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R
ON CALL: ISSUES IN
GRADUATE MEDICAL EDUCATION
Preparedne of !nternal
"edicine and Family Practice
#eident
for $reating %ommon %ondition

Francine C. Wiest, MD Timoth
G. Ferris, MD, M!" Man#$sha
Go%ha&e, MA
Eric G. Cam'(e&&, !hD

)oe& S. Weissman, !hD
Da*i+ ,&$mentha&, MD, M!!
ESIDENTS IN INTERNAL MEDICINE
(IM) and those in family prac-
tice (!) are trained to pro"ide
primary care for ad#lts$ yet they ha"e
"ery different residency e%periences& In-
ternal medicine trainin' (as ori'i-
nally hospital )ased and emphasi*ed
ac#te care and pathophysiolo'y of dis-
ease& More recently$ IM trainin' has in-
cl#ded an increased emphasis on pri-
mary care&
+$,
amily practice trainin'$
initiated in +-.-$ pro"ides more e%pe-
rience in office-)ased am)#latory and
lon'-term settin's and foc#ses more on
pre"enti"e and psychosocial aspects of
care&
+$/$0
In addition to primary care for
ad#lts$ ! residency incl#des trainin'
in pediatrics$ s#r'ery$ and o)stetrical
care& The different emphases in the ,
Conte%t Altho#'h )oth internal medicine (IM) and family practice (!) physicians
fre1#ently pro"ide care for the same common ad#lt conditions$ IM and ! residency
pro'rams differ in their trainin' emphases&
2)3ecti"e To assess differences in IM and ! residents4 self-percei"ed preparedness
to dia'nose and treat common ad#lt medical conditions&
Desi'n$ Settin'$ and !articipants Cross-sectional analysis of a national s#r"ey
administered in the sprin' of +--5 to residents in their final year of residency at 6S
academic health centers& A total of ,7- IM residents in ,8 pro'rams and /,. ! resi-
dents in 78 pro'rams responded to the s#r"ey&
Main 2#tcome Meas#res Residents4 self-rated preparedness to dia'nose and treat
0 inpatient conditions (ac#te myocardial infarction$ dia)etic 9etoacidosis$ ac#te asthma$
and ac#te renal fail#re) and 5 o#tpatient conditions (dia)etes$ hypertension$ lo( )ac9
pain$ "a'initis$ headache$ depression$ #pper respiratory tract infection$ and hyperlip-
idemia)$ controllin' for resident se%$ race:ethnicity$ 6S medical school 'rad#ate sta-
t#s$ intent to s#)speciali*e$ and estimates of e%pos#re to patients in inpatient and o#t-
patient settin's&
Res#lts Internal medicine residents (ere more li9ely to report )ein' "ery prepared
for all 0 inpatient conditions (P &;;+)$ (hile ! residents (ere more li9ely to report
)ein' "ery prepared for 8 of 5 o#tpatient conditions (P &;8)& Differences )et(een
IM and ! residents persisted in m#lti"ariate analyses for all inpatient conditions and
some o#tpatient conditions& E%pos#re to patients in inpatient and o#tpatient settin's
"aried )y specialty and (as si'nificantly associated (ith resident self-report of pre-
paredness for a ma3ority of conditions in"esti'ated&
Concl#sions Internal medicine and ! residents report differences in preparedness to
mana'e common ad#lt conditions& These differences (ere consistent (ith the emphasis
on an inpatient settin' for IM residents and on office-)ased care for ! residents&
JAMA. 2002;288:2609-2614 (((&3ama&com
types of residencies may affect ho( in-
ternists and family physicians ap-
proach their ad#lt patients& This may
also infl#ence their self-percei"ed pre-
paredness to pro"ide care for certain
types of patients and treat their asso-
ciated conditions&
!re"io#s st#dies s#''est that IM resi-
dents ass#me a more technical ap-
proach to patient care compared (ith
! residents$ (ho emphasi*e pre"en-
ti"e ser"ices and co#nselin'&
8$.
