medical School

Denson et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA 2016;316(21)2204-2213.

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Make Sure The Patient Is Part Of Teaching Rounds

Rounds: This description of highly-structured inpatient internal medicine “chiefs’ service” rounds, as compared with usual teaching service rounds, is a useful reminder of the importance of bedside rounds including the patient, as opposed to hallway or conference room rounds.  Both the chiefs’ service and usual teaching rounds were highly regarded by residents, and the minor differences in quantitative evaluations favoring the chiefs’ service may have simply been a “halo effect” created by the new program and more-invested attendings.  More interesting to this reviewer were resident comments on some of the more unique aspects of the rounding structure: presentation in front of each patient every day; extensive day-of-discharge rounding in front of the patient to ensure adequate understanding and follow-up; and having a care coordinator call all discharged patients and give the team feedback about the patient’s post-discharge course.  These elements sensitized the residents to patients’ difficulties understanding their medical care and navigating the system outside of the hospital. — Laura Willett, MD

Bennett, Nadia L. MD; Flesch, Judd D. MD; Cronholm, Peter MD, MSCE; Reilly, James B. MD, MS; Ende, Jack MD, Bringing Rounds Back to the Patient: A One-Year Evaluation of the Chiefs’ Service Model for Inpatient Teaching. Academic Medicine, December 2016

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Warning About Predatory Publishers 

Publishing: These rapidly-proliferating publishers are probably preying on your residents and your faculty, given that “publish or perish” has worked its way into fellowship applications as well as academic promotions.  Predatory publishers are defined as those providing “rapid and loose reviews leading to speedy publication in exchange for hefty publication fees.”  One academic “submitted a purposefully flawed scientific paper with meaningless results to 304 suspect journals.  A responsible peer review process would have promptly rejected the paper, yet over half of the journals accepted it.”  Not only are there many new predatory journals, some predatory publishers are purchasing existing journals in order to gain their PubMed index numbers.  How can responsible people fight back?  A first step might be to support efforts of people like librarian Jeffrey Beall and his list of predatory publishers, currently numbering 923! — Laura Willett, MD

Harvey, H. Benjamin MD, JD; Weinstein, Debra F. MD, Predatory Publishing: An Emerging Threat to the Medical Literature. Academic Medicine, Dec 2016

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What Behaviors Could Increase The Chances Of U.S. Senior Medical Students To Match Into Residency Programs? 

Match: This analysis of the National Resident Matching Program Applicant Survey responses of senior medical students in US allopathic medical schools (“U.S. seniors”) compares survey responses from students who matched into a residency program vs. those who did not, and contains much useful information for students and those who advise them.  The data is weakened by a 49% overall response rate and a fair amount of missing data; however the number of included students is high at 7,762 and the percentage of students in the cohort who were matched, 96%, is very similar to the overall percentage of US seniors who are matched at 94%.  Importantly, this matched percentage has not changed in the last few decades, despite increasing numbers of non-U.S. seniors applying during this time frame. Students were broken into 4 categories of “strength” based only on their self-reported USMLE Step 1 certifying examination score as compared to the mean and standard deviation (SD) of that score for US seniors who  matched into their preferred specialty.  Overall, “strong” or “solid” students who scored above the mean for their preferred specialty had only about a 2% risk of not matching, while “weak” students who scored below 1 SD of the mean had a 10% risk of not matching.  Unmatched students answered several survey questions quite differently (>10% differences) than students who matched, suggesting they had “a fundamental misunderstanding of how the matching algorithm works.”  For example, many fewer of the unmatched students ranked the programs in order of their preference, ranked all programs that they were willing to attend, or ranked a “safety net” program.  Surprising to this (older) reviewer were the sheer numbers of applications involved, which must be putting huge stresses on students and on residency programs.  Even “strong” students, with USMLE1  scores more than 1 SD over the mean, applied to an average of 31 programs.  Such large numbers of applications may not be necessary for most students, if they can utilize the Match more strategically. — Laura Willett, MD

