INTRODUCTION:A benefit of a milestone or Entrustable Professional Activity (EPA) assessment framework is the ability to capture longitudinal performance with growth curves using multi-level modelling (MLM). Growth curves can inform curriculum design and individualised learning. Residency programmes have found growth curves to vary by resident and by milestone. Only one study has analysed medical students' growth curves for EPAs. Analysis of EPA growth curves is critical because no change in performance raises concerns for EPAs as an assessment framework. METHODS:Spencer Fox Eccles School of Medicine-University of Utah students' workplace-based assessment ratings for 7 EPAs were captured at 3 time-points in years 3-4 of AY2017-2018 to AY2020-2021. MLM was used to capture EPA growth curves and determine if variation in growth curves was explained by internal medicine (IM) clerkship order. FINDINGS:A curvilinear slope significantly captured 256 students' average ratings overtime for EPA1a-history-taking, EPA2-clinical reasoning, EPA3-diagnostics, EPA5-documentation and EPA6-presentation, and a linear slope significantly captured EPA9-teamwork ratings, p ≤ 0.001. Growth curves were steepest for EPA2-clinical reasoning and EPA3-diagnostics. Growth curves varied by students, p < 0.05 for all EPA ratings, but IM clerkship rotation order did not significantly explain the variance, p > 0.05. DISCUSSION:The increase in ratings from Year 3 to Year 4 provides validity evidence for use of EPAs in an assessment framework. Students may benefit from more curriculum/skills practice for EPA2-clinical reasoning and EPA3-diagnostics prior to year 3. Variation in student's growth curves is important for coaching and skill development; a one size fits all approach may not suffice.

PURPOSE:To characterize the existence, accessibility, and content of parental leave policies, as well as barriers to program-level policy implementation among internal medicine (IM) program directors (PDs) and to assess the willingness of PDs to implement a national standardized policy.METHOD:In 2019, the Association of Program Directors in Internal Medicine conducted a survey of 422 IM PDs. Along with other content, 38 questions addressed 4 primary outcomes: parental leave policy existence, accessibility, content, and barriers. The authors compared programs with and without a program-level policy and applied qualitative content analysis to open-ended questions about barriers to policy implementation and openness to a national standard.RESULTS:The response rate was 69.4% (293/422). Of responding programs, 86% (250/290) reported a written parental leave policy with 43% (97/225) of these originating at the program level. Program-level policies, compared with policies at other levels, were more likely to address scheduling during pregnancy (38%, 36/95 vs 22%, 27/124; P = .018); peer coverage (24%, 21/89 vs 15%, 16/109; P = .037), how the duration of extended training is determined (81%, 72/89 vs 44%, 48/109; P < .001), and associated pay and benefits 61%, 54/89 vs 44%, 48/109; P = .009). PDs without program-level policy reported lacking guidance to develop policy, deferring upward to institutional policies, and wishing to retain flexibility. More than half of PDs (60%, 170/282) expressed agreement that a national standard for a residency program-level parental leave policy should exist. Those not in favor cited organization equity, lack of resources, implementation challenges, loss of flexibility, and potentially disadvantaging recruitment.CONCLUSIONS:While existing program-level policies included important content, most PDs reported not having them. A national standard to guide the development of program-level parental leave policies could be embraced if it provided flexibility for programs with limited resources.

Background:The personal statement is an integral part of a residency application but little guidance exists for medical students about what content to include.Objective:We use the framework of isomorphism, the process by which institutions model themselves after one another, to understand what internal medicine program directors (PDs) and associate program directors (APDs) recommend be included in the personal statement and how programs use personal statements in their selection of applicants to interview and rank.Methods:Semi-structured phone interviews were conducted between August and October 2020 with 13 academic PDs and APDs, who were selected for participation based on program size and geographic location. Interviews were recorded, transcribed, and coded using content analysis.Results:Effective personal statements should be well-written, present unique information, and demonstrate fit with a residency program. PDs and APDs recommended against expressing lack of interest in a program or highlighting negative personal characteristics. PDs and APDs used personal statements to distinguish between applicants and noted that personal statements help programs form an impression of the applicant. Consensus among PDs and APDs about what personal statements should include and how they are used indicates that isomorphism influences the match process.Conclusions:Our study found that the personal statement is a valued part of the residency application when it includes unique attributes and reveals personal values that align with that of the program. Additionally, PDs and APDs noted that when applicants highlight their unique characteristics, it can help distinguish themselves from others.