S#r-
"eys of IM residents ha"e fo#nd that
they )elie"e they are #nderprepared
for a "ariety of primary care tas9s$
incl#d- in' treatin' depression
7
and
perform-
&'thor &ffiliation: Ro)ert <ood =ohnson Clinical
Scholars !ro'ram$ Department of >eterans Affairs
!#'et So#nd ?ealthcare System$ and Department of
Medicine$ 6ni"ersity of <ashin'ton$ Seattle (Dr
<iest)@ Instit#te for ?ealth !olicy$ Di"ision of Aeneral
Medi- cine$ Massach#setts Aeneral ?ospital$ !artners
?ealth- care$ and ?ar"ard Medical School$ Boston
(Drs er- ris$ Camp)ell$ <eissman$ and Bl#menthal
and Ms Ao9hale)&
%orreponding &'thor and #eprint: Timothy A&
in' pel"ic e%aminations&
5
Similarly$ a
st#dy #sin' case "i'nettes compared the
self-percei"ed competencies of IM and
! residents and fo#nd that ! resi-
erris$ MD$ M!?$ Instit#te for ?ealth !olicy$ Di"ision
of Aeneral Medicine$ Massach#setts Aeneral ?ospi-
tal$ 8; Staniford St$ Boston$ MA ;,++0 (e-mailC tferris
Dpartners&or')&
(n %all )ection *ditor: =oseph E& Lim$ MD$ and Ste-
phen =& L#rie$ MD$ !hD@ Contri)#tin' EditorsC Ethan
M& Basch$ MD$ R& Sonia Batra$ MD$ M!?$ Natalie
?olt$ MD$ Alison =& ?#an'$ M!hil$ MD$ Nina Eim$
MD$ >in- cent Lo Re$ MD$ Dena E& Rif9in$ MD$ and
Mr#'esh- 9#mar E& Shah$ MD$ M!?&
+2002 &merican "edical &ociation. &ll right reer,ed. (Reprinted) =AMA$ No"em)er ,7$ ,;;,F>ol ,55$ No& ,; ,.;-
RESIDENT !RE!AREDNESS 2R C2MM2N C2NDITI2NS
dents report 'reater competence in
mana'in' depression (hereas IM resi-
dents report 'reater competence in
treatin' ac#te myocardial infarction and
its complications&
-
These st#dies$ ho(-
e"er$ are limited to sin'le trainin' sites&
Little is 9no(n a)o#t differences in IM
and ! trainin' across pro'rams or the
e%tent to (hich these differences may
affect resident preparedness to handle
common ad#lt conditions&
<e hypothesi*ed that the 'reater em-
phasis on o#tpatient care in ! residen-
cies (o#ld )e associated (ith 'reater
self-percei"ed preparedness for o#tpa-
tient conditions amon' ! residents
than IM residents and that$ similarly$
the 'reater emphasis on inpatient
care amon' IM residencies (o#ld )e
associ- ated (ith 'reater self-
percei"ed pre- paredness for
inpatient conditions amon' IM
residents than ! residents& <e f#rther
so#'ht to e%plore the rela- ti"e
importance of e%pos#re to the set-
tin's in (hich the specific clinical con-
ditions (ere fo#nd to IM and !
residents4 sense of preparedness& To
ad- dress these hypotheses$ (e #sed
data from a national s#r"ey of resident
pre- paredness&
+;
MET?2DS
Sample Selection
The samplin' methods #sed in this
st#dy ha"e )een descri)ed pre"i-
o#sly&
+;
Briefly$ (e #sed a m#ltista'e
process to assem)le a sample of resi-
dents across 5 specialties (incl#din' IM
and !) to o)tain a representati"e
sample of residents trainin' in their fi-
nal year at 6S academic health cen-
ters& The final list of academic health
centers$ defined as medical schools and
their closely affiliated or o(ned clini-
cal facilities$ contained +., hospitals
that (ere responsi)le for trainin' 0;
;;; of the -5 ;;; residents in +--7&
++
2#r final sample consisted of 875 IM
resi- dents in ,8 pro'rams (5G of
accred- ited IM cate'orical pro'rams)
and .85
! residents in 78 pro'rams (+.G of
ac- credited ! pro'rams)&
+;
<e
conser- "ati"ely estimated that o#r
sample rep- resents 8/G of senior
residents trainin' in IM and ,7G of
senior residents train-
in' in !$ or 00G of all senior resi-
dents in )oth specialties& The lo(er
per- centa'e of ! residents reflects
the 'reater n#m)er in nonacademic
health centers that sponsor !
residencies&
S#r"ey Desi'n and Administration
De"elopment of the s#r"ey instr#-
ments (+ for each specialty) (as in-
formed )y literat#re re"ie(s$ foc#s
'ro#ps$ re"ie( of rele"ant Accredita-
tion Co#ncil on Arad#ate Medical Ed#-
cation policies$ and comments from
e%perts in each of the respecti"e spe-
cialties&
+;
The instr#ments (ere pre-
tested #sin' co'niti"e inter"ie(s and
(ere desi'ned to ta9e +8 min#tes to
complete&
The s#r"ey (as administered in the
sprin' of +--5& Mailed s#r"eys consti-
t#ted -,G of the IM responses and -;G
of the ! responses$ (ith the remain-
der of the responses in each 'ro#p o)-
tained "ia telephone s#r"eys& Re-
sponse enhancement techni1#es
incl#ded ad"ance notification$ m#l-
tiple mailin's$ telephone follo(-#ps$
and fle%i)le sched#lin'& Respondents
(ere eli'i)le to recei"e cash pri*es or
(in some cases) payment for com-
pleted inter"ie(s& The initial (#nad-
3#sted) response rate (as 05G for IM
and 0-G for !$ reflectin' relati"ely
hi'h in"alid identification rates (,7G)
of residents (ho had left their pro-
'rams or (ere assi'ned the (ron' spe-
cialty s#r"ey& The final s#r"ey re-
sponse rate$ ad3#sted for in"alid sample$
(as .8G& Internal medicine and !
