Based upon student ratings of such factors as predictable work hours and personal time, medical specialties have been identified as lifestyle friendly, intermediate, or unfriendly. Lifestyle friendly programs may be more desirable, more competitive, and for students elected to the Alpha Omega Alpha (AOA) Honor Medical Society, more attainable.

In this issue, Mullan and colleagues propose a new social mission measure to evaluate and rank medical schools. The data presented show that medical schools differ greatly from each other in their ...

The Accreditation Council for Graduate Medical Education Outcomes Project has successfully initiated a shift in focus on residency education from process measures to educational outcomes. The next phase of this transformation is the development of clear milestones to mark incremental steps toward competency. The development of these milestones for internal medicine is an important and challenging task that has been undertaken by a group of educators and residents facilitated by the American Board of Internal Medicine. Representatives from multiple key stakeholder groups are participating in this initiative, including, but not limited to, the Alliance for Academic Internal Medicine, the Association of Program Directors in Internal Medicine, the Society of General Internal Medicine, and the American College of Physicians. This project will advance our understanding of the incremental achievement of competency in the many areas of professional development and inform the even more difficult next task of developing reliable tools to assess a resident's progress toward competency.1Chambers D.W. Glassman P. A primer on competency-based evaluation.J Dent Educ. 1997; 61: 651-666PubMed Google ScholarPerspectives Viewpoints•Development of residency education competency milestones for internal medicine has been undertaken by ABIM and key stakeholders such as AAIM, APDIM, SGIM, and ACP.•Residents will be empowered with a clear set of expectations, and program directors will be able to monitor residents' progress, identify those who are not reaching goals on schedule, and plan timely remediation.•However, advancement based not on time but on the achievement of competency ignores important realities that could have significant deleterious consequences. •Development of residency education competency milestones for internal medicine has been undertaken by ABIM and key stakeholders such as AAIM, APDIM, SGIM, and ACP.•Residents will be empowered with a clear set of expectations, and program directors will be able to monitor residents' progress, identify those who are not reaching goals on schedule, and plan timely remediation.•However, advancement based not on time but on the achievement of competency ignores important realities that could have significant deleterious consequences. If successful, this initiative will vastly improve current methods of evaluating residency programs and individual practitioners. With milestones and assessment tools in place, the Accreditation Council for Graduate Medical Education will measure the success of residency programs by the growth of their residents, rather than by the program's ability to conform to process rules.2Nasca T.J. Where will the milestones take us? The next accreditation system.in: ACGME Bulletin. September 2008: 3-5Google Scholar Likewise, with milestones and assessment tools in place, the American Board of Internal Medicine will certify individual practitioners with confidence that they have achieved competency not just in medical knowledge, the only area currently objectively assessed, but in the 5 remaining core competencies. We, the authors, fully support both of these objectives. We believe there will be significant benefits to individual residents and program directors. Residents will be empowered with a clear set of expectations that will allow monitoring of their own progress, as well as establishing and pursuing personal learning goals. Program directors will be able to monitor residents' progress, identify those who are not reaching goals on schedule, and plan timely remediation. Competency-based assessment also will allow identification of residents who are progressing more rapidly than expected.3Rethans J.J. Norcini J.J. Baron-Maldonado M. et al.The relationship between competence and performance: implications for assessing practice performance.Med Educ. 2002; 36: 901-909Crossref PubMed Scopus (278) Google Scholar, 4Davis M.H. Harden R.M. Competency-based assessment: making it a reality.Med Teach. 2003; 25: 565-568Crossref PubMed Scopus (32) Google Scholar We believe the choices we make about these “advanced” residents are critical and carry inherent risks that have not received sufficient attention. Some have suggested that once measurable competency is achieved, it makes sense for the resident to leave the core program and move on to the next step of their career, whether that is fellowship or practice. Advancement would be based not on the passage of an arbitrary period of time—3 years in the case of internal medicine—but on the achievement of competency.5Holmboe E. Competency Based Training: Overview and Issues. American Board of Internal Medicine, Philadelphia, PA2008Google Scholar Though this concept is initially compelling, we urge caution in moving training in this direction.6Norman G.R. The adult learner: a mythical species.Acad Med. 1999; 74: 886-889Crossref PubMed Scopus (94) Google Scholar This approach ignores