The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Internal Medicine (ABIM) recently updated their policies affecting resident parental leave.1-3 This change is a significant step toward gender equity in childcare, as parental leave has well-established benefits for parents and children. Maternity leave is associated with improved maternal mental and physical health, increased breastfeeding rates, and lower infant and child mortality.4-7 Although there is less research on the benefits of parental leave for the non-birthing parent, paternity leave specifically is associated with increased infant caretaking, more father-child bonding, improved infant health, and increased employment and pay for mothers.

Disparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern. Examine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity. Longitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014–2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square. A total of 689 IM residents, including 330 women and URiM residents (48%). ITE score There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F(2, 1321) 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p<0.001). Women and URiM residents had greater odds of being at potential risk for not passing the ABIM-CE (OR 1.75, 95% CI 1.10 to 2.78) with greatest odds in PGY3 (OR 3.13, 95% CI 1.54 to 6.37). Differences in ITE over training were associated with resident gender and race/ethnicity. Women and URiM residents had smaller ITE score gains across PGY translating into greater odds of potentially being seen as at-risk for not passing the ABIM-CE. Differences in ITE over training may reflect differences in experiences of women and URiM residents during training and may lead to further disparities.

BACKGROUND:A longstanding gender gap exists in the retention of women in academic medicine. Several strategies have been suggested to promote the retention of women, but there are limited data on impacts of interventions.OBJECTIVE:To identify what institutional factors, if any, impact women faculty's intent to remain in academic medicine, either at their institutions or elsewhere.DESIGN:A survey was designed to evaluate institutional retention-linked factors, programs and interventions, their impact, and women's intent to remain at their institutions and within academic medicine. Survey data were analyzed using non-parametric statistics and regression analyses.PARTICIPANTS:Women with faculty appointments within departments of medicine recruited from national organizations and specific social media groups.MAIN MEASURES:Institutional factors that may be associated with women's decision to remain at their current institutions or within academic medicine.KEY RESULTS:Of 410 surveys of women at institutions across the USA, fair and transparent family leave policies and opportunities for work-life integration showed strong associations with intent to remain at one's institution (leave policies: OR 2.22, 95% CI 1.20-4.18, p = 0.01; work-life: OR 4.82, 95% CI 2.50-9.64, p < 0.001) and within academic medicine (leave policies: OR 2.31, 95% CI 1.09-5.03, p = 0.03; work-life: OR 4.66, 95% CI 2.04-11.36, p < 0.001). Other institutional factors associated with intent to remain in academics include peer mentorship (OR 3.16, 95% CI 1.56-6.57, p < 0.01) and women role models (OR 2.21, 95% CI 1.04-4.68, p = 0.04). Institutions helping employees recognize bias, fair compensation and provision of resources, satisfaction with mentorship, peer mentorship, and women role models within the institutions were associated with intent to remain at an institution.CONCLUSIONS:Our findings suggest that institutional factors such as support for work-life integration, fair and transparent policies, and meaningful mentorship opportunities appear impactful in the retention of women in academic medicine.

BACKGROUND:In 2014, the Accreditation Council for Graduate Medical Education (ACGME) formally mandated trainee (resident and fellow) participation in health care quality improvement (QI) projects as one of the Clinical Learning Environment Review (CLER) Pathways to Excellence. Subsequent national reviews showed large variations in how QI education is conducted, as well as a significant mismatch between educational and organizational goals. OBJECTIVE:We developed a web-based platform to engage trainees in QI that better aligned with best practice methodology and matched identified institutional priorities. METHODS:A needs assessment survey was distributed to trainees to understand the obstacles to compliance with ACGME QI requirements. Based on the results, a web-based clearinghouse, called the QI Platform, was developed and launched in July 2016, and utilization was analyzed in February 2019. RESULTS:A total of 196 of 440 needs assessment surveys (45%) were completed. Themes extracted from surveys to identify barriers in QI participation included difficulties designing projects, lack of mentorship or expert support, and difficulty engaging an interprofessional team. Over 2.5 years, 151 projects were registered on the platform. Of these, 17 (11%) were collaborative entries. At the time of analysis, 166 of 437 trainees (38%) were listed as participants in active QI projects. A total of 22 projects were archived as complete, and 68 incomplete projects were reassigned to the "Ideas" section as works in progress after lead trainee graduation. CONCLUSIONS:An institutional QI Platform clearinghouse for GME QI projects was feasible to develop and maintain, and it appeared acceptable to most GME programs and trainees for recording and tracking QI projects, and linking these to hospital QI priorities.

