Non‐polio enteroviruses are the most common cause of aseptic meningitis in children.1 While bacterial meningitis requires parenteral antibiotics, aseptic meningitis requires only supportive care.1 Enteroviral reverse transcription polymerase chain reaction (EVPCR) testing of the cerebrospinal fluid (CSF) allows the virus to be detected with high sensitivity and specificity.2 Because children with a positive EVPCR test are at low risk of bacterial meningitis,3 access to rapid EVPCR results has the potential to impact the clinical management of children with meningitis.4, 5 We studied the impact of implementing an in‐hospital EVPCR testing protocol on the clinical management of children with meningitis in a single‐center retrospective cohort.

MATERIALS AND METHODS

RESULTS

Of the 593 children with meningitis, 152 (26%) were excluded for the reasons noted above. The 441 patients included in our analyses had the following final diagnoses: bacterial meningitis (1 patient with Streptococcus pneumoniae, 0.2%), pretreated culture‐negative meningitis (42 patients, 10%), and aseptic meningitis (398 patients, 90%).

We compared patient populations and EVPCR testing characteristics between the pre‐ and post‐study periods (Table 1). While CSF glucose differed between study periods, the difference was not felt to be clinically significant. However, during the post‐period, more children presented during enteroviral season. Clinicians were more likely to order an EVPCR test for children with aseptic, than bacterial, meningitis (213/370 [58%] vs 0/1 [0%]).

We evaluated the impact of the in‐hospital EVPCR test on the length of stay and duration of parenteral antibiotics for the 6 predefined patient groups (Table 2). Length of stay could be determined for 432 (98%) of study patients, and duration of parenteral antibiotics for 365 (83%). We found a clinically important decrease in both length of stay and duration of parenteral antibiotics for children with a positive EVPCR test in the post‐period. For every hour earlier the EVPCR results returned, length of stay was reduced by 0.3 hours ( = 0.3, 95% confidence interval [CI] 0.10.5), and parenteral antibiotics were reduced by 0.3 hours ( = 0.3, 95% CI 0.10.5). However, even in the post‐period, the median length of time from a positive EVPCR test result to hospital discharge was 14 hours (interquartile range, 533 hours).

We observed no trend in length of stay in either testing period ( = 0.17, 95% CI 3.9 to 3.6 pre vs = 1.64, 95% CI 6.3 to 3.0 post), with no change following the introduction of the faster EVPCR protocol (P = 0.52). We observed an increase in duration of parenteral antibiotics in the pre‐period ( = 5.4, 95% CI 0.3 to 10.6), with no trend in the post‐period ( = 1.7, 95% CI 5.2 to 1.8), but the difference was not significant (P = 0.08).

DISCUSSION

The in‐hospital EVPCR testing protocol reduced test turnaround time and increased testing. Children with a positive test had a shorter length of stay and duration of parenteral antibiotics. Decreasing the test turnaround time for EVPCR improved the care of children with enteroviral meningitis by reducing the length of unnecessary hospitalizations and parenteral antibiotics, with the potential for reducing the costs associated with these admissions.

Accurate identification of children with enteroviral meningitis, an often self‐limited infection requiring supportive care, can reduce hospitalization and unnecessary antibiotics. Previously, a positive EVPCR test result has been associated with a reduction in length of stay and of parenteral antibiotics,4, 5, 1012 with a direct correlation between test turnaround time and length of stay.12, 13 Moreover, positive EVPCR test results that were available prior to hospital discharge resulted in shorter length of hospital stay and duration of parenteral antibiotics.10

Our study is the largest to investigate the impact of implementing an in‐hospital EVPCR testing protocol, with the goal of making results available in a clinically useful time frame for all patients. Older EVPCR tests were typically performed in batches, or at centralized laboratories.4, 5, 1013 The in‐hospital EVPCR test utilized is a simple testing platform, which can be run multiple times daily. While there were higher charges associated with increased testing in the post‐period, these were more than offset by a reduced length of stay. Using study institution patient charges, we estimate that overall patient charges decreased approximately $80,000 in the post‐period, compared to the pre‐period (an average reduction of $375 per patient).

Many children were not discharged when a positive EVPCR test result became available. Some children with enteroviral meningitis will have persistent symptoms that require inpatient management. In addition, results that returned in the evening or nighttime were less likely to result in immediate hospital discharge. However, children with a positive EVPCR test are at very low risk for bacterial meningitis.3 As clinicians' knowledge of, and comfort with, the EVPCR test increase, this technology has the potential to further decrease the costs of caring for children with enteroviral meningitis.14

Our study had several limitations. First, it was retrospective; however, primary outcomes were objective measures accurately recorded in the medical record for most patients. Second, our study was single‐center, and findings may not be generalizable to other settings. Third, the management of children with meningitis may have been changing over the study period, independent of the in‐hospital EVPCR test. However, among children with a negative test, we observed no change in either of our primary outcomes. Fourth, given the large number of physicians involved with testing and treatment decisions, we could not adjust for clustering at the physician level. Fifth, we corrected CSF WBC in the case of a traumatic lumbar puncture (LP). Although use of this correction might underestimate the true CSF WBC count,6 the percentage of children with traumatic lumbar punctures was the same in both testing periods. Lastly, we evaluated the impact of a diagnostic test immediately after introduction into the clinical setting. As new medical technologies often take time to be adopted into clinical practice,15 we would expect the impact to increase over time.

CONCLUSIONS

In‐hospital EVPCR testing can improve the care of children with meningitis by reducing the length of unnecessary hospitalizations and parenteral antibiotics. Clinicians caring for children with meningitis should have access to in‐hospital EVPCR testing.

Non‐polio enteroviruses are the most common cause of aseptic meningitis in children.1 While bacterial meningitis requires parenteral antibiotics, aseptic meningitis requires only supportive care.1 Enteroviral reverse transcription polymerase chain reaction (EVPCR) testing of the cerebrospinal fluid (CSF) allows the virus to be detected with high sensitivity and specificity.2 Because children with a positive EVPCR test are at low risk of bacterial meningitis,3 access to rapid EVPCR results has the potential to impact the clinical management of children with meningitis.4, 5 We studied the impact of implementing an in‐hospital EVPCR testing protocol on the clinical management of children with meningitis in a single‐center retrospective cohort.