samples had ad3#sted response rates of
8-G and .5G$ respecti"ely& The Mas-
sach#setts Aeneral ?ospital (Boston)
Instit#tional Re"ie( Board appro"ed
this protocol&
>aria)les
%linical Preparedne.<e as9ed resi-
dents ho( prepared they felt to dia'-
nose and treat (+) inpatients$ critically
ill patients$ and am)#latory patients in
'eneral@ (,) fo#r specific conditions
typically associated (ith the inpatient
settin' (ac#te myocardial infarction$
dia)etic 9etoacidosis$ ac#te asthma$ and
ac#te renal fail#re)@ and (/) ei'ht spe-
cific conditions associated (ith the o#t-
patient settin' (dia)etes$ hyperten-
sion$ lo( )ac9 pain$ "a'initis$
headache$ depression$ #pper
respiratory tract in- fection$ and
hyperlipidemia)& All of these ad#lt
conditions (ere listed to- 'ether on
)oth IM and ! s#r"eys& The !
s#r"ey contained a separate sec- tion
listin' pediatric dia'noses& The re-
sponse cate'ories for each 1#estion
(ere very unprepared, somewha unpre-
pared, somewha prepared$ and very
pre- pared&
#eident *-po're by )etting. Be-
ca#se (e considered e%pos#re to pa-
tients a potentially important media-
tor of differences )et(een IM and !
preparedness$ (e attempted to assess
the infl#ence of e%pos#re to patients in
different settin's on IM and ! re-
ports of preparedness& E%pos#re to pa-
tients is a f#nction of )oth the time
spent in a settin' and the "ol#me of pa-
tients seen in that settin'& <e hypoth-
esi*ed that )oth components of e%po-
s#re (o#ld )e important )eca#se
pro'rams "ary in the amo#nt of time
residents are sched#led in inpatient and
o#tpatient settin's$ and medical cen-
ters and practices "ary in the "ol#me
of patients seen in each settin'& <e
had pre"io#sly tested 1#estions related
to resident reports of the percenta'e
of time spent and the n#m)er of
patients seen in inpatient and
o#tpatient set- tin's$ )oth alone and
in com)ination& <e fo#nd that a
com)ined meas#re pro"ided$ on
a"era'e$ the 'reatest e%- planatory
po(er and the hi'hest sta- tistical
si'nificance in o#r models$ and$
therefore$ #sed those in o#r analyses&
Inpatient e%pos#re (as calc#lated )y
m#ltiplyin' the a"era'e n#m)er of pa-
tients admitted d#rin' a shift as an in-
tern )y the percenta'e of residency
spent in the inpatient settin' (e%cl#d-
in' the operatin' room and emer-
'ency department)& 2#tpatient e%po-
s#re (as calc#lated )y m#ltiplyin' the
a"era'e n#m)er of patients typically
seen in a 0-ho#r o#tpatient clinic )y
the percenta'e of residency spent in
am- )#latory settin's&
(ther .ariable. Respondents (ere
as9ed a)o#t their se%$ (hether they
,.+; =AMA$ No"em)er ,7$ ,;;,F>ol ,55$ No& ,; (Reprinted) +2002 &merican "edical &ociation. &ll right reer,ed.