Background: HPV vaccination rates remain low in the United States despite efforts to increase them, although rates vary geographically both at the state and regional level within the United States. This study examines differences in teen HPV vaccination rates and associated sociodemographic factors among six regions in Texas to understand potential variation in smaller regions. These differences may inform planning of local public health interventions aimed at increasing vaccination uptake in teens. Methods: We analyzed sociodemographic and vaccination data for a total of 2256 teens 13-17 years old from six regions in Texas using the 2017 National Immunization Survey--Teen (NIS-Teen). We used survey-weighted chi-squared tests to compare demographic characteristics and HPV vaccination initiation and series completion across regions and multivariable robust Poisson regression models to examine the association between region of residence and HPV vaccination outcomes. Results: Rates of initiation and completion of the HPV vaccine series varied significantly between six regions in Texas and were both highest in El Paso County and lowest in Dallas County (initiation 82.8% vs 52.5%, P < 0.001; completion 51.3% vs 30.2%, P < 0.001). Adjusted multivariable log binomial regression models demonstrated that teens in Dallas county were significantly less likely to initiate the HPV vaccine series than teens in Travis county (RR = 0.79, 95% CI: (0.65, 0.95), P = 0.01). Discussion: HPV vaccination uptake varied significantly between six regions in Texas, highlighting the importance of closely examining local regions in public health planning efforts. Intervention efforts should consider the variation in sociodemographic characteristics as well as policy at the regional level to best improve vaccination rates in communities across the nation. (C) 2020 Elsevier Ltd. All rights reserved.

The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes. We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers. Cross-sectional study Seventy out of 100 (70%) IM primary care program directors completed the survey. Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences. Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs. IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.

In 2012, the Accreditation Council for Graduate Medical Education (ACGME) introduced a requirement for trainees to participate in quality improvement (QI) and patient safety (PS) work. This requirement increased trainee exposure to QI/PS, and created an opportunity for scholarly work. For traditional scholarly work, trainees must obtain approval from their Institutional Review Board (IRB) prior to conducting a study. In practice, the IRB process acts as a significant barrier for trainees, due to the significant amount of administrative work and advanced planning required during a trainee's other, unrelated rotations. Expansion of IRB submissions due to required QI/PS projects also creates the potential for IRB submission overload, bogging down timely review. Internal surveys at our urban, academic hospital confirmed that delays in IRB review already deter trainees from ambitions to create impactful projects.At our hospital, which is responsible for 450 trainees, we implemented our interpretation of ACGME requirements by requiring all residents to participate in QI/PS projects. We created an institution-wide curriculum and an online QI platform to facilitate QI/PS scholarship. During initial implementation, trainees submitted project applications through the IRB before starting these scholarly activities. Subsequently, we observed IRB feedback that (1) the majority of projects were not human subject research, and (2) the remaining submissions evaluated by the IRB were ultimately approved as exempt.Noting the opportunity to improve efficiency, we collaborated with our IRB to create a checklist that would appropriately route all institutional QI/PS projects. If the project met checklist criteria (figure), it would be approved as QA/QI Status and would not require separate IRB submission. The IRB included a quality assurance (QA) designation for this checklist in anticipation of other groups choosing to do projects in this area; our projects were predominantly focused on QI and PS. Enforcement of the checklist completion and umbrella protocol compliance was tasked to graduate medical education leaders overseeing the QI/PS effort at our institutions (A.C. and K.M.). This checklist was placed on an online QI platform so trainees can certify that a project qualifies; projects that do not qualify require IRB submission.From October 2016 to January 2017, a total of 47 projects have been entered onto the site. Of these projects, all but 3 have met QA/QI Status approval conditions, bypassing traditional IRB submission.Most QI/PS projects are initiated with the intent to improve systems at the home institution. In the event that any outcomes are deemed worthy of dissemination, and thus presentation or publication, they will fall under the original umbrella protocol and can be published. We also have anecdotal evidence (via focus groups) that residents are more satisfied and eager to complete QI projects without the barrier of IRB approval. We plan to continue to track submissions to the QI platform as well as IRB submissions for QI/PS work.This checklist for QI projects is easily transferable to other institutions in order to facilitate trainee QI/PS endeavors. Preliminary results suggest that this checklist will assist with initiation of QI projects while adhering to IRB guidelines.