MATERIALS AND METHODS

RESULTS

Of the 593 children with meningitis, 152 (26%) were excluded for the reasons noted above. The 441 patients included in our analyses had the following final diagnoses: bacterial meningitis (1 patient with Streptococcus pneumoniae, 0.2%), pretreated culture‐negative meningitis (42 patients, 10%), and aseptic meningitis (398 patients, 90%).

We compared patient populations and EVPCR testing characteristics between the pre‐ and post‐study periods (Table 1). While CSF glucose differed between study periods, the difference was not felt to be clinically significant. However, during the post‐period, more children presented during enteroviral season. Clinicians were more likely to order an EVPCR test for children with aseptic, than bacterial, meningitis (213/370 [58%] vs 0/1 [0%]).

We evaluated the impact of the in‐hospital EVPCR test on the length of stay and duration of parenteral antibiotics for the 6 predefined patient groups (Table 2). Length of stay could be determined for 432 (98%) of study patients, and duration of parenteral antibiotics for 365 (83%). We found a clinically important decrease in both length of stay and duration of parenteral antibiotics for children with a positive EVPCR test in the post‐period. For every hour earlier the EVPCR results returned, length of stay was reduced by 0.3 hours ( = 0.3, 95% confidence interval [CI] 0.10.5), and parenteral antibiotics were reduced by 0.3 hours ( = 0.3, 95% CI 0.10.5). However, even in the post‐period, the median length of time from a positive EVPCR test result to hospital discharge was 14 hours (interquartile range, 533 hours).

We observed no trend in length of stay in either testing period ( = 0.17, 95% CI 3.9 to 3.6 pre vs = 1.64, 95% CI 6.3 to 3.0 post), with no change following the introduction of the faster EVPCR protocol (P = 0.52). We observed an increase in duration of parenteral antibiotics in the pre‐period ( = 5.4, 95% CI 0.3 to 10.6), with no trend in the post‐period ( = 1.7, 95% CI 5.2 to 1.8), but the difference was not significant (P = 0.08).

DISCUSSION

The in‐hospital EVPCR testing protocol reduced test turnaround time and increased testing. Children with a positive test had a shorter length of stay and duration of parenteral antibiotics. Decreasing the test turnaround time for EVPCR improved the care of children with enteroviral meningitis by reducing the length of unnecessary hospitalizations and parenteral antibiotics, with the potential for reducing the costs associated with these admissions.

Accurate identification of children with enteroviral meningitis, an often self‐limited infection requiring supportive care, can reduce hospitalization and unnecessary antibiotics. Previously, a positive EVPCR test result has been associated with a reduction in length of stay and of parenteral antibiotics,4, 5, 1012 with a direct correlation between test turnaround time and length of stay.12, 13 Moreover, positive EVPCR test results that were available prior to hospital discharge resulted in shorter length of hospital stay and duration of parenteral antibiotics.10

Our study is the largest to investigate the impact of implementing an in‐hospital EVPCR testing protocol, with the goal of making results available in a clinically useful time frame for all patients. Older EVPCR tests were typically performed in batches, or at centralized laboratories.4, 5, 1013 The in‐hospital EVPCR test utilized is a simple testing platform, which can be run multiple times daily. While there were higher charges associated with increased testing in the post‐period, these were more than offset by a reduced length of stay. Using study institution patient charges, we estimate that overall patient charges decreased approximately $80,000 in the post‐period, compared to the pre‐period (an average reduction of $375 per patient).

Many children were not discharged when a positive EVPCR test result became available. Some children with enteroviral meningitis will have persistent symptoms that require inpatient management. In addition, results that returned in the evening or nighttime were less likely to result in immediate hospital discharge. However, children with a positive EVPCR test are at very low risk for bacterial meningitis.3 As clinicians' knowledge of, and comfort with, the EVPCR test increase, this technology has the potential to further decrease the costs of caring for children with enteroviral meningitis.14

Our study had several limitations. First, it was retrospective; however, primary outcomes were objective measures accurately recorded in the medical record for most patients. Second, our study was single‐center, and findings may not be generalizable to other settings. Third, the management of children with meningitis may have been changing over the study period, independent of the in‐hospital EVPCR test. However, among children with a negative test, we observed no change in either of our primary outcomes. Fourth, given the large number of physicians involved with testing and treatment decisions, we could not adjust for clustering at the physician level. Fifth, we corrected CSF WBC in the case of a traumatic lumbar puncture (LP). Although use of this correction might underestimate the true CSF WBC count,6 the percentage of children with traumatic lumbar punctures was the same in both testing periods. Lastly, we evaluated the impact of a diagnostic test immediately after introduction into the clinical setting. As new medical technologies often take time to be adopted into clinical practice,15 we would expect the impact to increase over time.

CONCLUSIONS

In‐hospital EVPCR testing can improve the care of children with meningitis by reducing the length of unnecessary hospitalizations and parenteral antibiotics. Clinicians caring for children with meningitis should have access to in‐hospital EVPCR testing.

Non‐polio enteroviruses are the most common cause of aseptic meningitis in children.1 While bacterial meningitis requires parenteral antibiotics, aseptic meningitis requires only supportive care.1 Enteroviral reverse transcription polymerase chain reaction (EVPCR) testing of the cerebrospinal fluid (CSF) allows the virus to be detected with high sensitivity and specificity.2 Because children with a positive EVPCR test are at low risk of bacterial meningitis,3 access to rapid EVPCR results has the potential to impact the clinical management of children with meningitis.4, 5 We studied the impact of implementing an in‐hospital EVPCR testing protocol on the clinical management of children with meningitis in a single‐center retrospective cohort.

