Internal Medicine Residents’ Exposure to and Confidence in Managing Hospital Acute Clinical Events

Assessment of Confidence

Both levels of training and exposure to acute events were associated with increased confidence in managing such events. PGY-1 residents felt confident in managing 24.9% of acute events independently, compared to 48.4% of events for PGY-2 residents and 72.5% of events for PGY-3/4 residents (P < .0001). There was considerable variation in confidence among the individual acute events (Supplementary Appendix Table 2). A majority of graduating PGY-3/4 residents did not feel confident in managing the following 10 of the 50 events (20%): use of emergency cardioversion, aortic dissection, thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS), torsades de pointes, posterior reversible encephalopathy syndrome (PRES), intracranial hemorrhage, use of emergency transcutaneous pacing, tension pneumothorax, elevated ICP/herniation, and acute mechanical valve failure.

Residents’ self-reported confidence also correlated with level of exposure. There was a significant increase in resident confidence with increasingly independent exposure stratified by level of training (Figure; all with P < .0001). In the multivariable logistic regression model, increasing exposure correlated with increased resident confidence (P < .0001) while controlling for PGY year (P = .001).

We developed an instrument to assess resident exposure to and confidence in managing 50 inpatient acute clinical events. Both exposure and level of training were associated with increasing resident confidence. We identified specific events with low levels of exposure and confidence that could be targeted for educational interventions.

To our knowledge, this is the first study to examine IM residents’ exposure to and confidence in managing a wide range of inpatient acute clinical events. A primary goal of residency is to provide physicians-in-training graduated responsibility to prepare them for eventual independent practice. Although our survey confirmed that IM residents’ exposure and confidence significantly increased as they advanced through training (a not unexpected finding), our data also show that even after controlling for year in training, independent exposures significantly correlated with increased confidence. This speaks to the importance of preserving opportunities for residents to manage critical events in a supported manner, an admittedly challenging prospect given the oft-competing calls for supervision of and mentored feedback for trainees.¹¹

Despite identifying independent exposure as an important factor that impacts resident confidence, we found that there was still a substantial proportion of events (28.3%) that senior medical residents near the end of their training had not managed independently in a primary leadership role. Although our study was not designed to determine the reasons for this varied resident exposure, possible explanations may include the relative rarity of certain acute clinical events compared with others, or less likely the effect of duty hour limitations, attending supervision of trainees, or programmatic changes in resident leadership responsibilities. Whatever the cause, this finding uniquely identifies an area for improvement to prevent new attending physicians from feeling unprepared to manage potentially critical emergencies.

An important goal of our study was to develop an instrument that would enable training programs to identify their learning needs. Both program-wide and individual assessments of resident case exposure and confidence are essential for identifying such learning needs and areas for curricular development. Program-wide assessments can spur an important debate about program goals and requirements with respect to what scenarios residents must be able to manage competently by graduation.¹² In addition, such assessments can help individualize learning exposures based on a specific learner’s needs and career goals. The administration of our survey instrument required minimal resources, and the high response rate in our study suggests that other programs can implement our instrument to accomplish these goals.

Alternative methods, such as electronic learning portfolios (efolios), can be utilized to assess resident case exposure. In comparison to our survey instrument, efolios limit recall bias by utilizing case logs and have additional capabilities such as compiling evaluations and enabling trainees to set learning goals. However, there are considerable barriers to the effective use of efolios, including software cost, learner attitudes, and time constraints.¹³ Tools such as our end-of-year assessment offer an alternative method that limits these barriers.

Once educational growth opportunities have been identified through survey-based or other methods, residency programs must determine how to optimize curricula for the needs and career goals of their trainees. We found considerable overlap among conditions that graduating residents had both limited exposure to and low confidence in managing (eg, torsades de pointes, tension pneumothorax, and emergency cardioversion), which are logical topics for future curriculum development. We also identified a few conditions (including PRES, TTP/HUS, and intracranial hemorrhage) that graduating residents did not feel confident in managing despite a relatively higher reported level of exposure. Whether to focus specific educational interventions on the most rare or most commonly encountered acute clinical events is likely to be a topic of debate among individual training programs, but the results of our survey indicate that there is likely to be educational benefit to both strategies.

Residency programs can employ a variety of modalities to enhance learner exposure and confidence in managing clinical scenarios that are deemed important by the program, including didactics, simulation, and changes in program structure. There is a substantial literature on the use of dedicated curricula for crisis management and the use of simulation as a training tool for responding to acute clinical events in multiple specialties^14-24 and in nonmedical domains such as aviation.^25-27 Simulation has been shown to improve residents’ clinical skills and comfort level with some acute events^28-30 and may even be superior to traditional clinical medical education.³¹ In addition, programs can utilize targeted clinical experiences such as intensive care unit and subspecialty rotations^32,33 in an effort to customize educational interventions to fill identified gaps in learner exposure or confidence.

Our study has several limitations. First, we investigated a single large IM residency program at a quaternary academic medical center, and therefore, our findings may not be externally generalizable to all IM residencies or other medical specialties. Our unique peer-led simulation curriculum, including 16 PGY-1 and 8 PGY-2 cases chosen based on clinical rotations at Massachusetts General Hospital,⁷ likely impacted residents’ exposure to simulation that is specific to our institution. However, although specific inpatient acute events may vary among other institutions, our finding that graduating residents still reported gaps in their clinical experience is likely generalizable to other programs given the varied and unpredictable nature of ward medicine training. In addition, our survey tool was simple to administer and could be tailored to reflect the acute events and training needs relevant to other residency programs, specialties, and institutions. Second, the retrospective nature of our study may be subject to participants’ recall bias. We did not restrict our survey questions to urgent conditions managed only on IM hospital wards and some may have been experienced in the emergency room or intensive care units; however, these exposures are still relevant as key components of IM training. Third, our list of 50 acute clinical events was intentionally broad and included several conditions that require multidisciplinary subspecialist consultation, which could have impacted residents’ self-report of “independent” exposures. However, these scenarios are ones that hospitalists may independently recognize and stabilize, engaging appropriate specialists. Fourth, we were not able to validate residents’ self-reported exposures against other measures of the frequency of housestaff management of acute events (such as billing data or patient logs) as this information is not routinely collected. We also did not attempt to identify the reasons underlying the variation seen in resident exposure and confidence for individual acute events, but as a needs assessment, this was beyond the scope of our study. Finally, our assessment of resident confidence was subjective and we were not able to assess competence, with prior studies demonstrating conflicting results regarding the relationship between self-reported proficiency and observed competence.^34-36 Future studies are needed to investigate whether case exposure assessment leads to changes in residency curricula and whether such curricula increase resident confidence and competence in managing hospital acute clinical events.