Halvorsen, Andrew J.

Background: Residency is a time of personal and professional growth. Resident assessment and feedback are an integral part of that process. However, assessment may be influenced by various types of bias, including gender bias. Women are less likely than men to be identified by their professional titles in many settings. The use of professional titles for residents in written assessments is unknown and may be a marker of bias. Objective: To assess for differences and trends regarding the use of professional and personal titles in formal resident assessments related to gender-based resident–faculty pairs. Methods: Electronic assessments of postgraduate year 1 (PGY1) internal medicine residents from the 2019–2020 academic year were used. Professional title use was analyzed, as it relates to resident–faculty gendered dyads, among other variables. The primary outcome of professional title usage was split into a binary variable by professional versus other titles and analyzed using logistic regression and random-effects model. Results: We analyzed 1,363 unique electronic assessments (37.8% from female faculty). Female residents were more likely to be addressed by a professional title than their male colleagues (odds ratio [OR], 1.7; confidence interval [CI], 1.2–2.4; p = 0.02). We found no difference in professional title usage based on resident–faculty gendered dyads. After adjusting for repeated faculty and resident encounters with random-effects model, secondary analysis found no significant difference in evaluation of word count between gendered dyads. Conclusions: The analysis found no significant difference in professional title usage based on resident–faculty dyads. In our analysis, female residents were significantly more likely to have their professional title used on assessments than male residents.

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

Abstract Background Eosinopenia has previously been studied as a predictor of bacteremia and sepsis, and has been identified as a marker of increased mortality in critically ill patients. To date, one study has examined changes in eosinophil count during bacterial infection, noting quicker normalization of eosinophil count versus traditional markers of inflammation, whereas no studies have examined eosinophil count recovery as a predictor of blood stream clearance. Methods We conducted a multicenter, retrospective cohort study of adult patients diagnosed with Staphylococcus aureus bacteremia (SAB) between January 2018 and December 2019 at Mayo Clinic campuses. Patients with eosinopenia on the date of the first positive blood culture were selected for further analysis. Eosinopenia was defined as an eosinophil count < 0.03 x10(9)/L. Eosinophil count recovery was defined as the first subsequent date where an eosinophil count ≥0.03 x10(9)/L was recorded. Clearance of SAB was defined as negative blood cultures at 48 hours on two consecutive days, and the date of clearance was defined as the date of first negative blood culture. Results A total of 213 cases of SAB were identified where an eosinophil count was obtained on date of first positive blood culture. Of these cases, 132 (62.0%) had eosinopenia at time of diagnosis. Data related to count recovery was available for 90 patients, with associated characteristics for this cohort detailed in Table 1. S. aureus isolates were oxacillin susceptible in 91.1% (82/90) of cases. The median time to clearance of bacteremia was 2.7 days (IQR 1.8-4.7 days), and the median time to eosinophil count recovery was 2.0 days (IQR 2.0-3.0 days). Data related to timing of eosinophil count recovery are presented in Table 2. Resolution of eosinopenia occurred within 48 hours of bloodstream clearance in 79/90 (87.8%) of cases and preceded or occurred within 48 hours of blood culture clearance in 88/90 (97.8%) of cases. Conclusion Eosinopenia is a common finding at time of diagnosis of SAB, and recovery of eosinophil count is suggestive of imminent clearance of blood cultures. Disclosures All Authors: No reported disclosures

AbstractBackgroundMany hospitalized patients do not understand or agree with their clinicians about their discharge plan. However, the effect of disagreement on discharge outcomes is unknown.ObjectiveTo measure the correlation between patient‐clinician care agreement and discharge outcomes.DesignA prospective cohort study was performed from September 2019 to March 2020 (Rochester, MN, USA).Setting and ParticipantsInternal medicine patients and their primary clinician (resident, advanced practice clinician or attending) hospitalized from September 2019‐March 2020 at Mayo Clinic Hospital. Participants were independently surveyed following hospital day #3 ward rounds regarding the goals of the hospitalization and discharge planning.Main Outcome and MeasuresPatient–clinician agreement for main diagnosis, patient's main concern, and four domains of discharge planning was assessed. Readiness for hospital discharge, delayed discharge, and 30‐day readmission was measured. Then, associations between patient‐clinician agreement, delayed discharge, and 30‐day readmissions were analyzed using multivariable logistic regression.ResultsOf the 436 patients and clinicians, 17.7% completely agreed about what needs to be accomplished before dismissal, 40.8% agreed regarding discharge date, and 71.1% agreed regarding discharge location. In the multivariable model, patient–clinician agreement scores were not significantly correlated with discharge outcomes. Patient–clinician agreement on discharge location was higher for those discharged to home (81.5%) versus skilled nursing facility (48.5%) or assisted living (42.9%) (p < .0001). The agreement on the expected length of stay was highest for home‐goers (45.9%) compared to skilled nursing (32.0%) or assisted living (21.4%) (p = .004).ConclusionsPatients and their clinicians frequently disagree about when and where a patient will go after hospitalization, particularly for those discharged to a skilled nursing facility. While disagreement did not predict discharge outcomes, our findings suggest opportunities to improve effective communication and promote shared mental models regarding discharge earlier in the hospital stay.