Purpose To characterize how female residents make decisions about childbearing, factors associated with the decision to delay childbearing, and satisfaction with these decisions. Method In 2017, the authors sent a voluntary, anonymous survey to 1,537 female residents enrolled across 78 graduate medical education programs, consisting of 25 unique specialties, at 6 U.S. academic medical centers. Survey items included personal, partner, and institutional characteristics, whether the respondent was delaying childbearing during residency, and the respondent's satisfaction with this decision. Results The survey response rate was 52% (n = 804). Among the 447 (56%) respondents who were married or partnered, 274 (61%) were delaying childbearing. Residents delaying childbearing were significantly more likely to be younger (P< .001), not currently a parent (P< .001), in a specialty with an uncontrollable lifestyle (P= .001), or in a large program (P= .004). Among self-reported reasons for delaying childbearing, which were not mutually exclusive, the majority cited a busy work schedule (n = 255; 93%) and desire not to extend residency training (n = 145; 53%). Many cited lack of access to childcare (n = 126; 46%), financial concerns (n = 116; 42%), fear of burdening colleagues (n = 96; 35%), and concern for pregnancy complications (n = 74; 27%). Only 38% (n = 103) of respondents delaying childbearing were satisfied with this decision, with satisfaction decreasing with increasing age. Conclusions Decisions to delay childbearing are more common in certain specialties, and many residents who delay childbearing are not satisfied with that decision. These findings suggest that greater attention is needed overall, and particularly in certain specialties, to promote policies and cultures that both anticipate and normalize parenthood in residency, thus minimizing the conflict between biological and professional choices for female residents.

In December 2019, an infectious respiratory illness of unknown causes was first identified in the city of Wuhan, in the Hubei province of China. The virus responsible for this syndrome was identified as a novel strain of coronavirus (SARS-CoV-2). It has subsequently undergone global spread, with the first case of the coronavirus disease (COVID-19) in the United States reported on January 20, 2020.1 As of April 30, 2020, there were over 3 million confirmed cases globally.2Graduate medical education (GME) programs face numerous challenges posed by the spread of COVID-19, including short staffing due to resident illness and quarantine measures, heavy workloads from a high burden of disease in the population, and disruption of normal training activities and schedules. Training programs all over the world are currently experiencing this initial surge of COVID-19 infections, but it is possible that programs will need to plan for multiple waves of the disease.3An institution's COVID-19 action plan should be developed by GME leaders in conjunction with clinical operations, employee health, and infection control leadership. Programs should develop strategies that balance resident and patient safety, clinical service, and education.During previous pandemics of viral illness, such as the global H1N1 influenza pandemic of 2009, physicians in training have reported high levels of exposure to circulating viruses, as well as low levels of adherence to work restrictions and personal protective equipment (PPE) recommendations.4 Appropriate PPE usage is as important for specialty training programs as it is for generalist services, as specialty programs care for patients on units throughout the hospital and draw from smaller pools of staff members. At all stages of pandemic preparedness, trainees should be given the opportunity to practice appropriate PPE techniques. For patient care requiring airborne precautions, trainees should be able to demonstrate the ability to appropriately use a powered air-purifying respirator and/or a N95 mask. Programs should be mindful that the model of N95 mask for which their residents are fit must match those available at each of their sites; fit testing is required for each model used. Consideration at some institutions has been given to excluding trainees from aerosolizing procedures on patients suspected of having COVID-19.5 Trainees often serve as leaders on cardiac arrest response teams. While the risk of COVID-19 transmission during cardiopulmonary resuscitation is not precisely known, the role of residents on cardiac response teams and any need for changes to standard "code blue" protocols should be discussed.6Modification of normal program activities to comply with public health recommendations regarding social distancing must be considered.7 One of the most challenging elements of COVID-19 epidemiology is the high rate of presymptomatic transmission.8 There is a possibility that the virus could spread within a residency program before any residents even report symptoms. Adjustments should be made to decrease or eliminate close resident contact when possible.9 Programs have devised electronic means of performing patient handoffs, educational conferences, meetings, and social events.5,10,11 High-touch surfaces in shared workspaces (including keyboards, telephones, mobile workstations, door handles, and pagers) should be cleaned regularly using an agent approved for disinfection.12 When appropriate, conversations with patients can occur using communication equipment. Physical examinations by trainees can be grouped with attending physician assessments so that trainees do not have to enter patient rooms multiple times. This also has the benefit of decreasing the already limited amount of PPE used in caring for patients. Some surgical services have increased the use of dissolvable sutures so that fewer return visits for suture removal need to be performed.13Institutional policies for returning to work after illness vary depending on available resources. Programs should be familiar with their institution's illness and COVID-19 testing policies. In general, residents with symptoms such as fever, cough, malaise, and myalgias should be excluded from work-related activities. Residents at risk of developing complications from COVID-19, such as those with immunosuppression or pregnancy, should be given an opportunity to confidentially contact program leadership with their concerns so that accommodations can be made to limit their exposure as much as possible. Finally, trainees during prior pandemics have reported high levels of stress and anxiety: programs should ensure mechanisms are in place for monitoring trainee emotional well-being.15Resident physicians are a critical component of the health care workforce and can be an asset in caring for those infected with COVID-19. Challenges to maintaining required clinical services faced by training programs will vary by specialty and disease prevalence. The Accreditation Council for Graduate Medical Education has outlined 3 levels of disruption to training programs, ranging from "business as usual" to emergency status (Table).14 In areas with high COVID-19 prevalence, health systems have been strained to the breaking point. Training programs in hospital systems overwhelmed by COVID-19 cases may find that they must shift their residents to help meet increased patient care demands. Training programs must partner early with clinical operations leaders in their health care system to develop a plan for what increased staffing requirements will be needed, as well as what can reasonably be provided by trainees. In a pandemic emergency, trainees will likely be asked to shift to higher acuity settings, such as intensive care units or hospital wards. In some cases, trainees may be asked to provide care in areas in which they have not traditionally been assigned.5 Institutional GME leadership should identify potential roles suitable for different groups of trainees before emergency status is reached. Programs should ensure that adequate supervision of trainees is provided, especially for those assigned to units with which they are less familiar.Clinical services also become disrupted in areas of lower COVID-19 prevalence due to the canceling of elective procedures and limiting of travel outside the home. Educating trainees in the use of telehealth equipment, procedures, and etiquette is vital to ensure patients are still able to receive care.13 Due to the likelihood of trainees becoming ill during the pandemic, thought should be given to expanding backup coverage of critical service lines.9,10 With the closure of schools and day care facilities, alternative sources of childcare should be identified.The challenges to trainee education from the COVID-19 pandemic vary by specialty. Many programs have reported success in providing didactics over videoconferencing software, even for interactive sessions such as morning report.11,16–18 In addition to maintaining education as a priority, continuing educational conferences helps maintain a feeling of normalcy, which programs have reported residents desire.10 The COVID-19 pandemic itself has served as an educational opportunity for residents to learn about epidemiology, population health, systems-based care, and advocacy.11Some programs will experience an impact on their trainees' ability to participate in enough cases or clinical activities to advance their training. This has been noted as a concern in surgical specialties, radiology, and radiation oncology.16–19 Possible methods proposed for providing exposure to a larger number of cases include the use of simulation centers, faculty-led review of surgical videos, and online discussion of board examination questions and topics.17 The cost of online and teleconferencing resources and simulation center time must be considered. Institutional subscriptions to these services should be leveraged when possible. Blinded historical radiology studies can be considered for evaluating reading aptitude.16 Time away from clinical duties due to canceled elective cases can be spent on scholarly activity.19 Ultimately, program leadership will need to closely monitor resident exposure to critical procedures in order to ensure they have the experience necessary to progress.Finally, providing trainees with clear, consistent messaging is both challenging and important. Programs should consider developing a standardized format and frequency of updates to prevent confusion from information overload.10,20 The pandemic also threatens the sense of community within programs. Programs should consider using virtual hangouts, social media, and check-ins with mentors to maintain this sense of community during the pandemic. The trajectory of the pandemic is uncertain; therefore, programs should have protocols for onboarding and graduating trainees if in-person orientations and graduations are not possible.The world currently faces perhaps the greatest acute public health crisis since the 1918 influenza pandemic. It is not known how long the challenges imposed by the COVID-19 pandemic will persist. However, GME programs will likely need to be prepared for future waves of infection. Each institution's response must be tailored to its unique circumstance and constantly adjusted as the situation develops. Now is the time to refine strategies that balance safety, clinical service, and education in order to weather the storm.