important realities that, if unaddressed, could have significant deleterious consequences to all physicians-in-training. We are concerned that the “one-resident-at-a-time” focus of competency-based training ignores the reality that a residency program is a delicate ecosystem where residents depend heavily on their peers for growth and learning. This supportive social learning community struggles, advances, and grows together, and mutually fosters the individual transition from student to physician for each member of the group. The high standards of the residency program, and of the profession, are embodied by the top residents in the program. Their example inspires and cultivates the growth of all residents in the program. In addition to sharing their knowledge in team-based conferences such as morning report and noon conference, these elite residents are role models for the embodiment of professionalism, the delivery of patient care, the effectiveness of interpersonal skills, and the importance of practice-based learning. Removal of the best peer role models, those residents who will be deemed competent earliest and encouraged by a system of competency-based advancement to leave the core residency early, will substantially reduce the educational environment for all residents. Allowing residents to become single-mindedly focused on their individual competency and advancement encourages them to lose sight of their responsibility to the rest of the learning community. When we recite the Hippocratic Oath, we promise “to consider dear to me … him who taught me this art; to look upon his children as my own brothers, to teach them this art.”6Norman G.R. The adult learner: a mythical species.Acad Med. 1999; 74: 886-889Crossref PubMed Scopus (94) Google Scholar The Accreditation Council for Graduate Medical Education declares that one of the central tenets of professionalism is that “residents are expected to demonstrate accountability to patients, society and the profession.”7Accreditation Council for Graduate Medical Education Program Requirements for Resident Education in Internal Medicine; Section IV.A.5.e.(4); July 1, 2009.Google Scholar Yet the hidden curricular message of “early graduation based on competency” is that residents should prioritize self-gain above their obligations to their peers, a lesson contradictory to both the profession's and the Accreditation Council for Graduate Medical Education's central tenets. We cannot allow residency education to be reduced to a linear gauntlet of learning stations made up of patient experiences and faculty evaluators that residents run through at different speeds until crossing the finish line. Rather, a residency program is a complex, supportive group dynamic where the interactions of the group create the moments of critical socialization and reflection that foster the many intangibles in the development of the physician. Our system of training must instill in our best residents a deep sense of dedication to their colleagues and to the good of the many before the good of the few. Commitment of the residents to each other, and to the profession, distinguishes great residency programs. Many of the beliefs that underpin competency-based advancement assume that we are able to accurately measure the acquisition of all important competencies. Yet the development of adequate and reliable assessment tools for even the most basic competencies is in the earliest of stages. We believe the central educational experience of residency is a dedicated learner and a dedicated teacher at a patient's bedside. Direct observation by the master teacher is the cornerstone of evaluation in this setting and leans equally on measurable components of competency and subjective judgments by the observer. Even under the best of circumstances, we believe many of the most crucial attributes that residents must acquire to become fully competent independent practitioners will prove especially difficult, if not impossible, to measure. Examples include judgment under uncertainty, clinical intuition, pattern recognition, recognition of diagnostic thinking errors, anticipatory thinking, well-practiced rapid response actions, calm self-assurance, calm under pressure, decisiveness, leadership, and the ability to mentor. Yet a system that enables early graduation hinges on objective criteria, and we fear that a process that focuses only on the measurable will lose sight of these less measurable, but no less critical, attributes that are often among the last to mature. Although we seek to strike a balance between service and learning, Osler's educational environment is made possible only by providing service in the care of patients. Residency programs have been entrusted with establishing teaching services to meet this end, and this commitment to staffing a residency service is fixed: Because patient needs are constant, the service cannot be sometimes staffed and sometimes not. The current model of training enables a program director to assess resources to ensure staffing of the medical service that is central to the residents' educational needs, as well as the patients' clinical needs. The proposal for early graduation based on competence would transform a fixed system into a fluid system, with intermittent periods of non-staffing proportional to the volume of residents who leave the program early. Educating the physician requires emotional engagement that is only accomplished when residents develop