ABSTRACT

Background

Ambulatory training in internal medicine residency programs has historically been considered less robust than inpatient-focused training, which prompted a 2009 revision of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Internal Medicine. This revision was intended to create a balance between inpatient and outpatient training standards and to spur innovation in the ambulatory setting.

Objective

We explored innovations in ambulatory education in internal medicine residency programs since the 2009 revision of the ACGME Program Requirements in Internal Medicine.

Methods

The authors conducted a scoping review of the literature from 2008 to 2017, searching PubMed, ERIC, and Scopus databases. Articles related to improving educational quality of ambulatory components of US-based internal medicine residency programs were eligible for inclusion. Articles were screened for relevance and theme categorization and then divided into 6 themes: clinic redesign, curriculum development, evaluating resident practice/performance, teaching methods, program evaluation, and faculty development. Once a theme was assigned, data extraction and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI) score were completed.

Results

A total of 967 potentially relevant articles were discovered; of those, 182 were deemed relevant and underwent full review. Most articles fell into curriculum development and clinic redesign themes. The majority of included studies were from a single institution, used nonstandardized tools, and assessed outcomes at the satisfaction or knowledge/attitude/skills levels. Few studies showed behavioral changes or patient-level outcomes.

Conclusions

While a rich diversity of educational innovations have occurred since the 2009 revision of the ACGME Program Requirements in Internal Medicine, there is a significant need for multi-institution studies and higher-level assessment.

Ten years ago, the Accreditation Council for Graduate Medical Education (ACGME) used the power of accreditation requirements to improve how residency programs train internal medicine residents in ambulatory settings.¹ In a scoping review in this issue of the Journal of Graduate Medical Education, Coyle and colleagues found that despite a number of educational innovations since 2009, virtually no studies have demonstrated improved patient-level outcomes.²

In some ways these findings are not surprising. In quality improvement (QI) terms, the ACGME's original directives of minimizing inpatient-outpatient conflicts, conducting 130 ambulatory sessions over 30 months, evaluating practice-based measures,

ABSTRACT

Background

The Accreditation Council for Graduate Medical Education (ACGME) has mandated revisions to residents' work hours to improve patient safety and enhance resident education and wellness. The impact on clinical outcomes on a national level is poorly understood.

Objective

We examined data from before and after the ACGME 2011 duty hour revision and looked for differences between teaching and nonteaching US hospitals.

Methods

A retrospective observational study of patients admitted to hospitals in the 2-year periods before and after the 2011 duty hour revision was conducted, utilizing a nationally representative data set. We compared patient and hospital characteristics using standardized differences. With nonteaching hospitals serving as the control group, we used multiple group interrupted time series segmented regression analysis to test for postrevision level and trend changes in mortality, length of stay (LOS), and costs.

Results

We examined more than 117 million hospitalizations. At teaching and nonteaching hospitals, trends in mortality and LOS in prerevision and postrevision periods were not significantly different (all P > .05). A significant monthly reduction in cost per hospitalization was noted postrevision at teaching hospitals (P = .019) but not at nonteaching hospitals (P = .62). In the 2 years following the 2011 revision, there was a monthly reduction in cost per hospitalization (–$52.28; 95% confidence interval –$116.90 to –$12.32; P = .026) at teaching relative to nonteaching hospitals.

Conclusions

There were no differences in mortality or LOS between teaching and nonteaching hospitals. However, there was a small decrease in cost per hospitalization at teaching hospitals following the 2011 revision.

ABSTRACT

Background

The Accreditation Council for Graduate Medical Education (ACGME) and Pediatrics Review Committee (RC) recommends the clinical procedures residents should master during their training. These guidelines may be partially based on consensus opinion or tradition rather than actual need. The literature defining which procedures general pediatricians actually perform in practice is limited.

Objective

Our objective was to determine how often general pediatricians perform procedures recommended by accreditation bodies, how well prepared they feel to perform them, and how important the procedures are to their practice.

Methods

We categorized recommended procedures as emergent, urgent, or office-based, then developed and administered a survey in 2017 based on these classes. We randomly sampled and polled 439 general pediatricians from urban, suburban, or rural regions across central Ohio. Responses were compared using the Welch ANOVA, Mann Whitney U, and post-hoc tests.

Results

The response rate was 60% (265 of 439). Pediatricians almost never performed 11 of 13 recommended procedures, yet felt well prepared to perform them all and believed that all were important. Rural pediatricians performed significantly more emergent and office-based procedures and rated them as more important. Commonly performed non-ACGME/RC procedures were circumcision, wart removal, cerumen removal, umbilical cauterization, and suture removal.

Conclusions

Findings suggest that pediatricians rarely perform most of the recommended procedures, but think they are important. There are several office-based non-ACGME recommended procedures that pediatricians commonly perform. Regional differences suggest the need for customized training based on future practice plans.

“Good” is bad. “Solid” is worse. Is “outstanding” the same as “superior”? Residency program directors spend hours deciphering the hidden meanings of carefully chosen adjectives from a heterogeneous pool of letter writers. Applicants agonize over selecting ideal advocates to endorse their applications. In an era when many medical schools employ “pass/fail” grading, it is difficult to differentiate residency applicants, especially those below the elite echelon of their class. To discern the relative capability of applicants, the Council of Residency Directors in Emergency Medicine (CORD) developed and implemented a standardized tool for experienced emergency medicine (EM) educators to recommend and evaluate