Purpose To characterize determinants of resident maternity leave and the effect of length of leave on maternal well-being. Method In 2017, the authors sent a voluntary, anonymous survey to female residents at 78 programs, in 25 unique specialties, at 6 institutions. Survey items included personal, partner, and child demographics, and logistics of leave, including whether leave was paid or vacation or sick leave was used. Outcomes were maternity leave length; duration of breastfeeding; burnout and postpartum depression screens; perceptions of support; and satisfaction with length of leave, breastfeeding, and childbearing during residency. Results Fifty-two percent (804/1,537) of residents responded. Among 16% (126) of respondents who were mothers, 50% (63) had their first child during residency. Seventy-seven maternity leaves were reported (range, 2-40 weeks), with most taking 6 weeks (32% of leaves; 25) and including vacation (81%; 62) or sick leave (64%; 49). Length of leave was associated with institution, use of sick leave or vacation, and amount of paid leave. The most frequently self-reported determinant of leave was the desire not to extend residency training (27%; 59). Training was not extended for 53% (41) of mothers; 9% (7) were unsure. Longer breastfeeding duration and perceptions of logistical support from program administration were associated with longer maternity leaves. Burnout affected approximately 50% (38) of mothers regardless of leave length. Conclusions This study illustrates variability in administration of resident maternity leaves. Targets for intervention include policy clarification, improving program support, and consideration of parent wellness upon return to work.

BACKGROUND: Feedback is a critical element of graduate medical education. Narrative comments on evaluation forms are a source of feedback for residents. As a shared mental model for performance, milestone-based evaluations may impact narrative comments and resident perception of feedback. OBJECTIVE: To determine if milestone-based evaluations impacted the quality of faculty members' narrative comments on evaluations and, as an extension, residents' perception of feedback. DESIGN: Concurrent mixed methods study, including qualitative analysis of narrative comments and survey of resident perception of feedback. PARTICIPANTS: Seventy internal medicine residents and their faculty evaluators at the University of Utah. APPROACH: Faculty narrative comments from 248 evaluations pre- and post-milestone implementation were analyzed for quality and Accreditation Council for Graduate Medical Education competency by area of strength and area for improvement. Seventy residents were surveyed regarding quality of feedback pre- and post-milestone implementation. KEY RESULTS: Qualitative analysis of narrative comments revealed nearly all evaluations pre- and post-milestone implementation included comments about areas of strength but were frequently vague and not related to competencies. Few evaluations included narrative comments on areas for improvement, but these were of higher quality compared to areas of strength (p <= 0.001). Overall resident perception of quality of narrative comments was low and did not change following milestone implementation (p = 0.562) for the 86% of residents (N = 60/70) who completed the pre- and post-surveys. CONCLUSIONS: The quality of narrative comments was poor, and there was no evidence of improved quality following introduction of milestone-based evaluations. Comments on areas for improvement were of higher quality than areas of strength, suggesting an area for targeted intervention. Residents' perception of feedback quality did not change following implementation of milestone-based evaluations, suggesting that in the post-milestone era, internal medicine educators need to utilize additional interventions to improve quality of feedback.