authentic personal accountability for their patients; a system that teaches that accountability is contingent on available residents detracts from this message. Teaching services must be constructed such that the implicit message is to encourage residents' sense of ownership of their patients, as well as allowing for incremental autonomy up to and including complete independence. Only on services where residents are consistently present and engaged with all other members of the health care team can the necessary levels of responsibility, accountability, and autonomy be maintained. Once a system has been fully calibrated and staffed to function without residents, residents begin to assume the mentality of visitors rather than full participants. An alternative to variable staffing on core teaching services would be to maintain full staffing on these services at all times to ensure their integrity by moving remaining residents from elective to core experiences to compensate for residents who have advanced early. This would sacrifice educational balance for the remaining residents, denying them career-defining clinical elective experiences or research opportunities. The good of the many residents and the learning environment of the program would be sacrificed for the benefit of the few. Competency-based advancement will allow some residents to begin fellowship after only 2 years of core internal medicine training. We acknowledge that well-established milestones and assessment tools may allow identification of a small number of residents who achieve competency after only 2 years. Practically, however, this determination could not be made until well into the second postgraduate year, certainly no more than 6 months before the proposed advancement to fellowship would occur. The current fellowship application and selection process requires applicants to interview 14 to 18 months before their fellowship begins and fills all slots more than 1 year in advance. Competency-based advancement to fellowship after 2 years is not compatible with this application/selection paradigm, unless fellowship programs would be willing to interview and select applicants during their second postgraduate year without any assurance that they would be ready to advance at the end of their second postgraduate year. Allowing early transition to fellowship may have additional unintended consequences. Residents considering competitive subspecialty careers will quickly learn that their best chance to enter fellowship is to pursue early advancement and to focus elective and research experiences (eg, cardiology or gastroenterology) to the exclusion of exploring less-competitive generalist or subspecialty careers. This will lead to premature career decision closure. Further, because of the timing and logistics of creating a match, it is likely that accelerated residents will only be able to move into fellowships at their “home” institution. This will quickly disadvantage community hospital programs that do not have the spectrum of fellowships. Finally, the consequences would be dire for residents selected for early advancement who suddenly had to cancel all of their plans because they did not achieve competency. Likewise, the fellowship would have to deal with an unfilled position very late in the process. Realizing this, core residency programs might feel pressure to pass on less-than-competent residents to the next level of training simply because plans had been made. This would not be in the best interests of either the candidate or the fellowship. We applaud and support the movement to competency-based education based on developmental milestones and reliable methods of assessment. We believe that graduate medical education programs should be judged on the quality of their educational outcomes, and that individual practitioners should be certified on the basis of achievement of broad-based competency in their discipline.

The American College of Physicians supports the need for reform throughout the continuum of training in internal medicine. Today's internists must have the necessary knowledge, skills, and attitudes to meet the challenges of an expanding body of medical knowledge and a rapidly evolving system of health care delivery. Suggested priorities for undergraduate medical education include redesigning curricular experiences to afford students earlier and more exposure to career opportunities in internal medicine, improving ambulatory education, exposing students to outstanding faculty role models in internal medicine, and incorporating educational experiences during the fourth year that optimize its value and relevance to the student's future career plans in internal medicine. Internal medicine residency training should remain a 3-year experience, with a component of core education common to all trainees and a component of customized training in the third year targeted toward the resident's career goals. Residency programs should be designed around educational rather than institutional service needs. The ambulatory component of training requires substantial reform in its structure, sites, content, and timing. Team-based models should be used both for patient care and for flexibility in design of residency training. Better faculty models must be developed that build on the concept of a "core faculty," improve the rewards for teaching faculty, and provide appropriate faculty development focusing on a necessary set of educator competencies.