RESIDENT !RE!AREDNESS 2R C2MM2N C2NDITI2NS
attended medical school in the 6nited
States$ and their race:ethnicity ((hite
non-?ispanic$ )lac9 non-?ispanic$
?ispanic$ Asian$ or Alas9a nati"e:
American Indian)& In separate analy-
ses$ (e fo#nd that (hite non-?ispanic
and Asian respondents (ere not si'-
nificantly different in demo'raphics and
responses$ so (e com)ined their
responses and compared these (ith the
other 'ro#ps constit#tin' #nderrepre-
sented minorities& <e also as9ed resi-
dents a)o#t their intention to s#)spe-
ciali*e after residency (yes$ no$ or
#ndecided)& Beca#se all respondents
s#r"eyed (ere in their final year of
resi- dency$ H#ndecidedI responses
(ere com)ined (ith HnoI responses
since these )oth reflected an a)sence
of defi- nite plans for s#)specialty
trainin'&
Statistical Analysis
J#estions (ith m#ltiple response cat-
e'ories (ere collapsed to form
dichoto- mo#s "aria)les& or o#r
main o#t- come "aria)le$
preparedness$ (e compared "ery
prepared (ith some- (hat
prepared:some(hat #nprepared: "ery
#nprepared )eca#se (e (ere in-
terested in factors that determine
s#perior preparation for dia'nosis and
treatment of the conditions s#r"eyed&
Beca#se differences )et(een "ery pre-
#sin' the
,
test& In addition$ (e con-
d#cted m#lti"ariate analyses of com-
parisons of preparedness )et(een IM
and ! residents controllin' for e%po-
s#re to patients$ se%$ 6S medical
school 'rad#ate stat#s$ race:ethnicity$
and plans to p#rs#e a s#)specialty or
fel- lo(ship& 2dds ratios (2Rs) from
m#l- ti"ariate analyses (ere con"erted
to ad- 3#sted relati"e ris9s
follo(in' the method descri)ed )y
Khan' and L#&
+,
Analyses (ere (ei'hted to ad3#st for
differences in samplin' and response
rates amon' the strata& M#lti"ariate
analyses incl#ded ad3#stment for the
m#ltista'e samplin' desi'n& Analyses
(ere comp#ted #sin' S6DAAN soft-
(are "ersion 7&8&+(Research Trian'le
Instit#te$ Research Trian'le !ar9$ NC)&
P &;8 (as considered statistically si'-
nificant&
RES6LTS
Characteristics of Sample
Internal medicine and ! residents (ere
similar in race:ethnicity and the propor-
tion (ho 'rad#ated from a 6S medical
school& amily practice respondents
(ere more li9ely to )e (omen and
(ere less li9ely to )e plannin'
s#)specialty trainin' ($&/0* 1)&
Differences )e- t(een IM and !
e%pos#re to patients
differed )y clinical settin'& Internal
medi- cine residents reported 'reater
e%po- s#re to inpatients$ and !
residents re- ported 'reater e%pos#re
to o#tpatients (P &;;+ for )oth
comparisons)&
!reparedness to Treat Different
Types of !atients
<e tested differences in resident-
reported preparedness to treat / differ-
ent types of patientsC inpatients$ criti-
cally ill patients$ and o#tpatients&
Internal medicine residents (ere more
li9ely than ! residents to report )ein'
"ery prepared to treat inpatients (,8,:
,77 M-+GN "s +7-:/,; M88GN@ P &;;+)
and critically ill patients (+5/:,75
M.5GN "s 87:/,+ M+7GN@ P &;;+)& am-
ily practice residents (ere more li9ely
than IM residents to report )ein' "ery
prepared to treat o#tpatients (,.,:
/,; M5,GN "s +/0:,77 M05GN$ P &
;;+)&
!reparedness for Specific Inpatient
and 2#tpatient Conditions
Internal medicine residents (ere si'-
nificantly more li9ely than ! resi-
dents to report )ein' "ery prepared to
care for patients (ith ac#te myocar-
dial infarction$ dia)etic 9etoacidosis$
ac#te asthma$ and ac#te renal fail#re
($&/0* 2)& These findin's persisted in
pared and some(hat prepared may not
)e clinically meanin'f#l$ (e com-
pared all conditions #sin' "ery pre-
pared and some(hat prepared (ith
Ta)le +& Characteristics of S#r"ey Sample )y Residency Type
*
Internal Medicine
(n = 279)
Sex
Family Practice
(n = 326) P Value
some(hat #nprepared and "ery #npre-
pared in a secondary analysis& The pa-
tient e%pos#re "aria)les (ere entered
Female 103 (36) 13 (!6)
"02
Male 176 (6!) 173 (!)
#S medical $c%&&l $tatu$
#S medical 'raduate 1( (61) 2( (7()
into o#r models as contin#o#s "ari-
a)les&
Internati&nal medical 'raduate 9! (39) 6( (22)
)ace*et%nicity
"10
<e tested differences )et(een IM
and
! characteristics #sin' the
,
statis-
tic (dichotomo#s "aria)les) and the
test (contin#o#s "aria)les)& <e
tested for differences )et(een IM and
! in responses to 1#estions re'ardin'
site- specific preparedness (inpatient$
o#t- patient$ or critically ill settin') as
(ell as differences in reported
prepared- ness for each of the 0
inpatient and 5 o#tpatient
conditions& All dichoto- mo#s
comparisons of preparedness )e-
#nderre+re$ented min&ritie$ 22 (() ! (1!)