Background: In May 2017, the Alliance for Academic Internal Medicine (AAIM) published guidelines intending to standardize and improve internal medicine residency program director (PD) letters of recommendation (LORs) for fellowship applicants. Objectives: This study aimed to examine fellowship PDs impressions of the new guidelines, letter writers’ adherence to the guidelines, and the impact of LORs that conformed to guidelines compared to non-standardized letters. Methods: The authors anonymously surveyed fellowship PDs from January to March 2018 to gather input about LORs submitted to their programs during the 2017 fellowship application cycle. Results: A total of 78% of survey respondents were satisfied with letters that followed the AAIM guidelines, whereas 48% of respondents were satisfied with letters that did not. Fellowship PDs felt that letters that followed the AAIM guidelines were more helpful than letters that did not, especially for differentiating between applicants from the same institution and for understanding residents’ performance across the six core competency domains. Fellowship PDs provided several suggestions for residency PDs to make the LORs even more helpful. Conclusion: Fellowship PD respondents indicated that LORs that followed the new AAIM guidelines were more helpful than letters that did not.

Perspectives Viewpoints•Despite its ubiquity, the current letter of recommendation has multiple limitations, including lack of standardization.•Program director letters should provide an accurate, fair assessment of a fellowship applicant's capabilities, while also enabling writers to advocate.•Standardized letters of recommendation have shown increased reliability as a predictor of future performance, greater inter-rater reliability, and improved task efficiency for writers and readers. •Despite its ubiquity, the current letter of recommendation has multiple limitations, including lack of standardization.•Program director letters should provide an accurate, fair assessment of a fellowship applicant's capabilities, while also enabling writers to advocate.•Standardized letters of recommendation have shown increased reliability as a predictor of future performance, greater inter-rater reliability, and improved task efficiency for writers and readers. A program director's letter of recommendation (LOR) for fellowship should provide an accurate, fair assessment of a fellowship applicant's capabilities while also retaining an advocacy function for the letter writer. The standard approach to these letters takes a “narrative” form. In this article, we will show why a standardized or templated approach is preferable. Recent surveys of fellowship program directors rated the program director LOR as one of the 3 most important factors for deciding whom to interview and how to rank, confirming the continued high stakes nature of these letters.1Grabowski G. Walker J.W. Orthopaedic fellowship selection criteria: a survey of fellowship directors.J Bone Joint Surg Am. 2013; 95: 154-159Crossref Scopus (49) Google Scholar One format for the LOR, defined as narrative letter of recommendation (NLOR), involves each author choosing personal and academic attributes of an applicant to advocate for fellowship placement without benefit of shared meaning or common standards. NLORs remain the “gold standard” despite multiple limitations, including: poor predictive power for performance; limited agreement on common terminology; leniency bias; variability in fellowship program director experience and interpretative ability; and bias in the favorability of the letter writing based on affective disposition of the writer and other writer-related attributes that do not relate to learner characteristics.2DeZee K.J. Thomas M.R. Mintz M. Durning S.J. Letters of recommendation: rating, writing, and reading by clerkship directors of internal medicine.Teach Learn Med. 2009; 21: 153-158Crossref PubMed Scopus (36) Google Scholar, 3Balentine J. Gaeta T. Spevack T. Evaluating applicants to emergency medicine residency programs.J Emerg Med. 1999; 17: 131-134Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 4Wright S.M. Ziegelstein R.C. Writing more informative letters of reference.J Gen Intern Med. 2004; 19: 588-593Crossref PubMed Scopus (18) Google Scholar, 5Hamdy H. Prasad K. Anderson M.B. et al.BEME systematic review: predictive values of measurements obtained in medical schools and future performance in medical practice.Med Teach. 2006; 28: 103-116Crossref PubMed Scopus (132) Google Scholar, 6Magarian G.J. Mazur D.J. A national survey of grading systems used in medicine clerkships.Acad Med. 1990; 65: 636-639Crossref PubMed Scopus (19) Google Scholar, 7Dirschl D.R. Adams G.L. Reliability in evaluating letters of recommendation.Acad Med. 2000; 75: 1029Crossref PubMed Scopus (57) Google Scholar, 8Alexander E.K. Osman N.Y. Walling J.L. Mitchell V.G. Variation and imprecision of clerkship grading in US medical schools.Acad Med. 2012; 87: 1070-1076Crossref PubMed Scopus (77) Google Scholar, 9Aamodt M.G. Applied Industrial Psychology.3rd ed. Brooks/Cole, London1999Google Scholar, 10Love J.N. Ronan-Bentle S.E. Lane D.R. Hegarty C.B. The standardized letter of evaluation for postgraduate training: a concept whose time has come?.Acad Med. 2016; 91: 1480-1482Crossref PubMed Scopus (20) Google Scholar, 11Judge T.A. Higgins C.A. Affective disposition and the letter of reference.Organ Behav Hum Decis Process. 1998; 75: 207-221Crossref PubMed Scopus (20) Google Scholar, 12Colarelli S.M. Hechanova-Alampay R. Canali K.G. Letters of recommendation: an evolutionary psychological perspective.Hum Relat. 2002; 55: 315-344Crossref Scopus (20) Google Scholar Moreover, there is an increased perception in the favorability of an NLOR based on its length. The longer the letter, the better the candidate is perceived to be by the reader—regardless of what is actually stated in the letter.11Judge T.A. Higgins C.A. Affective disposition and the letter of reference.Organ Behav Hum Decis Process. 1998; 75: 207-221Crossref PubMed Scopus (20) Google Scholar NLORs, therefore, have been criticized as achieving an advocacy function without providing sufficient objective evaluation of performance.13Lee A.G. Golnik K.C. Oetting T.A. et al.Re-engineering the resident applicant selection process in ophthalmology: a literature review and recommendations for improvement.Surv Ophthalmol. 