Background There has been limited research on the positive aspects of physician wellness and to our knowledge there have been no validity studies on measures of resilience and grit among internal medicine (IM) residents. Objectives To investigate the validity of resilience (10 items Connor-Davidson Resilience Scale (CD-RISC 10)) and grit (Short Grit Scale (GRIT-S)) scores among IM residents at a large academic centre, and assess potential associations with previously validated measures of medical knowledge, clinical performance and professionalism. Methods We evaluated CD-RISC 10 and GRIT-S instrument scores among IM residents at the Mayo Clinic Rochester, Minnesota between July 2017 and June 2019. We analysed dimensionality, internal consistency reliability and criterion validity in terms of relationships between resilience and grit, with standardised measures of residents’ medical knowledge (in-training examination (ITE)), clinical performance (faculty and peer evaluations and Mini-Clinical Evaluation Examination (mini-CEX)) and professionalism/dutifulness (conference attendance and evaluation completion). Results A total of 213 out of 253 (84.2%) survey-eligible IM residents provided both CD-RISC 10 and GRIT-S survey responses. Internal consistency reliability (Cronbach alpha) was excellent for CD-RISC 10 (0.93) and GRIT-S (0.82) overall, and for the GRIT subscales of consistency of interest (0.84) and perseverance of effort (0.71). CD-RISC 10 scores were negatively associated with ITE percentile (β=−3.4, 95% CI −6.2 to −0.5, p=0.02) and mini-CEX (β=−0.2, 95% CI −0.5 to −0.02, p=0.03). GRIT-S scores were positively associated with evaluation completion percentage (β=2.51, 95% CI 0.35 to 4.67, p=0.02) and conference attendance (β=2.70, 95% CI 0.11 to 5.29, p=0.04). Conclusions This study revealed favourable validity evidence for CD-RISC 10 and GRIT-S among IM residents. Residents demonstrated resilience within a competitive training environment despite less favourable test performance and grittiness that was manifested by completing tasks. This initial validity study provides a foundation for further research on resilience and grit among physicians in training.

Purpose Successful training of internal medicine (IM) residents requires accurate assessments. Patients could assess IM residents in a hospital setting, but medical educators must understand how contextual factors may affect assessments. The objective was to investigate relationships between patient, resident, and hospital-encounter characteristics and the results of patient assessments of IM resident professionalism. Method The authors performed a prospective cohort study of postgraduate year 1 (PGY-1) IM residents and their patients at 4 general medicine inpatient teaching services at Mayo Clinic Hospital–Rochester, Saint Marys Campus in Rochester, Minnesota, from July 1, 2015, through June 30, 2016. Patient assessments of resident professionalism were adapted from validated instruments. Multivariable modeling with generalized estimating equations was used to determine associations between patient assessment scores and characteristics of residents, residents’ clinical performance and evaluations (including professionalism assessments in other settings), patients, and hospital encounters and to account for repeated assessments of residents. Results A total of 409 patients assessed 72 PGY-1 residents (mean [SD], 5.7 [3.0] patient assessments per resident). In the multivariable model, only the highest rating out of 5 levels for overall satisfaction with hospital stay was significantly associated with patient assessment scores of resident professionalism (β [SE], 0.80 [0.08]; P < .001). Hospitalized patients’ assessment scores of resident professionalism were not significantly correlated with assessment scores of resident professionalism in other clinical settings. Conclusions Hospitalized patients’ assessment scores of in-hospital resident professionalism were strongly correlated with overall patient satisfaction with hospital stay but were not correlated with resident professionalism in other settings. The limitations of patient evaluations should be considered before incorporating these evaluations into programs of assessment.

Purpose To measure the association between institutional investment in high-value care (HVC) performance improvement and resident HVC experiences. Method The authors analyzed data from two 2014 surveys assessing institutions’ investments in HVC performance improvement as reported by program directors (PDs) and residents’ perceptions of the frequency of HVC teaching, participation in HVC-focused quality improvement (QI), and views on HVC topics. The authors measured the association between institutional investment and resident-reported experiences using logistic regression, controlling for program and resident characteristics. Results The sample included 214 programs and 9,854 residents (59.3% of 361 programs, 55.2% of 17,851 residents surveyed). Most PDs (158/209; 75.6%) reported some support. Residents were more likely to report HVC discussions with faculty at least a few times weekly if they trained in programs that offered HVC-focused faculty development (odds ratio [OR] = 1.19; 95% confidence interval [CI] 1.04–1.37; P = .01), that supported such faculty development (OR = 1.21; 95% CI 1.04–1.41; P = .02), or that provided physician cost-of-care performance data (OR = 1.19; 95% CI 1.03–1.39; P = .02). Residents were more likely to report participation in HVC QI if they trained in programs with a formal HVC curriculum (OR = 1.83; 95% CI 1.48–2.27; P < .001) or with HVC-focused faculty development (OR = 1.46; 95% CI 1.15–1.85; P = .002). Conclusions Institutional investment in HVC-related faculty development and physician feedback on costs of care may increase the frequency of HVC teaching and resident participation in HVC-related QI.