MATERIALS AND METHODS

RESULTS

Of the 593 children with meningitis, 152 (26%) were excluded for the reasons noted above. The 441 patients included in our analyses had the following final diagnoses: bacterial meningitis (1 patient with Streptococcus pneumoniae, 0.2%), pretreated culture‐negative meningitis (42 patients, 10%), and aseptic meningitis (398 patients, 90%).

We compared patient populations and EVPCR testing characteristics between the pre‐ and post‐study periods (Table 1). While CSF glucose differed between study periods, the difference was not felt to be clinically significant. However, during the post‐period, more children presented during enteroviral season. Clinicians were more likely to order an EVPCR test for children with aseptic, than bacterial, meningitis (213/370 [58%] vs 0/1 [0%]).

We evaluated the impact of the in‐hospital EVPCR test on the length of stay and duration of parenteral antibiotics for the 6 predefined patient groups (Table 2). Length of stay could be determined for 432 (98%) of study patients, and duration of parenteral antibiotics for 365 (83%). We found a clinically important decrease in both length of stay and duration of parenteral antibiotics for children with a positive EVPCR test in the post‐period. For every hour earlier the EVPCR results returned, length of stay was reduced by 0.3 hours ( = 0.3, 95% confidence interval [CI] 0.10.5), and parenteral antibiotics were reduced by 0.3 hours ( = 0.3, 95% CI 0.10.5). However, even in the post‐period, the median length of time from a positive EVPCR test result to hospital discharge was 14 hours (interquartile range, 533 hours).

We observed no trend in length of stay in either testing period ( = 0.17, 95% CI 3.9 to 3.6 pre vs = 1.64, 95% CI 6.3 to 3.0 post), with no change following the introduction of the faster EVPCR protocol (P = 0.52). We observed an increase in duration of parenteral antibiotics in the pre‐period ( = 5.4, 95% CI 0.3 to 10.6), with no trend in the post‐period ( = 1.7, 95% CI 5.2 to 1.8), but the difference was not significant (P = 0.08).

DISCUSSION

The in‐hospital EVPCR testing protocol reduced test turnaround time and increased testing. Children with a positive test had a shorter length of stay and duration of parenteral antibiotics. Decreasing the test turnaround time for EVPCR improved the care of children with enteroviral meningitis by reducing the length of unnecessary hospitalizations and parenteral antibiotics, with the potential for reducing the costs associated with these admissions.

Accurate identification of children with enteroviral meningitis, an often self‐limited infection requiring supportive care, can reduce hospitalization and unnecessary antibiotics. Previously, a positive EVPCR test result has been associated with a reduction in length of stay and of parenteral antibiotics,4, 5, 1012 with a direct correlation between test turnaround time and length of stay.12, 13 Moreover, positive EVPCR test results that were available prior to hospital discharge resulted in shorter length of hospital stay and duration of parenteral antibiotics.10

Our study is the largest to investigate the impact of implementing an in‐hospital EVPCR testing protocol, with the goal of making results available in a clinically useful time frame for all patients. Older EVPCR tests were typically performed in batches, or at centralized laboratories.4, 5, 1013 The in‐hospital EVPCR test utilized is a simple testing platform, which can be run multiple times daily. While there were higher charges associated with increased testing in the post‐period, these were more than offset by a reduced length of stay. Using study institution patient charges, we estimate that overall patient charges decreased approximately $80,000 in the post‐period, compared to the pre‐period (an average reduction of $375 per patient).

Many children were not discharged when a positive EVPCR test result became available. Some children with enteroviral meningitis will have persistent symptoms that require inpatient management. In addition, results that returned in the evening or nighttime were less likely to result in immediate hospital discharge. However, children with a positive EVPCR test are at very low risk for bacterial meningitis.3 As clinicians' knowledge of, and comfort with, the EVPCR test increase, this technology has the potential to further decrease the costs of caring for children with enteroviral meningitis.14

Our study had several limitations. First, it was retrospective; however, primary outcomes were objective measures accurately recorded in the medical record for most patients. Second, our study was single‐center, and findings may not be generalizable to other settings. Third, the management of children with meningitis may have been changing over the study period, independent of the in‐hospital EVPCR test. However, among children with a negative test, we observed no change in either of our primary outcomes. Fourth, given the large number of physicians involved with testing and treatment decisions, we could not adjust for clustering at the physician level. Fifth, we corrected CSF WBC in the case of a traumatic lumbar puncture (LP). Although use of this correction might underestimate the true CSF WBC count,6 the percentage of children with traumatic lumbar punctures was the same in both testing periods. Lastly, we evaluated the impact of a diagnostic test immediately after introduction into the clinical setting. As new medical technologies often take time to be adopted into clinical practice,15 we would expect the impact to increase over time.

CONCLUSIONS

In‐hospital EVPCR testing can improve the care of children with meningitis by reducing the length of unnecessary hospitalizations and parenteral antibiotics. Clinicians caring for children with meningitis should have access to in‐hospital EVPCR testing.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.

Although the advent of small ultraportable bedside ultrasound devices have heralded the age of the ultrasonic stethoscope,15 realizing the widespread potential of ultrasound‐assisted physical examination68 requires the creation of an imaging protocol that can be successfully taught to all physicians within the confines of accredited medical education. Prior feasibility studies of teaching internal medical residents are characterized by heterogeneity in imaging protocols, nonrandomized enrollment of a small number of trainees, and training that is short‐lived,6, 914 making their results difficult to generalize. Few data exist on the effects of sustained incorporation of a comprehensive, structured program within a conventional 3‐year internal medicine residency.

Over the past 14 years, we have developed cardiovascular limited ultrasound examination (CLUE), with the specific purpose of detecting prevalent cardiovascular pathologies that: (1) have been shown to affect morbidity and mortality in an adult population, (2) are often missed by physical examination, and (3) have been detected by medical residents who have been taught a simplified ultrasound examination. In this report, we will detail our observations regarding CLUE and its training curriculum with assessment of proficiency, program requirements, and the overall academic effect once firmly integrated into an internal medicine residency program.