Introduction Since the release of the Institute of Medicine's To Err Is Human, there has been an increased focus on quality improvement (QI). QI training is now a requirement monitored via ACGME's clinical learning environment review committees. Given the significant cost of health care waste, teaching physicians to incorporate costs and value into medical decision making is crucial. Increasing information is available on methods to teach high-value care (HVC), but there is little information on combining HVC with QI. As these topics are intimately linked in efforts to provide effective, efficient care, a joint curriculum is a feasible solution. Methods We adapted material from two online resources—(1) Institute of Healthcare Improvement Open School and (2) American College of Physicians High Value Cost-Conscious Care Curriculum—to create a combined curriculum for use in a limited-resource setting. Our curriculum is divided into 10 seminars, each including both QI techniques and HVC theories, which are reinforced using a series of patient scenarios. Residents apply their knowledge in self-directed projects presented in the final seminar. Evaluation includes a pre-/postexposure QI knowledge application test, survey of self-assessed knowledge, and anonymous course feedback. Results For the 46 residents who completed the series, a statistically significant improvement in both tests was measured, and feedback was positive overall. Tailoring our in-seminar patient scenarios allowed residents to demonstrate their HVC knowledge acquisition. Discussion This seminar-based curriculum can be adapted to the time availability in any residency program and transfer to other disciplines with modification of the patient scenarios.