In recent years, medical professionalism has been scrutinized by physicians, educators, medical literature, and the media. The result of this examination is a generally accepted consensus that professionalism is decreasing in medicine due to a failure to satisfy patient and societal expectations as well as a loss of the medical profession’s dedication to its core values. This seeming deterioration has placed increased pressure on physician educators to measure professionalism among physicians-in-training.1Association of American Medical Colleges. A Guide to the Preparation of the Medical Student Performance Evaluation. Available at: www.aamc.org/members/gsa/mspeguide.pdf. Accessed November 3, 2004.Google Scholar Criticism regarding professionalism in medicine has often focused on younger physicians, members of a generation that appear to many older physicians as uniquely unprofessional.2Adams D. Generation Gripe: Young doctors less dedicated, hardworking? American Medical News. February 2, 2004. Available at: www.ama-assn.org/amednews/2004/02/02/prl20202.htm. Accessed November 3, 2004.Google Scholar, 3Merritt, Hawkins and Associates. Summary Report 2004 Survey of Physicians. Available at: www.merritthawkins.com/pdf/2004_physician50_survey.pdf. Accessed November 3, 2004.Google Scholar This younger generation, with its focus on personal lifestyle and balance, appears to lack the intrinsic virtues necessary for the medical profession. The conflict between generations accentuates the “crisis of professionalism” and has the potential to divide the profession along generational lines, creating many unintended and negative consequences.4Lancaster L.C. Stillman D. When Generations Collide. HarperCollins Publisher Inc, New York, NY2002Google Scholar, 5Zemke R. Generations at Work. American Management Association, New York, NY2000Google Scholar However, in focusing on generational loss of virtue, the current discussion has overlooked a key element to professionalism—the transformation of “lay person” to physician. In the past decade, professionalism has been a topic of hundreds of articles in medical literature (Figure). A possible explanation for this explosion of articles is that the corporatization of medicine and the resulting consumerism of patients has disrupted the contract implicit in the meaning of a “trusted profession.” Another possible explanation is the term “professionalism,” in its current usage, is a meaningless catchphrase and therefore defies satisfactory description. Most of these articles define professionalism as a set of virtues, including altruism, honesty, compassion, and integrity, then create behavioral definitions under each of these virtues that are quantifiable in physicians. In addition to the medical literature’s attempt to define and evaluate professionalism, the American Board of Internal Medicine Foundation, American College of Physicians Foundation, and European Federation of Internal Medicine developed Medical Professionalism in the New Millennium: A Physician Charter, a statement that outlines physicians’ responsibilities to both patients and society.6Medical professionalism in the new millennium a physician charter.Ann Intern Med. 2002; 136: 5Google Scholar Although valuable in the debate, these attempts to define professionalism as a set of virtues, obligations, and behaviors fall short of capturing its essence. The core of professionalism is the personal transformation of self that takes place in stages during the early years of medical training and practice. Once “lay persons,” medical students redefine themselves as physicians, accepting that they now interact with all of society in a new and different manner.7Kegan R. The Evolving Self. Harvard University Press, Boston, MA1982Google Scholar, 8Branch W.T. Supporting the moral development of medical students.JGIM. 2000; 15: 503-508Crossref PubMed Scopus (161) Google Scholar Accepting this role colors all of one’s perceptions and opinions, setting standards for behavior. Once this transformation occurs, it is impossible to believe being a physician is “just a job.” With this role comes respect, privilege, and trust. The tradition in society is to bestow the title of “doctor” not only on individuals while working in the ambulatory or outpatient setting; rather, the title is given to the persons themselves, believing that the transformation from “lay person” to physician has occurred.9Pellegrino E.D. Professionalism, profession and the virtues of the good physician.Mt. Sinai J Med. 2002; 69: 378-384PubMed Google Scholar Students today come from a unique generation. This generation has grown up culturally skeptical and technologically savvy and values free time and life balance. As a class, students enter training later in life and include a higher percentage of women. They come predominantly from higher-income families, and will incur record-setting amounts of educational debt.10Association of American Medical Colleges. 2003 All Schools Reports. Available at: www.aamc.org/data/gq/allschoolsreports/2003.pdf. Accessed November 3, 2004.Google Scholar, 11Evolution of Medicine. Academic Internal Medicine Insight. 