METHODS

Assessment and Follow‐Up

A proficiency test was performed at the end of each resident's senior year. The test, cardiovascular limited ultrasound exam‐clinical exercise (CLUE‐CEX), involved imaging any available, consenting patient and assessing the resident's technical skills by image quality, knowledge of diagnostic criteria, and ability to discuss the clinical aspects of potential findings in a question‐and‐answer oral interview format, typically requiring 2030 minutes to perform. Each resident CLUE view was rated for: (1) image quality which accounted for 44% of total exam points, (2) specific knowledge related to each view which accounted for 28% of total exam points, and (3) diagnostic accuracy of the interpretation of each view which accounted for 28% of total exam points (see Figure 1). CLUE‐CEX scores were recorded as a percentage of total possible points, normalized to the difficulty of imaging the individual patient as determined by the Director's imaging. The test encompassed performance of all 7 views, demonstrated in 2 exams employing 2 transducers (cardiac and vascular) on the same patient (Figure 1). A passing threshold had been empirically derived at >80% of the total available points, a value that: (1) required performance in all 3 categories, (2) subjectively correlated to competency when assessed by the Director, and (3) had parity with other thresholds of clinical skill assessment by faculty and in graduate education. The Director had no knowledge of non‐CLUE resident evaluations, In‐training scores, or academic performance outside of CLUE. Residents were not remanded for CLUE‐CEX failure.

Figure 1

The graduating class of 2011 was the first class to initially enter into an entire residency program fully immersed in the CLUE curriculum, and was therefore specifically asked to report their impression of the CLUE program after graduation through a post‐residency questionnaire. A Likert‐type scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree) was used to assess the perceived validity of the following statements: (1) CLUE improved my own bedside cardiovascular evaluation; and (2) I would use CLUE if ultrasound were available in my future position. Each resident was then asked if too much, not enough, or an appropriate amount of time was spent to learn CLUE, and to choose the most effective form of CLUE teaching to which they were exposed: didactic lectures, bedside ICU teaching, Web site/syllabus, and one‐to‐one training with the Director or sonographer.

RESULTS

Residency and CLUE Performance

In attempting to achieve a CLUE proficiency score of >80% on the CLUE‐CEX in their graduating year, 8/41 (19.5%) senior residents failed. In these 8 residents, imaging quality, knowledge, and interpretative accuracy were all depressed: 55% 19%, 79% 11%, and 75% 11%, respectively. Two of these 8 had been selected as future chief residents over the 4‐year period, positions typically awarded to 2 residents per graduating year. The performance of the residents is seen in Table 3. The CLUE program did not exert a negative effect upon the academic performance of the residency, as evidenced by the lack of a significant difference in the Pre‐CLUE, 2‐year CLUE, and CLUE‐CEX periods in regards to average resident In‐training percentile rank scores (67.5 20.1, 62.3 20.5, 69.4 16.9, respectively; P = 0.37).

Table 3.Resident Performance

Time Era (Year of Graduation)	n	Fail Rate	CLUE‐CEX (Mean SD)	Resident IT Percentile Rank (Mean SD) (Range)
NOTE: Table shows mean standard deviation of CLUE‐CEX scores and resident In‐training percentile rank which represents the average of the residents' national percentile ranks of their In‐training PGY‐3 total scores during the corresponding time (Pre‐CLUE 4 years, CLUE phase‐in 2 years, CLUE‐CEX 4 years). Fail rate represents the % of residents who did not pass the CLUE‐CEX (80% correct criterion). Yearly data is listed for each of the CLUE‐CEX years, 20082011. Year denotes the year of graduation. Abbreviations: CLUE‐CEX, cardiovascular limited ultrasound exam‐clinical exercise; IT, In‐training; PGY, postgraduate year; SD, standard deviation.
Pre‐CLUE (20022005)	39			67.5 20.1 (2099)
Phase‐in CLUE (20062007)	19			62.3 20.5 (2097)
CLUE‐CEX (20082011)	41	19%	87.4 11.9	69.4 16.9 (3499)
Year 2008	11	36%	84.3 13.9	74.7 17.9 (4599)
Year 2009	9	11%	89.1 7.0	73.0 16.6 (3493)
Year 2010	10	30%	84.2 16.9	57.1 12.7 (4287)
Year 2011	11	0%	92.1 5.7	72.4 15.9 (3499)

Figure 2 shows the relationship between CLUE‐CEX scores and In‐training PGY‐3 scores. There was no significant relationship between resident academic performance and CLUE capabilities (r = 0.05, P = 0.75). Similarly, chief resident performance (n = 14) was not significantly associated with CLUE‐CEX scores (r = 0.15, P = 0.37), nor was male gender (P = 0.07). Approximately one‐half (49%) of the residents in the 4‐year CLUE‐CEX era entered fellowships, unchanged from historic rates, with only 1 resident during this era entering into a cardiology fellowship.

Figure 2

The Likert‐type questionnaire was returned by 11/11 graduating residents in 2011. Mean score of 4.3 0.6 (range: 35), with 6/11 responding agree, was given for the statement of whether CLUE improved the resident's own bedside exam. A score of 4.5 0.7 (range: 35), with 7/11 responding strongly agree, was given for whether the resident would use CLUE in the future if ultrasound were available. The majority (9/11) of residents felt that the time spent on CLUE was appropriate, with 2 residents responding not enough. Residents ranked one‐to‐one training with the Director(n = 6), followed by bedside ICU rounds (n = 5) as the preferred teaching methods to learn CLUE.

DISCUSSION

We report the experience of enrolling 6 consecutive classes, in an internal medicine residency, to test the feasibility of incorporating ongoing training in a specific, evidence‐based cardiovascular limited ultrasound examination within an already existing 3‐year curriculum. Using unbiased and complete enrollment, we found that residents who perform well on standardized academic testing or who are selected as chief residents do not necessarily perform more competently in CLUE, and that a significant overall initial resident failure rate can be anticipated. By questionnaire, residents felt confident in using the technique to improve their future bedside exams.