2008; 53: 164-176Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar In contrast to NLORs, standardized letters of recommendation (SLORs) demonstrate increased reliability as predictors of performance, greater interrater reliability, and improved task efficiency for writers and readers.14Walters A.M. Kyllonen P.C. Plante J.W. Developing a standardized letter of recommendation.J Coll Admiss. 2006; 190: 8-17Google Scholar, 15Prager J.D. Perkins J.N. McFann K. Myer 3rd, C.M. Pensak M.L. Chan K.H. Standardized letter of recommendation for pediatric fellowship selection.Laryngoscope. 2012; 122: 415-424Crossref PubMed Scopus (15) Google Scholar, 16Love J.N. Deiorio N.M. Ronan-Bentle S. et al.Characterization of the council of emergency medicine residency directors' standardized letter of recommendation in 2011-2012.Acad Emerg Med. 2013; 20: 926-932Crossref PubMed Scopus (30) Google Scholar, 17Love J.N. Smith J. Weizberg M. et al.Council of emergency medicine residency directors' standardized letter of recommendation: The program director's perspective.Acad Emerg Med. 2014; 21: 680-687Crossref PubMed Scopus (48) Google Scholar SLORs have proven easier to interpret, regardless of the level of experience of the interpreter.10Love J.N. Ronan-Bentle S.E. Lane D.R. Hegarty C.B. The standardized letter of evaluation for postgraduate training: a concept whose time has come?.Acad Med. 2016; 91: 1480-1482Crossref PubMed Scopus (20) Google Scholar Use of the Accreditation Council for Graduate Medical Education competencies to organize SLORs has been shown to be the most predictive of future performance.18Stohl H.E. Hueppchen N.A. Bienstock J.L. The utility of letters of recommendation in predicting resident success: Can the ACGME competencies help?.J Grad Med Educ. 2011; 3: 387-390Crossref PubMed Google Scholar In particular, commentary on 3 specific competencies—patient care and procedure skills, medical knowledge, and interpersonal and communication skills—was significantly different between high performers and low performers.18Stohl H.E. Hueppchen N.A. Bienstock J.L. The utility of letters of recommendation in predicting resident success: Can the ACGME competencies help?.J Grad Med Educ. 2011; 3: 387-390Crossref PubMed Google Scholar, 19Greenburg A.G. Doyle J. McClure D.K. Letters of recommendation for surgical residencies: what they say and what they mean.J Surg Res. 1994; 56: 192-198Abstract Full Text PDF PubMed Scopus (54) Google Scholar Standardization improves reviewer ability to directly compare applicants and supports the increasing interest within the graduate medical education community to create common principles.20Liu O.L. Minsky J. Ling G. Kyllonen P. Using the standardized letters of recommendation in selection: results from a multidimensional rasch model.Educ Psychol Meas. 2009; 69: 475-492Crossref Scopus (16) Google Scholar, 21Lang V.J. Aboff B.M. Bordley D.R. et al.Guidelines for writing department of medicine summary letters.Am J Med. 2013; 126: 458-463Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar In 2015, the Alliance for Academic Internal Medicine (AAIM) Resident to Fellow Interface Committee created draft guidelines for an SLOR template for internal medicine fellowship letter writers after an extensive literature review. After early feedback from leadership and membership entities, AAIM charged a task force to further modify the draft guidelines and to address issues identified by stakeholders in the Association of Program Directors in Internal Medicine (APDIM) and the Association of Specialty Professors (ASP). The updated draft guidelines, with minor modifications, were approved by association councils and endorsed by the AAIM Board of Directors in January 2017. These guidelines present the program director's letter as a summary of residency performance (Figure). However, recognizing that LORs are most commonly written at the end of the second year of training, applicants may not have achieved competence in all training milestones. Without exceeding 2 pages, the letter should provide wide-ranging but specific information on observed performance. Comments should be as succinct as possible. The letters should be completed by July 1 to maximize availability to fellowship program directors.FigureGuidelines for writing program director summary letters. IM-ITE = Internal Medicine In-Training Examination; USMLE = United States Medical Licensing Examination.View Large Image Figure ViewerDownload Hi-res image Download (PPT) To provide context for the reader or reviewer, the opening paragraph of the letter should include key facts about the hospital training site(s), types of rotations completed, and unique features of the residency program. Subsequent paragraphs should include information from direct observations of the resident that may not be apparent from the Electronic Residency Application Service application. Potential items include degree of engagement in residency initiatives; emotional intelligence; and measures of resiliency, such as capacity for self-reflection, proactive engagement in addressing personal and professional limitations, responsiveness to coaching/mentoring, and interests outside of medicine.22Zwack J. Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians.Acad Med. 2013; 88: 382-389Crossref PubMed Scopus (265) Google Scholar, 23Epstein R.M. Krasner M.S. Physician resilience: what it means, why it matters, and how to promote it.Acad Med. 2013; 88: 301-303Crossref PubMed Scopus (274) Google Scholar The program director should then report on the performance of the resident in each of the 6 competencies, including competency achievement. This information should not be a synopsis of clinical competency committee evaluations because those documents should be formative and protected. Medical knowledge should be assessed via direct observation from supervisors. As such, it may be inferior to the results of the Internal Medicine In-Training Examination, which are protected data and limited to learner assessment and program evaluation.24Collichio F.A. Hess B.J. Muchmore E.A. et al.Medical knowledge assessment by hematology and medical oncology in-training examinations are better