"16
,%ite*-$ian 20 (92) 2(0 ((6)
Su.$+eciali/ati&n*0ell&1$%i+
2& intent t& $u.$+eciali/e 127 (!() 27! (()
"001
Intent t& $u.$+eciali/e 1!7 (2) !( (1)
-3era'e ex+&$ure4
In+atient 3"27 1"33 "001
5ut+atient 1"72 !"9 "001
*6ata are +re$ented a$ 2&" (7) unle$$ &t%er1i$e $+eci0ied" 2um.er$ may n&t $um t& &3erall t&tal$ due t&
mi$$in' re$+&n$e$"
8%e P 3alue$ +re$ented are 0r&m
2
analy$e$ in c&m+ari$&n$ &0 +ercenta'e$ and 0r&m t te$t$ in c&m+ari$&n$ &0
c&n9 tinu&u$ 3aria.le$"
4In+atient ex+&$ure 1a$ calculated .y multi+lyin' t%e a3era'e num.er &0 +atient$ admitted durin' an in+atient
r&tati&n a$ an intern .y t%e +ercenta'e &0 re$idency $+ent in t%e in+atient $ettin'" 5ut+atient ex+&$ure 1a$
calculated .y multi+lyin' t%e a3era'e num.er &0 +atient$ $een durin' a !9%&ur clinic .y t%e +ercenta'e &0
re$idency $+ent in t%e &ut+atient $ettin'"
t(een IM and ! (ere initially tested
+2002 &merican "edical &ociation. &ll right reer,ed. (Reprinted) =AMA$ No"em)er ,7$ ,;;,F>ol ,55$ No& ,; ,.++
6e+re$$i&n 1"!1 (1"2191"6) "001
6ia.ete$ 1"21 (1"0191"!) "0!
:eadac%e 1"23 (1"0(91"39) "003
:y+erli+idemia 1"30 (1"0(91"() "007
:y+erten$i&n 1"33 (1"0691"6() "01
;&1 .ac< +ain 1"17 (1"0191"36) "0!
#++er re$+irat&ry 1"23 (0"9091"6() "1(
RESIDENT !RE!AREDNESS 2R C2MM2N C2NDITI2NS
Ta)le ,& Internal Medicine and amily !ractice Residents4 Self-reported !reparedness to Dia'nose and Treat Selected Inpatient and 2#tpatient
Conditions
*
)e$ident$ )e$+&ndin' =Very Pre+ared>
In+atient
?&nditi&n$
IM FP
2&" 7 (97 ?I) 2&" 7 (97 ?I)
)) (97 ?I)
0&r FP 3$ IM
-d@u$ted )) (97 ?I)
0&r FP 3$ IM
P Value 0&r
Multi3ariate
-naly$i$
-cute my&cardial in0arcti&n 2( 9! (91996) 22( 71 (6976) 0"7 (0"6(90"(3) 0"3! (0"1(90"62) "001
-cute renal 0ailure 216 7( (719() 77 2! (19929) 0"31 (0"2390"!1) 0"13 (0"0(90"23) "001
-$t%ma 2 93 ((9997) 233 73 (6797() 0"7( (0"7090"(7) 0"9 (0"2990"9!) "02
6ia.ete$ <et&acid&$i$ 262 9 (9299() 192 60 (966) 0"6! (0"690"72) 0"27 (0"1290"!) "001
5ut+atient
6e+re$$i&n 10 36 (309!2) 239 7! (70979) 2"07 (1"6792"6!) 1"12 (1"0091"21) "06
6ia.ete$ 21 91 ((799!) 27 (1 (769() 0"(9 (0"(190"97) 0"61 (0"3690"(!) "001
:eadac%e 129 !( (!29!) 19 62 (6967) 1"29 (1"091"() 0"93 (0"7391"11) "0(
:y+erli+idemia 220 7( (739(3) 22! 71 (6697) 0"91 (0"(091"0!) 0"( (0"!390"76) "001
:y+erten$i&n 261 9! (91997) 2(2 (( ((992) 0"9! (0"((91"01) 0"72 (0"!990"90) "001
;&1 .ac< +ain 1!9 2 (!99) 229 71 (67976) 1"37 (1"1!91"6() 1"0( (0"9391"19) "23
#++er re$+irat&ry tract in0ecti&n 2!9 (9 ((992) 301 9 (93996) 1"06 (1"0191"13) 1"01 (0"9091"0!) "(0
Va'initi$ 119 !3 (3690) 2(! (9 ((992) 2"06 (1"6992"() 1"11 (1"0991"12) "001
*IM indicate$ internal medicineA FPB 0amily +racticeA ))B relati3e ri$<A and ?IB c&n0idence inter3al"
6ata 1ere calculated 0r&m re're$$i&n m&del$ ad@u$ted 0&r $+ecialtyB ex+&$ure t& +atient$B $exB attendance at a #S medical $c%&&lB race*et%nicityB and +lan$ 0&r 0ell&1$%i+ &n
c&m+leti&n &0 re$idency ($ee =Met%&d$> $ecti&n &0 text 0&r detail$)"
Ta)le /& 2dds Ratios )y Condition for
the Association of E%pos#re to !atients
and the Li9elihood of Respondin' as
H>ery !reparedI to Mana'e Common
2#tpatient Conditions
*
5ut+atient
Cx+&$ureB P
patient e%pos#re (ere more li9ely to
re- port )ein' "ery prepared to
mana'e (2R$ +&/0@ -8G confidence