Burgeoning interest in the limited or focused application of ultrasound during bedside evaluation has already resulted in the incorporation of ultrasound training into emergency medicine residencies and critical care fellowships, with minimal standardization on curriculum, teaching methodology, or competency requirements. Given the multiple subspecialty applications for ultrasound, the potential exists of excessive diversity in bedside ultrasound practice, weakening the development of a single, simplified exam technique as a clinical tool for all physicians.31 Prior feasibility studies914 have evaluated the learning curve of internal medicine or primary care residents in performing various limited exams, but have not provided the rationale regarding the imaging protocols, the methods used for teaching, and the assessment of the program results over a sustained period of time. Furthermore, prior studies have not randomized subject trainees, likely resulting in the selected enrollment of highly motivated or skilled residents who want to perform a particular technique or have a bias to learn it. Our reported 19% unremanded failure rate on CLUE‐CEX will likely be more reflective of the general experience when initially integrating entire classes of internal medicine residents into a standard curriculum. The feasibility of introducing ultrasound at an earlier stage than residency may improve familiarity with the modality, and a 4‐year medical‐student curriculum has been recently described.32 Although introduction in medical school could allow for more adept and specific clinical training during residency, the optimal time for education in bedside ultrasound remains unclear.

Critical to the development of our program was the necessity to commit to teaching a single exam, the CLUE. We derived CLUE to quickly screen for important targets that had evidence‐basis to affect outcome, such as manifestations of subclinical atherosclerosis or chamber enlargement due to elevated filling pressures. Subsequent CLUE outcome studies have demonstrated diagnostic accuracy and prognostic value in its components,18, 26, 29, 30 and an effect upon medical decision‐making,21 even when performed by briefly trained novices.18, 21, 30 It is anticipated that this cardiovascular examination will later expand to a more advanced version or become a component of a full‐body ultrasound‐assisted physical. Therefore, evidence‐basis and brevity governed the development of a practical and teachable fundamental CLUE, and our skill assessment results are likely specific to CLUE itself.

This report contains primarily observations noted during the development of our program, written in retrospect with emphasis on real world feasibility. It was not a rigorous evaluation of specific ultrasound teaching methods. We found that training is feasible, at modest costs, when existing in‐hospital resources are utilized and include a part‐time faculty appointment and shared devices. Training the sonographers to perform CLUE as a part of the standard echocardiogram was a trivial task, but created the great benefit of being able to retrospectively review both the CLUE and formal echo in case review and teaching. Monthly CLUE lectures in the daily noon conference docket, and the use of the cardiology consultation and ICU rotations, allowed integration of the CLUE curriculum into preexisting venues and persistent practice opportunities within the residency. To prevent bias, we intentionally did not track, bring attention to, or incentivize resident performance in CLUE over any other topic; therefore, we can only approximate lecture and bedside teaching hours spent by each resident in light of detractions due to residency hour restrictions, vacations, and away rotations (Table 2). The CLUE‐CEX, although subject to the biases of any subjective resident skill assessment, was easily accomplished using a single form and faculty member, and was an efficient tool for program feedback and development.

In conclusion, we report the feasibility of sustained incorporation of an ultrasound training program in an internal medicine residency. We await studies regarding clinical outcome and validation of similar experiences in larger, multicenter programs.

Although the advent of small ultraportable bedside ultrasound devices have heralded the age of the ultrasonic stethoscope,15 realizing the widespread potential of ultrasound‐assisted physical examination68 requires the creation of an imaging protocol that can be successfully taught to all physicians within the confines of accredited medical education. Prior feasibility studies of teaching internal medical residents are characterized by heterogeneity in imaging protocols, nonrandomized enrollment of a small number of trainees, and training that is short‐lived,6, 914 making their results difficult to generalize. Few data exist on the effects of sustained incorporation of a comprehensive, structured program within a conventional 3‐year internal medicine residency.

Over the past 14 years, we have developed cardiovascular limited ultrasound examination (CLUE), with the specific purpose of detecting prevalent cardiovascular pathologies that: (1) have been shown to affect morbidity and mortality in an adult population, (2) are often missed by physical examination, and (3) have been detected by medical residents who have been taught a simplified ultrasound examination. In this report, we will detail our observations regarding CLUE and its training curriculum with assessment of proficiency, program requirements, and the overall academic effect once firmly integrated into an internal medicine residency program.

METHODS

Assessment and Follow‐Up

A proficiency test was performed at the end of each resident's senior year. The test, cardiovascular limited ultrasound exam‐clinical exercise (CLUE‐CEX), involved imaging any available, consenting patient and assessing the resident's technical skills by image quality, knowledge of diagnostic criteria, and ability to discuss the clinical aspects of potential findings in a question‐and‐answer oral interview format, typically requiring 2030 minutes to perform. Each resident CLUE view was rated for: (1) image quality which accounted for 44% of total exam points, (2) specific knowledge related to each view which accounted for 28% of total exam points, and (3) diagnostic accuracy of the interpretation of each view which accounted for 28% of total exam points (see Figure 1). CLUE‐CEX scores were recorded as a percentage of total possible points, normalized to the difficulty of imaging the individual patient as determined by the Director's imaging. The test encompassed performance of all 7 views, demonstrated in 2 exams employing 2 transducers (cardiac and vascular) on the same patient (Figure 1). A passing threshold had been empirically derived at >80% of the total available points, a value that: (1) required performance in all 3 categories, (2) subjectively correlated to competency when assessed by the Director, and (3) had parity with other thresholds of clinical skill assessment by faculty and in graduate education. The Director had no knowledge of non‐CLUE resident evaluations, In‐training scores, or academic performance outside of CLUE. Residents were not remanded for CLUE‐CEX failure.