3 (2);6.Google Scholar, 12Association of American Medical CollegesAAMC Data Book 2003. Association of American Medical Colleges, Washington, D.C2004Google Scholar Led by women, this generation of students will work fewer hours and demand flexible employment opportunities. Today’s students are potentially as competent and professional as the physicians that have come before. Vying for few positions in US medical schools, today’s students are smart and energetic. This generation of students, however, is criticized for shunning primary care and choosing specialties which provide positive lifestyle factors. As a result, this generation appears to members of other generations as placing personal priorities above those of the patient. In addition, a decreasing number of students appear enthusiastic about the possibility of being someone’s doctor.13Newton D.A. Grayson M.S. Trends in career choice by US medical school graduates.JAMA. 2003; 290: 1179-1182Crossref PubMed Scopus (192) Google Scholar, 14Dorsey E.R. et al.Influence of controllable lifestyle on recent trends in specialty choice by US medical students.JAMA. 2003; 290: 1173-1178Crossref PubMed Scopus (554) Google Scholar, 15The End of Primary Care. New York Times. April 18, 2004.Google Scholar, 16Young Doctors and Wish lists. No Weekend Calls, No Beepers. New York Times. January 7, 2004.Google Scholar, 17Ibrahim T. The case for invigorating internal medicine.Am J Med. 2004; 117: 365-369Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar This is an important area of concern because this younger generation—skeptical of “total commitment”—may resent the personal transformation to physician. The conflict in the medical workplace that triggered this recent dialogue on professionalism is between the Baby Boomer Generation and Generation X. Baby boomers define professionalism predominantly in terms of hours worked and “complete” dedication to the job. Dedicated to life balance, Generation Xers do not aspire to be like baby boomers. They believe baby boomers are hypocritical and susceptible to early burnout. In fact, having been raised by absentee, workaholic baby boomers, their priorities are very different from their parents. Their focus on caring for themselves and their families is a positive attribute of Generation X. Baby boomers—creating a value system based on their own life ethic—have confused work ethic with professionalism. Still in charge of the medical system, baby boomer physicians have continued to enforce a workplace that demands long hours, total dedication to work, rigid approaches to patient care, and disdain for anyone who does not accept their “rules of life.” Generation X physicians are not eager to join this work environment. In addition, Generation Xers—skeptical of organizations and hesitant to make total commitments—appear to be afraid of truly embracing physicianhood and the personal transformation that is critical to professional development. Table 1Generational profilesVeterans 1922–1945 55 MillionBaby Boomers 1946–1964 78 MillionGeneration X 1965–1980 47 MillionMillennium 1981–2000 80 MillionStyletraditionalpersonal satisfactionself-reliantmodern traditionalSizerapidly decliningdominantsmall grouplargeEthicrespect, loyaltyambitious, politicalprogressive, cynicalloyal, conservativeGender Roleclassic gender rolesmixing gender rolesuncleargoneWorkrespect the systemrespect experiencerespect expertisework to livework for securitylikes to workwork to liveHeroesstrong heroessome heroesno heroesanti-heroesSeminal EventsDepression, WWIIVietnam, BCPweak USA9–11Upbringingtraditional familytraditional familyabsenteeism parentsprotective parentsRewarda job well donemoney, title, recognitionfreedom and timeworkData source: Zemke R, et al. Generations at Work. New York, NY: American Management Association, 2000. Open table in a new tab Data source: Zemke R, et al. Generations at Work. New York, NY: American Management Association, 2000. The recent enactment of work hour regulations by the Accreditation Council for Graduate Medical Education has created a typical generational conflict. Baby boomer physicians, who “thrived” in the old system, blame residents and students for these new regulations. They fail to acknowledge that society is deeply concerned about the harmful effects of long work hours and fatigue on making life and death decisions. The new regulations have the potential to accentuate the professionalism rift as older physicians blame residents for being less dedicated. Likewise, some less motivated young physicians use these rules to justify less than complete commitment to excellence and altruism in caring for their patients. It is clear that as long as physician leaders are allowed to equate professionalism with hours worked, an unbridgeable divide between the generations in the physician workforce will remain. Professionalism must be defined by the essential qualities of a physician regardless of hours worked (Table 2). Physicians across all generations have far more qualities that unite than divide them, and this common ground should be the basis of future dialogue on professionalism. It is clear that physician educators should ensure that physicians-in-training are aware of and embrace the transformation from “lay person” to physician. As a result of this transformation, physicians-in-training will put the care of patients first and deliver care with quality, honesty, and integrity.Table 2Essential attributes of the “physician”Embrace being a physicianCaring and altruisticHonesty, integrityTeam playerStrive for excellenceAccept the duty for serving patients and societyCourage, heroism Open table in a new tab Future physicians will have to be team players who expect nothing less than excellence in the workplace and accept—not shirk—the responsibility to serve patients and society. Future physicians will need to continue to be courageous healers and perhaps even heroes. Furthermore, physician educators must be cognizant that the current trend of measuring observable virtuous behaviors is one step removed from the most critical element of professionalism: ensuring physicians-in-training understand, accept, and transform into their new role in society as physicians. The learning environment should accept generational differences, forgive students