than program director assessments at predicting subspecialty certification examination performance.J Cancer Educ. 2016; ([e-pub ahead of print])https://doi.org/10.1007/s13187-016-0993-6Crossref PubMed Scopus (7) Google Scholar, 25American College of PhysiciansIM-ITE®. The ACP Internal Medicine In-Training Examination® is a web-based self-assessment exam for residents to assess their progress.https://www.acponline.org/featured-products/medical-educator-resources/im-iteGoogle Scholar In addition, a description of scholarly contributions should be included to highlight specific areas of the resident's curriculum vitae. Broadly defined, scholarly activity includes involvement of the resident in formulation of questions about quality improvement, patient safety, education, or clinical research. The description should also include the type of scholarly activity, such as oral abstract presentation or peer-reviewed publication. When relevant to the resident's candidacy, previous scholarly pursuits in medical school or other activities could be emphasized. The final paragraphs of the letter should include any skills the resident sought to master beyond the ones usually required of residents (eg, proficiency in interpreting echocardiograms) and a statement of any performance-related extensions in training, curtailment of clinical privileges, or formal probation. The letter should conclude with an overall assessment of the resident's suitability as a candidate for the fellowship. It is recommended that this material should not include a ranking of the resident's performance in the residency program because it may impair the advocacy function of the letter of recommendation. These guidelines represent the perspectives of faculty and staff who read and write program director letters of recommendation and who seek to structure the SLOR to effectively achieve its dual purposes. The proposed template provides areas to discuss institutional features regarding the clinical and learning environment and a competency-based overview of performance, while still allowing for anecdotal evidence of noncognitive traits and delineation of special skills. Few program directors have received formal training in the writing of letters of recommendation. Combined with increasing turnover of program directors in internal medicine, there is often inadequate time to achieve mastery of this skill.26Prager J.D. Myer 3rd, C.M. Pensak M.L. Improving the letter of recommendation.Otolaryngol Head Neck Surg. 2010; 143: 327-330Crossref PubMed Scopus (9) Google Scholar, 27Alliance for Academic Internal Medicine2015 APDIM program director survey summary file.http://www.im.org/p/cm/ld/fid=506Google Scholar Standardizing the process will assist the novice program director's portrayal of the resident's skillsets and areas for continued growth as capably as an experienced program director. Similarly, the novice letter-reader will benefit from receiving information in a standardized manner, allowing for a more direct comparison between candidates. This shared template should therefore be a more efficient method of information delivery and save time for both the letter writer and the letter reader (Table).TableDifferences Between NLOR and SLORNLORSLORVariation in terminologySignificantLessVariation in lengthSignificantLessInter-rater reliabilityLowHighInterpretationCan be difficultEasierACGME competenciesVariableAlways mentionedMeaningful comparison of applicantsCan be difficultEasierInstitution/program characteristicsVariableAlways mentionedACGME = Accreditation Council for Graduate Medical Education; NLOR = narrative letter of recommendation; SLOR = standardized letters of recommendation. Open table in a new tab ACGME = Accreditation Council for Graduate Medical Education; NLOR = narrative letter of recommendation; SLOR = standardized letters of recommendation. Nevertheless, an SLOR may not be a panacea. Although not reported in specialties already using standardized letter formats (eg, emergency medicine and pediatric otorhinolaryngology), the possibility remains that increased standardization will result in a lack of variation in the letters, making it more difficult, rather than less, to distinguish between applicants. Program directors may choose not to use or may not know of the recommended format, leading to confusion and potentially disadvantaging candidates if their program director letter of recommendation does not match the expectations of the fellowship program director. There is also the possibility that small residency programs or programs with small numbers of residents who pursue fellowship may be disadvantaged by the reporting of demographic data in the template. Program directors of large residency programs may also struggle to base recommendations on observed performance of all applicants without using clinical competency committee evaluations or Internal Medicine In-Training Examination scores. In these instances, we encourage all program leaders to share in the development of SLORs. Use of the new format will require faculty development and widespread dissemination, which will result in increased resource utilization during the transition period. Additionally, because the guidelines are not mandatory, the effects of uneven adoption across programs will need further study. No formal assessment of whether program directors will feel comfortable with or capable of reporting mid-training competency assessments was conducted. Because each subcompetency is unlikely to be assessed continuously during all phases of residency training, data on an individual subcompetency may be limited or nonexistent at the time the letters need to be written for inclusion in the Electronic Residency Application Service application. Finally, the template has not been the subject of validity studies or psychometric analyses; therefore, it may not be structurally successful in reporting the material in the manner expected. These guidelines represent the position that an SLOR is superior to the traditional NLOR. Further validity studies are needed to test the supposition that this template will allow novice and experienced residency and fellowship program directors to share a common lexicon, while becoming more efficient in the processes of advocacy and performance reporting.