Figure 1

The graduating class of 2011 was the first class to initially enter into an entire residency program fully immersed in the CLUE curriculum, and was therefore specifically asked to report their impression of the CLUE program after graduation through a post‐residency questionnaire. A Likert‐type scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree) was used to assess the perceived validity of the following statements: (1) CLUE improved my own bedside cardiovascular evaluation; and (2) I would use CLUE if ultrasound were available in my future position. Each resident was then asked if too much, not enough, or an appropriate amount of time was spent to learn CLUE, and to choose the most effective form of CLUE teaching to which they were exposed: didactic lectures, bedside ICU teaching, Web site/syllabus, and one‐to‐one training with the Director or sonographer.

RESULTS

Residency and CLUE Performance

In attempting to achieve a CLUE proficiency score of >80% on the CLUE‐CEX in their graduating year, 8/41 (19.5%) senior residents failed. In these 8 residents, imaging quality, knowledge, and interpretative accuracy were all depressed: 55% 19%, 79% 11%, and 75% 11%, respectively. Two of these 8 had been selected as future chief residents over the 4‐year period, positions typically awarded to 2 residents per graduating year. The performance of the residents is seen in Table 3. The CLUE program did not exert a negative effect upon the academic performance of the residency, as evidenced by the lack of a significant difference in the Pre‐CLUE, 2‐year CLUE, and CLUE‐CEX periods in regards to average resident In‐training percentile rank scores (67.5 20.1, 62.3 20.5, 69.4 16.9, respectively; P = 0.37).

Table 3.Resident Performance

Time Era (Year of Graduation)	n	Fail Rate	CLUE‐CEX (Mean SD)	Resident IT Percentile Rank (Mean SD) (Range)
NOTE: Table shows mean standard deviation of CLUE‐CEX scores and resident In‐training percentile rank which represents the average of the residents' national percentile ranks of their In‐training PGY‐3 total scores during the corresponding time (Pre‐CLUE 4 years, CLUE phase‐in 2 years, CLUE‐CEX 4 years). Fail rate represents the % of residents who did not pass the CLUE‐CEX (80% correct criterion). Yearly data is listed for each of the CLUE‐CEX years, 20082011. Year denotes the year of graduation. Abbreviations: CLUE‐CEX, cardiovascular limited ultrasound exam‐clinical exercise; IT, In‐training; PGY, postgraduate year; SD, standard deviation.
Pre‐CLUE (20022005)	39			67.5 20.1 (2099)
Phase‐in CLUE (20062007)	19			62.3 20.5 (2097)
CLUE‐CEX (20082011)	41	19%	87.4 11.9	69.4 16.9 (3499)
Year 2008	11	36%	84.3 13.9	74.7 17.9 (4599)
Year 2009	9	11%	89.1 7.0	73.0 16.6 (3493)
Year 2010	10	30%	84.2 16.9	57.1 12.7 (4287)
Year 2011	11	0%	92.1 5.7	72.4 15.9 (3499)

Figure 2 shows the relationship between CLUE‐CEX scores and In‐training PGY‐3 scores. There was no significant relationship between resident academic performance and CLUE capabilities (r = 0.05, P = 0.75). Similarly, chief resident performance (n = 14) was not significantly associated with CLUE‐CEX scores (r = 0.15, P = 0.37), nor was male gender (P = 0.07). Approximately one‐half (49%) of the residents in the 4‐year CLUE‐CEX era entered fellowships, unchanged from historic rates, with only 1 resident during this era entering into a cardiology fellowship.

Figure 2

The Likert‐type questionnaire was returned by 11/11 graduating residents in 2011. Mean score of 4.3 0.6 (range: 35), with 6/11 responding agree, was given for the statement of whether CLUE improved the resident's own bedside exam. A score of 4.5 0.7 (range: 35), with 7/11 responding strongly agree, was given for whether the resident would use CLUE in the future if ultrasound were available. The majority (9/11) of residents felt that the time spent on CLUE was appropriate, with 2 residents responding not enough. Residents ranked one‐to‐one training with the Director(n = 6), followed by bedside ICU rounds (n = 5) as the preferred teaching methods to learn CLUE.

DISCUSSION

We report the experience of enrolling 6 consecutive classes, in an internal medicine residency, to test the feasibility of incorporating ongoing training in a specific, evidence‐based cardiovascular limited ultrasound examination within an already existing 3‐year curriculum. Using unbiased and complete enrollment, we found that residents who perform well on standardized academic testing or who are selected as chief residents do not necessarily perform more competently in CLUE, and that a significant overall initial resident failure rate can be anticipated. By questionnaire, residents felt confident in using the technique to improve their future bedside exams.

Burgeoning interest in the limited or focused application of ultrasound during bedside evaluation has already resulted in the incorporation of ultrasound training into emergency medicine residencies and critical care fellowships, with minimal standardization on curriculum, teaching methodology, or competency requirements. Given the multiple subspecialty applications for ultrasound, the potential exists of excessive diversity in bedside ultrasound practice, weakening the development of a single, simplified exam technique as a clinical tool for all physicians.31 Prior feasibility studies914 have evaluated the learning curve of internal medicine or primary care residents in performing various limited exams, but have not provided the rationale regarding the imaging protocols, the methods used for teaching, and the assessment of the program results over a sustained period of time. Furthermore, prior studies have not randomized subject trainees, likely resulting in the selected enrollment of highly motivated or skilled residents who want to perform a particular technique or have a bias to learn it. Our reported 19% unremanded failure rate on CLUE‐CEX will likely be more reflective of the general experience when initially integrating entire classes of internal medicine residents into a standard curriculum. The feasibility of introducing ultrasound at an earlier stage than residency may improve familiarity with the modality, and a 4‐year medical‐student curriculum has been recently described.32 Although introduction in medical school could allow for more adept and specific clinical training during residency, the optimal time for education in bedside ultrasound remains unclear.