inter"al MCIN$ +&;8-+&7,@ P O &;,)&
The res#lts (ere more "aria)le for the
5 o#tpatient conditions (Ta)le ,)& More
si'nificant for depression (Ta)le ,)& <e
fo#nd that increased e%pos#re to pa-
tients in the o#tpatient settin' (as as-
sociated (ith 'reater preparedness to
treat o#tpatient conditions for . of the
5 conditions st#died ($&/0* 1)& The
ef-
?&nditi&n$
tract in0ecti&n
5) (97 ?I) Value IM residents than ! residents re-
ported )ein' "ery prepared to treat dia-
)etes& In contrast$ ! residents (ere
si'- nificantly more li9ely than IM
residents to report )ein' "ery
prepared to treat depression$
headache$ lo( )ac9 pain$ #pper
respiratory tract infection$ and
fects of e%pos#re to o#tpatients on
resi-
dent reports of preparedness (ere most
mar9ed for headache and depression
and some(hat less mar9ed for lo(
)ac9 pain&
Some resident characteristics other
than specialty (ere si'nificantly re-
Va'initi$ 1"02 (0"(91"23) "(3
*6ata 1ere calculated 0r&m re're$$i&n m&del$
ad@u$ted 0&r $+ecialtyB ex+&$ure t& +atient$B $exB
attendance at a #S medical $c%&&lB race*et%nicityB
and +lan$ 0&r 0el9 l&1$%i+ &n c&m+leti&n &0 re$idency
($ee =Met%&d$> $ec9 ti&n &0 text 0&r detail$)" 5)
indicate$ &dd$ rati&A ?IB c&n9 0idence inter3al"
5ut+atient ex+&$ure 1a$ calculated .y multi+lyin' t%e
a3era'e num.er &0 +atient$ $een durin' a !9%&ur
clinic .y t%e +ercenta'e &0 re$idency $+ent in t%e
&ut+atient $ettin'"
m#lti"ariate analyses& Resident char-
acteristics (ere not si'nificantly asso-
ciated (ith preparedness for any of the
0 inpatient conditions (data not
sho(n)& 2#r meas#re of resident e%-
pos#re to inpatients (as 'enerally not
associated (ith reports of prepared-
ness for inpatient conditions& 2ne e%-
ception (as dia)etic 9etoacidosis$
(hich residents reportin' increased in-
"a'initis& Differences )et(een IM and
! residents (ere not statistically
si'nificant for hyperlipidemia and hy-
pertension& The direction of the asso-
ciations )et(een specialty and pre-
paredness did not chan'e (hen (e
recate'ori*ed the dependent "aria)le
to "ery prepared and some(hat pre-
pared "s some(hat #nprepared and
"ery #nprepared$ )#t most differences
(ere no lon'er statistically si'nif-
icant&
In the m#lti"ariate analysis control-
lin' for e%pos#re to patients$ IM resi-
dents reported 'reater preparedness to
treat dia)etes$ hyperlipidemia$ and hy-
pertension& Reports of 'reater prepared-
ness )y ! residents remained si'nifi-
cant for "a'initis and mar'inally
lated to preparedness to dia'nosis and
treat the o#tpatient conditions& <omen
(ere si'nificantly more li9ely than
men to report )ein' "ery prepared to
dia'- nose and treat depression (2R$
+&7;@
-8G CI$ ;&---/&;.@ P O &;,) and
"a'ini- tis (2R$ ,&8/@ -8G CI$
+&./-/&-0@ P &;;+)& Also$ residents
(ho did not intend to s#)speciali*e
(ere more li9ely to report )ein' "ery
prepared to treat "a'initis (2R$
,&;0@ -8G CI$ +&/.-
/&;8@ P O &
;;8)&
C2MMENT
This report presents the res#lts of a na-
tional s#r"ey of IM and ! residents in
their final year of trainin' in +., 6S
aca- demic health center hospitals&
<e fo#nd si'nificant differences
)et(een
,.+, =AMA$ No"em)er ,7$ ,;;,F>ol ,55$ No& ,; (Reprinted) +2002 &merican "edical &ociation. &ll right reer,ed.