OBJECTIVES:To determine the impact of systemwide charge display on laboratory utilization.METHODS:This was a randomized controlled trial with a baseline period and an intervention period. Tests were randomized to a control arm or an active arm. The maximum allowable Medicare reimbursement rate was displayed for tests in the active arm during the intervention period. Total volume of tests in the active arm was compared with those in the control arm. Residents were surveyed before and after the intervention to assess charge awareness.RESULTS:Charge display had no effect on order behavior. This result held for patient type (inpatient vs outpatient) and for insurance category (commercial, government, self-pay). Residents overestimated the charges of tests both before and after the intervention. Many residents failed to notice the charge display in the computerized order entry system.CONCLUSIONS:The impact of charge display depends on context. Charge display is not always effective.

Welcome to Annals of Global Health,Annals of Global Health is a peer-reviewed, fully open access, online journal dedicated to publishing high quality articles dedicated to all aspects of global health. The journal's mission is to advance global health, promote research, and foster the prevention and treatment of disease worldwide. Its goals are to improve the health and well-being of all people, advance health equity, and promote wise stewardship of the earth's environment. The latest journal impact factor is 3.64.Annals of Global Health is supported by the Program for Global Public Health and the Common Good at Boston College. It was founded in 1934 by the Icahn School of Medicine at Mount Sinai as the Mount Sinai Journal of Medicine. It is a partner journal of the Consortium of Universities for Global Health. Authors of articles accepted for publication in Annals of Global Health will be asked to pay an Article Publication Charge (APC) to cover publication costs. This charge can normally be sourced from your funder or institution. We are committed to supporting authors from all countries to publish their work in Annals of Global Health regardless of national income level, and to achieve this goal, we waive the Article Publication Charge for manuscripts where all authors are from low-income or lower-middle-income countries (as defined by the World Bank). From time to time, Annals of Global Health publishes Special Collections, a series of articles organized around a common theme in global health. Recent Special Collections have included “Strengthening Women’s Leadership in Global Health”, “Decolonizing Global Health Education”, and “Capacity Building for Global Health Leadership Training”. Global health workers interested in developing a Special Collection are strongly encouraged to contact the Managing Editor in advance to discuss the project.

BACKGROUND:Musculoskeletal (MSK) problems are common, and a recent US Bone and Joint Initiative calls for new models of education and professional collaboration. Evidence of feasibility and acceptability of innovative methods are needed.OBJECTIVE:We assessed if an experimental immersion interdisciplinary MSK curriculum would be acceptable to residents from different specialties, be feasible within existing rotations, and be effective in strengthening clinical skills.METHODS:Through funding from the Veterans Affairs Office of Academic Affiliations and the Office of Specialty Care, we developed a Center of Excellence in MSK Care and Education. A core element is the monthly MSK Education Week, which teaches skills and provides opportunities to apply these in clinical settings. Participants include internal medicine, physical medicine and rehabilitation, and orthopaedic surgery residents, as well as students and residents from other health professions programs. All were assigned to the MSK week in lieu of other clinical experiences. Faculty encompassed primary care, rheumatology, endocrinology, orthopaedics, and physical medicine and rehabilitation. Assessments include surveys and a 2-station objective structured clinical examination (OSCE).RESULTS:Since 2012, a total of 176 trainees have participated. Percentage of trainees reporting ability to evaluate and manage MSK complaints increased (9% to 87% for shoulder; 18% to 86% for knee), and confidence performing MSK injections increased from 10% to 70%. Competency in evaluation of shoulder and knee pain was confirmed by OSCEs.CONCLUSIONS:The MSK week program was accepted by residents from the 3 specialties, with learners reporting improved ability to perform shoulder and knee examinations, as demonstrated by OSCEs.