struggling at the start of the transformation to physician, and nurture the process. Educators need to talk more about the wonder, privilege, and honor of being someone’s doctor, creating a positive, professional “hidden curriculum.” The medical workplace of the future must embrace and nurture this new generation of physicians. Simultaneously, it must allow and encourage the next generation of physicians to grow to be true professionals’ accepting society’s role of “doctor.” The future environment must be patient focused but have flexible work hours and flexible practice design (Table 3). This workplace must recognize that physician well being and balance in life is a valid and important concern and does not negate the attainment of professionalism. It must reward excellence, not endurance. These systems, which by nature will become more discontinuous, must promote seamless team care so that patients never sense a loss of the professional dedication to their well being. The profession has a right to expect excellence and total commitment to medicine but should also allow for structures that encourage balance in life. Finally, this environment should foster the joy of being a physician.Table 3Attributes of the “future environment”Patient focusedFlexible work hoursPrioritize physician well-being and life balanceReward excellence, not endurancePromote seamless team careExpect excellence and total commitment doing workFoster joy of being a doctor Open table in a new tab The ultimate challenge that all physicians face, regardless of generation, is to flexibly and respectfully redefine excellence and professionalism in terms that are both generationally diverse and appropriate. Physician leaders need to build bridges instead of barriers. Established physicians need to stop defining perfection as being “just like ourselves” and realize that encouraging professional excellence in ways that are culturally and generationally diverse is the only hope for the future of the medical profession. Let us never allow a medical culture to exist where young physicians are afraid of falling in love with being a doctor.18Worley L.L. et al.Generational evolution and the future of pediatrics.J Pediatr. 2004; 145: 143-144Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 19Epstein J. The Perpetual Adolescent. The Weekly Standard. 9(26).Google Scholar

PURPOSE:The possible correlation between the frequency and significance of prescribing errors and the number of hours worked during a 24-hour shift by hospital house staff was studied.METHODS:A prospective observational trial was conducted in two internal medicine units at an academic medical center. Orders written by medical house staff covering the study units between January 8 and March 10, 2001, were collected daily and evaluated for obvious prescribing errors, the type and significance of the errors, and the number of hours the resident had worked during a 24-hour shift at the time of the prescribing error.RESULTS:A total of 45,366 orders (including orders for medications, laboratory tests, diagnostic procedures, and nursing care) were entered on the study units during the study period. A total of 498 erroneous prescribing orders were identified. A majority of the erroneous orders (77%) could have resulted in significant morbidity or mortality had they reached the patient. The most common errors involved the wrong dose (18%), the wrong dosage frequency (15%), and duplicate orders (15%). There was no statistically significant correlation between the number of hours worked and the frequency or significance of the errors.CONCLUSION:The number of hours worked by medical house staff during a 24-hour shift did not appear to affect the frequency or significance of their prescribing errors.

o celebrate its 50th anniversary, the APM has dedicated its pages in The American Journal of Medicine in 2004 to the future of academic internal medicine. In this issue, the APM has invited the Association of Program Directors in Internal Medicine to discuss the future of residents' education.

National surveys indicate a need for additional training in geriatrics during internal medicine residencies. This paper describes 1) best practices for integrating geriatrics education into internal medicine residency programs, 2) barriers to implementation of these practices, and 3) possible ways to improve geriatrics training for internal medicine residents. These best practices were determined by a systematic review of the literature and through interviews with leaders of 26 residency and geriatrics programs concerned with geriatrics training for residents. The most successful programs have clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, in the hospital or in ambulatory practice), patient care across sites or transitions of care, and interdisciplinary teamwork. Barriers include attitudes, few faculty, need for relationships with nontraditional training sites, and lack of funding. Local solutions include engaging the internal medicine program director to accomplish a mutual goalfor example, by creating a model geriatrics training experience in which residents demonstrate their skill in a new Accreditation Council of Graduate Medical Education competency (such as systems-based practice). National solutions include reaching consensus on the competencies in geriatrics that should be achieved by board-eligible internists. This may mean increasing the number of questions that test geriatrics competency in the certifying and in-training examinations, increasing numbers of faculty members able to teach and model geriatric care, developing effective medical resident teaching courses for nonphysician faculty, and lobbying for improved systems of care.