RESIDENT !RE!AREDNESS 2R C2MM2N C2NDITI2NS
IM and ! residents4 self-reported pre-
paredness to dia'nose and treat com-
mon conditions in inpatient and o#t-
patient settin's& Internal medicine
residents reported 'reater prepared-
ness than ! residents to dia'nose and
treat all 0 inpatient conditions$ (hile
! residents reported 'reater prepared-
ness to dia'nosis and treat most of the
5 o#tpatient conditions incl#ded in o#r
s#r"ey&
In this st#dy$ (e meas#red resi-
dents4 perceptions of their prepared-
ness& The techni1#e of self-assessment
has )een (idely #sed$
8$.$+/-+.
altho#'h
ho( (ell residents4 perceptions match
some o)3ecti"e standard of prepared-
ness is not (ell 9no(n&
+7
Some a#thors
ha"e fo#nd little correlation )et(een
physician self-assessment and o)3ec-
ti"ely meas#red competency$
+5-,;
)#t
others ha"e fo#nd that physicians are
a)le to predict their performance reli-
a)ly&
,+-,0
Residents$ ho(e"er$ may #n-
derrate themsel"es compared (ith the
ratin's of their s#per"isors&
,8$,.
There-
fore$ o#r res#lts m#st )e interpreted
(ithin the limitations of self-assess-
ment&
There are se"eral possi)le e%plana-
tions for the differences in IM and !
residents4 reports of preparedness fo#nd
in this st#dy& Internal medicine and !
pro'rams differ in their trainin' em-
phases and their residency re"ie( com-
mittee re1#irements for e%pos#re to in-
patients and o#tpatients& Internal
medicine residents spend at least +,
months in inpatient teachin' ser"ices
compared (ith . months of ad#lt in-
patient care for ! residents& The
'reater time spent on inpatient care for
IM resi- dents and o#tpatient care for
! resi- dents (as reflected in o#r
findin's& The IM residency re"ie(
committee has noted internists are
distin'#ished )y their dia'nostic
s9ills
,
(hereas the ! residency
re"ie( committee hi'h- li'hts
a)ilities in pro"idin' contin#- o#s
and comprehensi"e care&
0
In addi-
tion$ differences in self-reported
preparedness may reflect differences in
the interests and career choices of the
residents in each specialty&
,7
Internal
medicine is a 'ate(ay for many s#)-
specialties$ (hereas ! is predicated
on pro"idin' comprehensi"e primary
care for a )road ran'e of patients&
E%pos#re to patients in inpatient and
o#tpatient settin's (as si'nificantly as-
sociated (ith preparedness for se"eral
conditions incl#ded in the st#dy& It is
#n- li9ely that the "aria)le (e #sed for
pa- tient e%pos#re reflects the
comple%ity of patient-resident
interactions@ nonethe- less$ o#r res#lts
do reflect the impor- tance of patient
e%pos#re on resident reports of
preparedness for certain in- patient
and o#tpatient conditions& 2f note$
the / o#tpatient conditions for (hich
IM residents rated themsel"es hi'her
than did ! residents (dia)etes$
hypertension$ and hyperlipidemia) (ere
conditions also commonly fo#nd in in-
patient settin's& Additional condition
and trainin' pro'ram characteristics in-
fl#encin' the relationship )et(een e%-
pos#re and preparedness may incl#de
di- a'nostic and therape#tic
comple%ity$ e"idence )ase$ fre1#ency
of comor)idi- ties$ li9elihood of
complications$ resi- dent (or9load$
and 1#ality of resident instr#ction& In
addition$ there may )e a lo(er limit
(threshold) of necessary e%- pos#re&
Internal medicine and ! resi- dents
may all ha"e s#fficient e%pos#re to
se"eral conditions$ (hich may e%-
plain the lac9 of association )et(een
e%- pos#re and preparedness for
se"eral of the inpatient and
o#tpatient condi- tions&
Se% of the resident (as the most si'-
nificant factor for care of patients (ith
"a'initis& This is consistent (ith a pre-
"io#s st#dy of IM and ! physicians
that fo#nd that )oth types of physi-
cians rated their s9ill and comfort (ith
se%-specific e%aminations hi'her (ith
patients of the same se%& Beca#se fe-
male patients often prefer female phy-
sicians$
,5-/+
it is possi)le that female
resi- dents enco#ntered more
cases of "a'initis in their trainin'&
Altho#'h (e fo#nd that IM and !
residents reported differences in pre-
paredness$ there are se"eral limita-
tions to o#r concl#sions& There may )e
systematic )iases in the (ay IM and !
residents respond to 1#estions a)o#t
preparedness& Indi"id#als (ith a par-
tic#lar approach to self-assessment may
)e dra(n more to one specialty than
the other$ or residents (ithin each
spe- cialty may )ecome acc#lt#rated
to rate themsel"es a certain (ay&
Altho#'h (e separated ad#lt and
pediatric dia'- noses in o#r s#r"ey$
! residents may ha"e factored their
feelin's of prepared- ness (ith
pediatric care into their re- sponses
for preparedness on the ad#lt
conditions (here these o"erlap& Addi-
tionally$ IM and ! practices may not
)e directly compara)le )eca#se !