Critical to the development of our program was the necessity to commit to teaching a single exam, the CLUE. We derived CLUE to quickly screen for important targets that had evidence‐basis to affect outcome, such as manifestations of subclinical atherosclerosis or chamber enlargement due to elevated filling pressures. Subsequent CLUE outcome studies have demonstrated diagnostic accuracy and prognostic value in its components,18, 26, 29, 30 and an effect upon medical decision‐making,21 even when performed by briefly trained novices.18, 21, 30 It is anticipated that this cardiovascular examination will later expand to a more advanced version or become a component of a full‐body ultrasound‐assisted physical. Therefore, evidence‐basis and brevity governed the development of a practical and teachable fundamental CLUE, and our skill assessment results are likely specific to CLUE itself.

This report contains primarily observations noted during the development of our program, written in retrospect with emphasis on real world feasibility. It was not a rigorous evaluation of specific ultrasound teaching methods. We found that training is feasible, at modest costs, when existing in‐hospital resources are utilized and include a part‐time faculty appointment and shared devices. Training the sonographers to perform CLUE as a part of the standard echocardiogram was a trivial task, but created the great benefit of being able to retrospectively review both the CLUE and formal echo in case review and teaching. Monthly CLUE lectures in the daily noon conference docket, and the use of the cardiology consultation and ICU rotations, allowed integration of the CLUE curriculum into preexisting venues and persistent practice opportunities within the residency. To prevent bias, we intentionally did not track, bring attention to, or incentivize resident performance in CLUE over any other topic; therefore, we can only approximate lecture and bedside teaching hours spent by each resident in light of detractions due to residency hour restrictions, vacations, and away rotations (Table 2). The CLUE‐CEX, although subject to the biases of any subjective resident skill assessment, was easily accomplished using a single form and faculty member, and was an efficient tool for program feedback and development.

In conclusion, we report the feasibility of sustained incorporation of an ultrasound training program in an internal medicine residency. We await studies regarding clinical outcome and validation of similar experiences in larger, multicenter programs.

Although the advent of small ultraportable bedside ultrasound devices have heralded the age of the ultrasonic stethoscope,15 realizing the widespread potential of ultrasound‐assisted physical examination68 requires the creation of an imaging protocol that can be successfully taught to all physicians within the confines of accredited medical education. Prior feasibility studies of teaching internal medical residents are characterized by heterogeneity in imaging protocols, nonrandomized enrollment of a small number of trainees, and training that is short‐lived,6, 914 making their results difficult to generalize. Few data exist on the effects of sustained incorporation of a comprehensive, structured program within a conventional 3‐year internal medicine residency.

Over the past 14 years, we have developed cardiovascular limited ultrasound examination (CLUE), with the specific purpose of detecting prevalent cardiovascular pathologies that: (1) have been shown to affect morbidity and mortality in an adult population, (2) are often missed by physical examination, and (3) have been detected by medical residents who have been taught a simplified ultrasound examination. In this report, we will detail our observations regarding CLUE and its training curriculum with assessment of proficiency, program requirements, and the overall academic effect once firmly integrated into an internal medicine residency program.

METHODS

Assessment and Follow‐Up

A proficiency test was performed at the end of each resident's senior year. The test, cardiovascular limited ultrasound exam‐clinical exercise (CLUE‐CEX), involved imaging any available, consenting patient and assessing the resident's technical skills by image quality, knowledge of diagnostic criteria, and ability to discuss the clinical aspects of potential findings in a question‐and‐answer oral interview format, typically requiring 2030 minutes to perform. Each resident CLUE view was rated for: (1) image quality which accounted for 44% of total exam points, (2) specific knowledge related to each view which accounted for 28% of total exam points, and (3) diagnostic accuracy of the interpretation of each view which accounted for 28% of total exam points (see Figure 1). CLUE‐CEX scores were recorded as a percentage of total possible points, normalized to the difficulty of imaging the individual patient as determined by the Director's imaging. The test encompassed performance of all 7 views, demonstrated in 2 exams employing 2 transducers (cardiac and vascular) on the same patient (Figure 1). A passing threshold had been empirically derived at >80% of the total available points, a value that: (1) required performance in all 3 categories, (2) subjectively correlated to competency when assessed by the Director, and (3) had parity with other thresholds of clinical skill assessment by faculty and in graduate education. The Director had no knowledge of non‐CLUE resident evaluations, In‐training scores, or academic performance outside of CLUE. Residents were not remanded for CLUE‐CEX failure.

Figure 1

The graduating class of 2011 was the first class to initially enter into an entire residency program fully immersed in the CLUE curriculum, and was therefore specifically asked to report their impression of the CLUE program after graduation through a post‐residency questionnaire. A Likert‐type scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree) was used to assess the perceived validity of the following statements: (1) CLUE improved my own bedside cardiovascular evaluation; and (2) I would use CLUE if ultrasound were available in my future position. Each resident was then asked if too much, not enough, or an appropriate amount of time was spent to learn CLUE, and to choose the most effective form of CLUE teaching to which they were exposed: didactic lectures, bedside ICU teaching, Web site/syllabus, and one‐to‐one training with the Director or sonographer.

RESULTS

Residency and CLUE Performance

In attempting to achieve a CLUE proficiency score of >80% on the CLUE‐CEX in their graduating year, 8/41 (19.5%) senior residents failed. In these 8 residents, imaging quality, knowledge, and interpretative accuracy were all depressed: 55% 19%, 79% 11%, and 75% 11%, respectively. Two of these 8 had been selected as future chief residents over the 4‐year period, positions typically awarded to 2 residents per graduating year. The performance of the residents is seen in Table 3. The CLUE program did not exert a negative effect upon the academic performance of the residency, as evidenced by the lack of a significant difference in the Pre‐CLUE, 2‐year CLUE, and CLUE‐CEX periods in regards to average resident In‐training percentile rank scores (67.5 20.1, 62.3 20.5, 69.4 16.9, respectively; P = 0.37).