Decentralized pharmacists have a valuable role in preventing medication errors. At Mount Sinai Hospital, each pharmacist's contact with a prescriber to correct or clarify a possible prescribing error is documented on the original order. Our pharmacists are also encouraged to document interventions as part of the pharmacist intervention program. The authors undertook a blinded observational study to determine the percentage of prescriber contacts documented as pharmacist clinical interventions. This 2-month study was conducted in two nursing units with computerized physician order entry. All orders from these units were collected and evaluated for possible prescribing errors and documentation of a pharmacist's contact with a prescriber. Additionally, all pharmacist interventions documented in these units during the study period were collected and entered into the pharmacist intervention database. The percentage of all pharmacist interventions vs the number of documented prescriber contacts on original orders was then calculated. A total of 14 pharmacists were involved in the provision of pharmaceutical care to patients in the study units. During the 2-month study period, a total of 221 orders required pharmacists to contact prescribers regarding potential prescribing errors. However, only 109 (49.3%) of these were documented as clinical interventions. The findings indicate a need for improved documentation of clinical services (eg, interventions) performed by pharmacists.

Medical educators face enormous challenges in teaching students and housestaff the knowledge and skills that are required to become a physician. More important, however, is the responsibility to mentor students as they make the cultural and personal identity changes necessary to insure their transition from “lay person” to “professional.” This transition involves two related but distinct processes. The first is recognizing the great powers they exercise as physicians and understanding that those powers are predicated on their assumption of an equal level of responsibility when they voluntarily professed an oath to place their patient’s interests above their own. The second is not only accepting responsibility for their own actions, but also accepting responsibility for the medical profession as a whole; each physician insures that all physicians in the profession serve the public good with distinction and integrity.

BACKGROUND:Although curricular reforms have attempted to address sources of stress in medical residency, no recent studies have examined the financial or emotional situations of current medicine residents.OBJECTIVE:To question medicine residents about financial status, educational debt, moonlighting, and psychological issues.DESIGN:Survey distributed in a nonrandomized fashion to medicine residents.SETTING:All 415 U.S. medicine residency programs.RESULTS:According to the questionnaire responses submitted by the 4128 (18%) participating residents, a substantial number of residents had financial and emotional distress that could have interfered with training. The reported educational debt was at least $50 000 for 1657 (42%) of the respondents and at least $100 000 for 737 (19%). The monthly disposable income was $100 or less for 1620 (43%) of the residents, and 637 residents (16%) could not afford safe housing. Among respondents in their 2nd through 5th year of postgraduate training, 2187 (52%) had insufficient funds to purchase books and equipment, and 678 (29%) could not afford the required fees for the American Board of Internal Medicine certifying examination; 2659 (33%) worked as moonlighters, and this percentage increased progressively with increasing educational debt. Four or five depressive symptoms during residency were reported by 1461 (35%) residents. Eight hundred ninety-nine residents (23%) thought they had become less humanistic over the course of their residency training; 2347 (61%) reported becoming more cynical. Female residents were more likely than male residents to report increased cynicism and multiple depressive symptoms. Increased cynicism and depressive symptoms were associated with increasing educational debt.CONCLUSIONS:Despite recent curricular reforms, an alarming number of current medicine residents report depressive symptoms, increasing cynicism, and decreasing humanism, which were associated with increasing educational debt and a need to moonlight for financial survival. Ongoing curricular reform, legislative relief from early loan repayment, and salary increases may be necessary to address these problems.

Medical Writings: Book Notes7 December 1999Clinical Evidence: A Compendium of the Best Available Evidence for Effective Health CareLawrence G. Smith, MDLawrence G. Smith, MDMount Sinai School of Medicine, New York, New York. (Smith)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-131-11-199912070-00021 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Issue 1. 598 pages. London: BMJ Publishing Group; 1999. Two issues per year. $99. ISBN 0727913646. Order phone 800-236-6265.Field of medicine: Primary care medicine.Format: Softcover book.Audience: Primary care physicians and trainees.Purpose: To present easily accessible evidence-based summaries that answer clinical questions about common medical problems.Content: The book covers treatment options for common medical problems seen in general practice. Disease summaries are based on a set of clinically relevant questions that are then answered by data from randomized, controlled trials and systematic reviews.Highlights: Each chapter consists of clinically important questions, interventions rated for their beneficial ... Author, Article, and Disclosure InformationAffiliations: Mount Sinai School of Medicine, New York, New York. (Smith) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 7 December 1999Volume 131, Issue 11Page: 872KeywordsEvidence based medicineHealth careHealth information technologyPrimary carePrimary care physiciansSoftware toolsSystematic reviews ePublished: 15 August 2000 Issue Published: 7 December 1999 Copyright & PermissionsCopyright © 1999 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

To the Editor -I would like to applaud Dr