ad#lt o#tpatient pop#lations ha"e
)een fo#nd$ on a"era'e$ to )e
yo#n'er and to ha"e fe(er chronic
conditions&
/,
The 'enerali*a)ility of
o#r res#lts may )e limited )y o#r
sample$ (hich tar'eted residents at
academic health centers&
In s#mmary$ in a national s#r"ey of
residents$ (e fo#nd differences in IM
and ! resident reports of prepared-
ness to dia'nose and treat common in-
patient and o#tpatient conditions& This
st#dy fo#nd IM and ! reports of pre-
paredness to )e 'enerally consistent
(ith the differin' emphases of these
dis- tinct specialty trainin' pro'rams&
These differences raise an important
policy 1#estion& If different trainin'
re'i- mens res#lt in differin' le"els of
pre- paredness$ can trainin' pro'rams
)e de- si'ned to optimi*e preparedness
for the anticipated practice settin'P
To im- pro"e residency ed#cation and
the care physicians pro"ide for ad#lt
patients$ (e m#st contin#e to
in"esti'ate the fac- tors promotin'
)etter resident pre- paredness as
(ell as the )est means to meas#re
them&
&'thor %ontrib'tion: !udy "on"ep and des#$nC
erris$ Bl#menthal$ <eissman&
A"%u#s##on o& daa: Bl#menthal$ Camp)ell$ <eissman&
Ana'ys#s and #nerprea#on o& daaC <iest$ erris$
Ao9hale$ Camp)ell&
(ra&#n$ o& he manus"r#p: <iest$ erris$ Ao9hale&
)r##"a' rev#s#on o& he manus"r#p &or #mporan #n-
e''e"ua' "onen: <iest$ erris$ <eissman$ Camp)ell$
Ao9hale$ Bl#menthal&
!a#s#"a' e*per#se: erris$ Ao9hale$ Camp)ell&
+,a#ned &und#n$: Bl#menthal$ <eissman&
Adm#n#sra#ve, e"hn#"a', or maer#a' suppor: <iest$
erris$ Ao9hale&
!udy superv#s#on: Bl#menthal$ erris&
F'nding/)'pport: #ndin' (as pro"ided )y the Com-
mon(ealth #nd Tas9 orce on Academic ?ealth Cen-
ters& Dr <iest (as s#pported )y the Ro)ert <ood
=ohnson Clinical Scholars !ro'ram and Dr erris (as
s#pported )y the !ediatric Scientist De"elopment
!ro- 'ram (AA!:NIC?D ;;58;)&
+2002 &merican "edical &ociation. &ll right reer,ed. (Reprinted) =AMA$ No"em)er ,7$ ,;;,F>ol ,55$ No& ,; ,.+/
RESIDENT !RE!AREDNESS 2R C2MM2N C2NDITI2NS
#*F*#*2%*)
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cation$ Residency Re"ie( Committee& !ro'ram re-
1#irements for residency ed#cation in internal medi-
cine& A"aila)le atC httpC::(((&ac'me&or'& Accessed
2cto)er 0$ ,;;+&
2. Accreditation Co#ncil on Arad#ate Medical Ed#-
cation& -raduae Med#"a' .du"a#on (#re"ory: Pro-
$ram /e%u#remens &or /es#den"y .du"a#on #n 0ner-
na' Med#"#ne. Chica'o$ IllC American Medical
Association@ +--7&
1. Accreditation Co#ncil on Arad#ate Medical Ed#-
cation$ Residency Re"ie( Committee& !ro'ram re-
1#irements for residency ed#cation in family prac-
tice& A"aila)le atC httpC::(((&ac'me&or'& Accessed
2cto)er 0$ ,;;+&
3. Accreditation Co#ncil on Arad#ate Medical Ed#-
cation& -raduae Med#"a' .du"a#on (#re"ory: Pro-
$ram /e%u#remens &or /es#den"y .du"a#on #n 1am-
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Association@
+--7&
4. Berta9is ED$ Callahan E=$ ?elms L=$ A*ari R$ Ro)-
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+---@/+C+57-+-0&
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E"al#ation of am)#latory care trainin' )y 'rad#ates
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6. Mandel =?$ Rich EC$ L#%en)er' MA$ Spilane MT$
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Al#mni perspecti"es comparin' a 'eneral internal medi-
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J -en 0nern Med. +--+@.C800-88,&
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thin'& 3MJ. +--5@/+.C+.;--+.+;&
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?o( many a man has dated a ne( era in his life from
the readin' of a )oo9Q
F?enry Da"id Thorea# (+5+7-+5.,)
,.+0 =AMA$ No"em)er ,7$ ,;;,F>ol ,55$ No& ,; (Reprinted) +2002 &merican "edical &ociation. &ll right reer,ed.