Table 3.Resident Performance

Time Era (Year of Graduation)	n	Fail Rate	CLUE‐CEX (Mean SD)	Resident IT Percentile Rank (Mean SD) (Range)
NOTE: Table shows mean standard deviation of CLUE‐CEX scores and resident In‐training percentile rank which represents the average of the residents' national percentile ranks of their In‐training PGY‐3 total scores during the corresponding time (Pre‐CLUE 4 years, CLUE phase‐in 2 years, CLUE‐CEX 4 years). Fail rate represents the % of residents who did not pass the CLUE‐CEX (80% correct criterion). Yearly data is listed for each of the CLUE‐CEX years, 20082011. Year denotes the year of graduation. Abbreviations: CLUE‐CEX, cardiovascular limited ultrasound exam‐clinical exercise; IT, In‐training; PGY, postgraduate year; SD, standard deviation.
Pre‐CLUE (20022005)	39			67.5 20.1 (2099)
Phase‐in CLUE (20062007)	19			62.3 20.5 (2097)
CLUE‐CEX (20082011)	41	19%	87.4 11.9	69.4 16.9 (3499)
Year 2008	11	36%	84.3 13.9	74.7 17.9 (4599)
Year 2009	9	11%	89.1 7.0	73.0 16.6 (3493)
Year 2010	10	30%	84.2 16.9	57.1 12.7 (4287)
Year 2011	11	0%	92.1 5.7	72.4 15.9 (3499)

Figure 2 shows the relationship between CLUE‐CEX scores and In‐training PGY‐3 scores. There was no significant relationship between resident academic performance and CLUE capabilities (r = 0.05, P = 0.75). Similarly, chief resident performance (n = 14) was not significantly associated with CLUE‐CEX scores (r = 0.15, P = 0.37), nor was male gender (P = 0.07). Approximately one‐half (49%) of the residents in the 4‐year CLUE‐CEX era entered fellowships, unchanged from historic rates, with only 1 resident during this era entering into a cardiology fellowship.

Figure 2

The Likert‐type questionnaire was returned by 11/11 graduating residents in 2011. Mean score of 4.3 0.6 (range: 35), with 6/11 responding agree, was given for the statement of whether CLUE improved the resident's own bedside exam. A score of 4.5 0.7 (range: 35), with 7/11 responding strongly agree, was given for whether the resident would use CLUE in the future if ultrasound were available. The majority (9/11) of residents felt that the time spent on CLUE was appropriate, with 2 residents responding not enough. Residents ranked one‐to‐one training with the Director(n = 6), followed by bedside ICU rounds (n = 5) as the preferred teaching methods to learn CLUE.

DISCUSSION

We report the experience of enrolling 6 consecutive classes, in an internal medicine residency, to test the feasibility of incorporating ongoing training in a specific, evidence‐based cardiovascular limited ultrasound examination within an already existing 3‐year curriculum. Using unbiased and complete enrollment, we found that residents who perform well on standardized academic testing or who are selected as chief residents do not necessarily perform more competently in CLUE, and that a significant overall initial resident failure rate can be anticipated. By questionnaire, residents felt confident in using the technique to improve their future bedside exams.

Burgeoning interest in the limited or focused application of ultrasound during bedside evaluation has already resulted in the incorporation of ultrasound training into emergency medicine residencies and critical care fellowships, with minimal standardization on curriculum, teaching methodology, or competency requirements. Given the multiple subspecialty applications for ultrasound, the potential exists of excessive diversity in bedside ultrasound practice, weakening the development of a single, simplified exam technique as a clinical tool for all physicians.31 Prior feasibility studies914 have evaluated the learning curve of internal medicine or primary care residents in performing various limited exams, but have not provided the rationale regarding the imaging protocols, the methods used for teaching, and the assessment of the program results over a sustained period of time. Furthermore, prior studies have not randomized subject trainees, likely resulting in the selected enrollment of highly motivated or skilled residents who want to perform a particular technique or have a bias to learn it. Our reported 19% unremanded failure rate on CLUE‐CEX will likely be more reflective of the general experience when initially integrating entire classes of internal medicine residents into a standard curriculum. The feasibility of introducing ultrasound at an earlier stage than residency may improve familiarity with the modality, and a 4‐year medical‐student curriculum has been recently described.32 Although introduction in medical school could allow for more adept and specific clinical training during residency, the optimal time for education in bedside ultrasound remains unclear.

Critical to the development of our program was the necessity to commit to teaching a single exam, the CLUE. We derived CLUE to quickly screen for important targets that had evidence‐basis to affect outcome, such as manifestations of subclinical atherosclerosis or chamber enlargement due to elevated filling pressures. Subsequent CLUE outcome studies have demonstrated diagnostic accuracy and prognostic value in its components,18, 26, 29, 30 and an effect upon medical decision‐making,21 even when performed by briefly trained novices.18, 21, 30 It is anticipated that this cardiovascular examination will later expand to a more advanced version or become a component of a full‐body ultrasound‐assisted physical. Therefore, evidence‐basis and brevity governed the development of a practical and teachable fundamental CLUE, and our skill assessment results are likely specific to CLUE itself.

This report contains primarily observations noted during the development of our program, written in retrospect with emphasis on real world feasibility. It was not a rigorous evaluation of specific ultrasound teaching methods. We found that training is feasible, at modest costs, when existing in‐hospital resources are utilized and include a part‐time faculty appointment and shared devices. Training the sonographers to perform CLUE as a part of the standard echocardiogram was a trivial task, but created the great benefit of being able to retrospectively review both the CLUE and formal echo in case review and teaching. Monthly CLUE lectures in the daily noon conference docket, and the use of the cardiology consultation and ICU rotations, allowed integration of the CLUE curriculum into preexisting venues and persistent practice opportunities within the residency. To prevent bias, we intentionally did not track, bring attention to, or incentivize resident performance in CLUE over any other topic; therefore, we can only approximate lecture and bedside teaching hours spent by each resident in light of detractions due to residency hour restrictions, vacations, and away rotations (Table 2). The CLUE‐CEX, although subject to the biases of any subjective resident skill assessment, was easily accomplished using a single form and faculty member, and was an efficient tool for program feedback and development.

In conclusion, we report the feasibility of sustained incorporation of an ultrasound training program in an internal medicine residency. We await studies regarding clinical outcome and validation of similar experiences in larger, multicenter programs.