Purpose: Smartphone technology offers a multitude of applications (apps) that provide a wide range of functions for healthcare professionals. Medical trainees are early adopters of this technology, but how they use smartphones in clinical care remains unclear. Our objective was to further characterize smartphone use by medical trainees at two United States academic institutions, as well as their prior training in the clinical use of smartphones. Methods: In 2014, we surveyed 347 internal medicine and emergency medicine resident physicians at the University of Utah and Brigham and Women's Hospital about their smartphone use and prior training experiences. Scores (0%-100%) were calculated to assess the frequency of their use of general features (email, text) and patient-specific apps, and the results were compared according to resident level and program using the Mann-Whitney U-test. Results: A total of 184 residents responded (response rate, 53.0%). The average score for using general features, 14.4/20 (72.2%) was significantly higher than the average score for using patient-specific features and apps, 14.1/44 (33.0%, P<0.001). The average scores for the use of general features, were significantly higher for year 3-4 residents, 15.0/20 (75.1%) than year 1-2 residents, 14.1/20 (70.5%, P=0.035), and for internal medicine residents, 14.9/20 (74.6%) in comparison to emergency medicine residents, 12.9/20 (64.3%, P=0.001). The average score reflecting the use of patient-specific apps was significantly higher for year 3-4 residents, 16.1/44 (36.5%) than for year 1-2 residents, 13.7/44 (31.1%; P=0.044). Only 21.7% of respondents had received prior training in clinical smartphone use. Conclusion: Residents used smartphones for general features more frequently than for patient-specific features, but patient-specific use increased with training. Few residents have received prior training in the clinical use of smartphones.

Welcome to Annals of Global Health,Annals of Global Health is a peer-reviewed, fully open access, online journal dedicated to publishing high quality articles dedicated to all aspects of global health. The journal's mission is to advance global health, promote research, and foster the prevention and treatment of disease worldwide. Its goals are to improve the health and well-being of all people, advance health equity, and promote wise stewardship of the earth's environment. The latest journal impact factor is 3.64.Annals of Global Health is supported by the Program for Global Public Health and the Common Good at Boston College. It was founded in 1934 by the Icahn School of Medicine at Mount Sinai as the Mount Sinai Journal of Medicine. It is a partner journal of the Consortium of Universities for Global Health. Authors of articles accepted for publication in Annals of Global Health will be asked to pay an Article Publication Charge (APC) to cover publication costs. This charge can normally be sourced from your funder or institution. We are committed to supporting authors from all countries to publish their work in Annals of Global Health regardless of national income level, and to achieve this goal, we waive the Article Publication Charge for manuscripts where all authors are from low-income or lower-middle-income countries (as defined by the World Bank). From time to time, Annals of Global Health publishes Special Collections, a series of articles organized around a common theme in global health. Recent Special Collections have included “Strengthening Women’s Leadership in Global Health”, “Decolonizing Global Health Education”, and “Capacity Building for Global Health Leadership Training”. Global health workers interested in developing a Special Collection are strongly encouraged to contact the Managing Editor in advance to discuss the project.

Background The effects of electronic health records (EHRs) on doctor-patient communication are unclear.Objective To evaluate the effects of EHR use compared with paper chart use, on novice physicians' communication skills.Design Within-subjects randomized controlled trial using observed structured clinical examination methods to assess the impact of use of an EHR on communication.Setting A large academic internal medicine training program.Population First-year internal medicine residents.Intervention Residents interviewed, diagnosed, and initiated treatment of simulated patients using a paper chart or an EHR on a laptop computer. Video recordings of interviews were rated by three trained observers using the Four Habits scale.Results Thirty-two residents completed the study and had data available for review (61.5% of those enrolled in the residency program). In most skill areas in the Four Habits model, residents performed at least as well using the EHR and were statistically better in six of 23 skills areas (p<0.05). The overall average communication score was better when using an EHR: mean difference 0.254 (95% CI 0.05 to 0.45), p = 0.012, Cohen's d of 0.47 (a moderate effect). Residents scoring poorly (>3 average score) with paper methods (n = 8) had clinically important improvement when using the EHR.Limitations This study was conducted in first-year residents in a training environment using simulated patients at a single institution.Conclusions Use of an EHR on a laptop computer appears to improve the ability of first-year residents to communicate with patients relative to using a paper chart.

Welcome to Annals of Global Health,Annals of Global Health is a peer-reviewed, fully open access, online journal dedicated to publishing high quality articles dedicated to all aspects of global health. The journal's mission is to advance global health, promote research, and foster the prevention and treatment of disease worldwide. Its goals are to improve the health and well-being of all people, advance health equity, and promote wise stewardship of the earth's environment. The latest journal impact factor is 3.64.Annals of Global Health is supported by the Program for Global Public Health and the Common Good at Boston College. It was founded in 1934 by the Icahn School of Medicine at Mount Sinai as the Mount Sinai Journal of Medicine. It is a partner journal of the Consortium of Universities for Global Health. Authors of articles accepted for publication in Annals of Global Health will be asked to pay an Article Publication Charge (APC) to cover publication costs. This charge can normally be sourced from your funder or institution. We are committed to supporting authors from all countries to publish their work in Annals of Global Health regardless of national income level, and to achieve this goal, we waive the Article Publication Charge for manuscripts where all authors are from low-income or lower-middle-income countries (as defined by the World Bank). From time to time, Annals of Global Health publishes Special Collections, a series of articles organized around a common theme in global health. Recent Special Collections have included “Strengthening Women’s Leadership in Global Health”, “Decolonizing Global Health Education”, and “Capacity Building for Global Health Leadership Training”. Global health workers interested in developing a Special Collection are strongly encouraged to contact the Managing Editor in advance to discuss the project.