Liang, Mei MS; Curtin, Laurie S. PhD; Signer, Mona M. MPH; Savoia, Maria C. MD, “Unmatched U.S. Allopathic Seniors in the 2015 Main Residency Match: A Study of Applicant Behavior, Interview Selection, and Match Outcome.” Academic Medicine Nov, 2016

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In Search Of Continuity For Resident Continuity Practice

Continuity: Those involved in resident continuity practice will want to make note of this article that describes factors associated with continuity at 4 ambulatory residency training programs (internal medicine, pediatrics, family medicine, and med-peds), all at Level 3 PCMH (Patient-Centered Medical Home) designated practices in Upstate New York. Visit data (provider and patient characteristics) from these sites were compared to those from 30 affiliated non-teaching primary care practices in the community. Of almost 400,000 visits analyzed, continuity was higher in non-teaching community practices (87.3%) compared to resident practices (56%) or faculty practices (62%, p <.001). Factors associated with continuity included consistent use of scheduling protocols, absence of advanced practitioners, higher clinical faculty time, policies for handoffs from graduating seniors to interns, and dismissal policies for excessive missed appointments. While this study confirms what is already known about lack of continuity in resident practices, it also adds useful insight into how we might improve continuity, especially as many of the factors identified should be modifiable and likely not cost-prohibitive.  — Sarang Kim, MD

Fortuna et al, Factors Associated With Resident Continuity In Ambulatory Training Practices. Journal of Graduate Medical Education October 2016

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Program Directors Weigh In On 13 Core Entrustable Professional Activities (EPAs) 

Entrustable Professional Activities: Thirteen core EPAs have been proposed as a standard for North American medical school graduation.  In this study, researchers surveyed internal medicine program directors (PDs) for their views on the EPAs: their importance, observed performance gaps in their own trainees, and methods of communication across training settings.  The survey response rate was 57%, with a modest over-representation of larger and university-based programs.  At least 75% of these PDs thought that their entering interns “must” or “should” be able to perform without direct supervision 11 of the 13 proposed EPAs.  The two activities not meeting this bar were “Identify systems failures and contribute to a culture of safety and improvement” and “Perform general procedures of a physician”. {Editor’s note: surgical PDs might well rank this last EPA higher.}  Major gaps were noted between entering interns’ actual capabilities under indirect supervision and our expectations, even in EPAs rated among the most important, including developing a prioritized differential diagnosis, providing oral presentations, and recognition of patients requiring urgent or emergent care.  Majorities of PDs agreed that EPA information should be shared by medical schools with residency programs, and then by residency programs  with fellowship programs and employers; and 71% felt that an EPA checklist from medical schools would be helpful.  There was less consensus on the timing and optimal use of such information. — Laura Willett, MD

Angus, Steven V. MD; Vu, T. Robert MD; Willett, Lisa L MD, MACM; Call, Stephanie MD, MSPH; Halvorsen, Andrew J. MS; Chaudhry, Saima MD, MSHS “Internal Medicine Residency Program Directors’ Views of the Core Entrustable Professional Activities for Entering Residency: An Opportunity to Enhance Communication of Competency Along the Continuum.” Academic Medicine, Oct 2016

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Should Implicit Bias Testing Be Required On The Admissions Committee? 

Admissions: Maybe, according to these results.  All 140 admissions committee members took a test for white-black implicit bias, and then took a survey based on their experiences.  This was followed by a discussion of aggregate results by the committee along with an implicit bias expert.  Results were reported by gender and faculty vs. student status, but not by under-represented minority (URM) status.  No group of committee members reported explicit bias, but all groups (male and female, students and faculty) displayed moderate to substantial implicit bias based on the test.  Sixty-seven percent felt that the exercise was worthwhile.  In the next admissions cycle, there were no statistically significant changes in the percentage of URM applicants interviewed (20% to 19%), the percentage URM interviewees offered acceptance (32% to 29%), or the percentage of accepted URM students matriculating (43% to 54%). — Laura Willett, MD


Quinn Capers IV, MD, Daniel Clinchot, MD, Leon McDougle, MD, and Anthony G. Greenwald, PhD, Implicit Racial Bias in Medical School Admissions, Academic Medicine, September 2016

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