During recruitment, program directors (PDs) embody roles that run the gamut from marketing director, webmaster, adviser, and advocate to used-car salesman, interrogator, proud parent, and spin doctor. The residency application process begins immediately after the previous year's Match cycle (figure). Initially, PDs examine the previous Match for (1) matched programs of ranked applicants; (2) characteristics of matched and unmatched ranked applicants; (3) applicant characteristics and timing of interview cancellations; (4) lowest-ranked Match compared with previous years; (5) recruitment communication, marketing, faculty and resident involvement, and interviews; and (6) overall costs. Next, applicants from a PD's home institution schedule appointments with the PD to confirm information provided by student affairs deans, clerkship directors,1 and various websites regarding the application process.By September 15, PDs are inundated with applications far in excess of the time allotted for review. For example, if an anesthesiology PD at our institution uses 10 minutes per application review, and the program routinely receives more than 1000 applications for 8 positions, then at least 167 hours are required to review all applicants. If the PD reviews all applications, without breaks, 8 hours a day for 2 nonclinical days per week, it would take more than 10 weeks to review all applications! Thus, the reality is that some deserving applicants do not receive a comprehensive review; PDs increasingly work during nights, weekends, and clinical time, and associates must assist in the process.The interview process varies greatly among specialties and programs, yet all programs experience the financial and time-related costs of interviewing. Clinical service and educational disruptions punctuate the interview period from October to February.When applications outnumber positions by 120 to 1, as typically occurs for competitive programs, it may appear that programs have the advantage in the balance between supply and demand. However, by dividing the process into 2 phases, the application and the interview, the balance shifts. In the earlier anesthesiology example, a subset of roughly 150 top-tier candidates apply and are granted the vast majority of interviews to the same set of regional, peer schools with similar demographics. Consequently, demand outstrips supply once programs reach the interview phase, as roughly 350 positions are available at peer-grouped programs. Applicants offered interviews may keep their interview slots until the last minute, which prevents other candidates from being interviewed. This puts 200 positions at risk for not matching. Moreover, applicants who are not top tier are unnecessarily shunted to less competitive programs or a non-match. Because of interview hoarding by top applicants, some PDs report forgoing interview offers to top applicants who historically have matched elsewhere and instead favor lower-tier candidates.2Another unintended consequence of overapplying is the urgency for PDs to offer early interviews. The PDs know that applicants apply to far more programs than they will ultimately visit for an interview. To pitch their program and avoid cancellations, PDs make early interview offers, prior to the release of the Medical Student Performance Evaluation (MSPE), with interview dates as early as October. Early interview offers prevent holistic review, however, because decisions are made based on incomplete applications.Application creep occurs primarily because “we” tell students to apply to more programs. We, the student affairs deans, look at the prior year application numbers and figuratively push down on the accelerator. We, the accreditation and clinical association bodies, forge an aggressive campaign for Medicare dollars based on the premise of a looming graduate medical education position shortfall. We, the organizations that sponsor the Match and application process, fail to implement effective process improvements to curb the overapplying frenzy despite early warnings that the process is out of control.Other reasons include the ease of applying, lack of fourth-year curriculum requirements, low-intensity program interviews, and basic game theory economics. The ease of the application process leads to overapplying when adding programs to an application list requires only a few clicks on the common application.3 Further, the personal statement does not push students to engage in thoughtful responses to questions.Medical schools and residency programs deserve some blame as well. At 1 school in 2014–2015, only 40% of the students took a clinical elective during interview season, and less than 50% of the students took one after Match Day.4 Consequently, some students have no curriculum-related constraints. By fostering a culture of unstructured interviews that require almost no preparation, residency programs do not dissuade applicants who are only modestly interested in a program from interviewing.5A game theory concept known as the prisoner's dilemma has been posited by Weissbart et al2 to explain the annual increase in applications by medical school applicants to residency programs. Game theory addresses the interactions among individuals during decision making. The prisoner's dilemma posits that all members of a group are worse off when each member of the group acts in his or her own self-interest.6 Weissbart et al2 demonstrated that the probability of matching does not increase with an increasing number of applications. As an example to illustrate the Match dilemma, we suggest an application ideal value that uses 2005 program-specific averages as a baseline adjusted for the difference between total applicants and total positions offered annually (table).7,8 The vast majority of applicants must adhere to the ideal application strategy rather than the overapply strategy for this approach to be successful; this is unlikely for one-time negotiations.From a PD's perspective, medical school records that accurately depict a struggling student are largely nonexistent. Attempting to save the lowest-performing students from failure reflects not only a medical disposition to heal but also US culture; as Garrison Keillor noted in A Prairie Home Companion, “all the children are above average”9 in the fictional town of Lake Wobegon. For several medical schools, more than 90% of students are graded as honors or high pass for clerkships or are ranked in the top 2 tiers on the MSPE.10 Comments on the MSPE are overwhelmingly positive for even the lowest tier of students. Further, standardized letters of recommendation, used by emergency medicine to improve transparency, reveal ranking distributions for letter writers but also tend toward advocacy as the vast majority of responses are in the top 2 deciles.10 Some letter writers have mentioned that their deans prohibit them from completing standardized letters of recommendation that require student rankings. Hence, medical schools embolden students to apply to reach programs by obscuring their actual ranking.Because Match participants cannot be counted on to self-regulate applications due to the aforementioned reasons, an outside group, acting on behalf of student applicants, should tackle this mounting problem. Consider the following:Both the AAMC and the NRMP are more likely to provide education materials and data to support medical students and their advisers in an effort to curb applications, rather than to impose application limits. As we do not believe these efforts will be sufficient, the NRMP should impose application limits, using adjusted, 2005 program-specific averages as a baseline, which would not worsen applicants' Match probability.A more aggressive strategy would be to change the current single round of applications, plus the Supplemental Offer and Acceptance Program (SOAP), to a 3-round format for applications. This would permit up to 5 programs per round before the SOAP process. The third round could allow unlimited applications with tiered pricing as in the current system. Further, this proposal permits applications to 1 or more backup specialties. This strategy has a precedent: in Europe, the University and Colleges Admissions Services successfully limits the first round of applications to 5 courses of study at up to 5 institutions and then permits an extra application in a second round.12It has been suggested that medical students would stop overapplying and applying to out-of-reach programs if they had an accurate composite of applicants who matched to a particular program.13 This approach, however, could have considerable drawbacks from our perspective: (1) data reported from small programs would be identifiable, or small programs would need to combine several years of data and thus be outdated; (2) the academic diversity of trainees in a program is surprisingly vast (eg, posting an average United States Medical Licensing Examination [USMLE] Step 1 score of 220 doesn't capture the fact that 1 trainee actually failed the boards on the first attempt due to a valid reason, or that 2 other trainees scored 250, while a fourth scored 203); and (3) such a database might impede a program's recruitment of top candidates despite improvement efforts.For a holistic review, medical schools need to provide fair and honest evaluations of each student's knowledge, skills, and attributes. Objective data derived from milestones and core entrustable professional activities may be helpful. Student rankings would allow PDs to redirect time currently spent deciphering the MSPE riddle for each school toward holistic consideration of nonscoring metrics. The PDs and their teams will require additional nonclinical time between mid-September and mid-October.The Accreditation Council for Graduate Medical Education (ACGME) should deemphasize the annual evaluation of board pass rates for program accreditation. Instead, they should consider including other outcome measures of trainee performance in the workforce, such as legal claims or complication rates.14 Many board examinations are not completed until months or even years after completion of residency training, which seriously calls into question a program's ability to adequately prepare candidates for certification examinations and may reflect instead relatively brief periods of intense study of review course materials. As a result of ACGME's scrutiny of board pass rates, programs strongly prefer candidates who can independently pass an examination. An ACGME focused review of a program to discuss low board scores sends a strong message that holistic review, often a euphemism for considering intriguing candidates who score poorly on standardized tests, can lead to program citation or worse.First, the AAMC should reassess the unintended consequences of technological advances that improved the ease of applying at the expense of discretion. One solution would be to introduce mass customization. This concept allows for personalized applications, perhaps including video-based statements of interest, and responses to several program-directed essays in lieu of the current generic personal statement. For example, when hiring an au pair, a host family has the opportunity to select from a wide variety of personalized video profiles of applicants before proceeding with multiple video-chat interviews that allow both parties to be fully satisfied prior to mutual agreement.Second, the ACGME should consider the board pass rate as part of a larger set of posttraining outcome metrics for accreditation consideration.Third, medical schools should provide rankings of all students on the MSPE. The quid pro quo for schools providing meaningful data will be for programs to authorize the release of composite data on matched applicants from previous years and to release screening algorithms to the NRMP for applicant and medical school consideration. A single specialty trial over 3 recruitment cycles is warranted to determine if concerns over transparency are founded.Fourth, PDs should expand on semistructured interviews by incorporating elements of behavioral and situational interview techniques, such as multiple mini interviews,15 for residency recruitment.Fifth, the NRMP should institute application limits for the first 2 rounds of a new 3-round application process plus SOAP. Up to 5 programs could be applied to at up to 5 institutions per round.Opening meaningful dialogue between accreditations bodies, Match organizations, medical schools, students, PDs, and other interested parties is the first step to improve the current application and interview process. A series of regional or specialty-specific forums on overapplying in the residency application process could set the stage for recommending reforms and piloting a more efficient, informative, and transparent process.

A 29-year-old man with no medical history presented with a left scalp abscess and left temporal oedema. He was initially started on treatment for community acquired Methicillin-resistant Staphylococcus aureus with sulfamethoxazole and trimethoprim. Over the next 2 weeks, his swelling improved; however, he continued to have localised swelling and drainage from the area. Eventually, larvae of a botfly were removed from his scalp, and his symptoms resolved.

OBJECTIVE:Alcohol misuse is common among primary care patients, yet many do not receive treatment because doctors believe problem drinkers are "in denial," or are unwilling to change their drinking habits. The real problem, however, may be that patients are being offered treatment modalities that do not meet their needs. This study was designed to measure the acceptability of various treatment options among drinkers who were currently not receiving treatment.METHOD:Patients in a primary care clinic were given a self-report questionnaire that included: (1) the Alcohol Use Disorders Questionnaire, (2) a measure of readiness to change drinking behavior, and (3) a list of treatment modalities to be rated based on level of interest.RESULTS:Within a random sample of 402 patients, 40.2% reported high risk drinking and 16.3% reported problem drinking. Among the latter group, 89.3% were either considering change, or had begun to take steps to make changes in their drinking behaviors. When asked about treatment preferences, the modalities most frequently recommended by physicians-group therapy and Alcoholics Anonymous-were among the least acceptable. The most popular options were getting help from a primary care doctor and taking a medication that would make it easier to avoid drinking without making them sick if they drank.CONCLUSIONS:The belief that problem drinkers are unwilling to change was not supported by this study. Treatment for problem drinking should involve a collaborative evaluation of options with an emphasis on patient preference and treatment within the primary care setting.