Faculty Bibliography

• LAA membranes are exceedingly rare with variable morphologies. • Thromboembolic risk with LAA membranes remains unknown. • Use of 3D TEE transillumination may assist in visualization and understanding.

BACKGROUND:Experiential learning through patient care is fundamental to graduate medical education. Despite this, the actual content to which trainees are exposed in clinical practice is difficult to quantify and is poorly characterized. There remains an unmet need to define precisely how residents' patient care activities inform their educational experience.  METHODS: Using a recently-described crosswalk tool, we mapped principal ICD-10 discharge diagnosis codes to American Board of Internal Medicine (ABIM) content at four training hospitals of a single Internal Medicine (IM) Residency Program over one academic year to characterize and compare residents' clinical educational experiences. Frequencies of broad content categories and more specific condition categories were compared across sites to profile residents' aggregate inpatient clinical experiences and drive curricular change. RESULTS:There were 18,604 discharges from inpatient resident teams during the study period. The crosswalk captured > 95% of discharges at each site. Infectious Disease (ranging 17.4 to 39.5% of total discharges) and Cardiovascular Disease (15.8 to 38.2%) represented the most common content categories at each site. Several content areas (Allergy/Immunology, Dermatology, Obstetrics/Gynecology, Ophthalmology, Otolaryngology/Dental Medicine) were notably underrepresented (≤ 1% at each site). There were significant differences in the frequencies of conditions within most content categories, suggesting that residents experience distinct site-specific clinical content during their inpatient training. CONCLUSIONS:There were substantial differences in the clinical content experienced by our residents across hospital sites, prompting several important programmatic and curricular changes to enrich our residents' hospital-based educational experiences.

PROBLEM/OBJECTIVE:Internal medicine training programs operate under the assumption that the three-year residency training period is sufficient for trainees to achieve the depth and breadth of clinical experience necessary for independent practice; however, the medical conditions to which residents are exposed in clinical practice are not easily measured. As a result, residents' clinical educational experiences are poorly understood. APPROACH/METHODS:A crosswalk tool (a repository of international classification of diseases [ICD]-10 codes linked to medical content areas) was developed to query routinely collected inpatient principal diagnosis codes and translate them into an educationally meaningful taxonomy. This tool provides a robust characterization of residents' inpatient clinical experiences. OUTCOMES/RESULTS:This pilot study has provided proof of principle that the crosswalk tool can effectively map one year of resident-attributed diagnosis codes to both the broad content category level (for example "Cardiovascular Disease") and to the more specific condition category level (for example "Myocardial Disease"). The authors uncovered content areas in their training program that are overrepresented and some that are underrepresented relative to material on the American Board of Internal Medicine (ABIM) Certification Exam. NEXT STEPS/UNASSIGNED:The crosswalk tool introduced here translated residents' patient care activities into discrete, measurable educational content and enabled one internal medicine residency training program to characterize residents' inpatient educational experience with a high degree of resolution. Leaders of other programs seeking to profile the clinical exposure of their trainees may adopt this strategy. Such clinical content mapping drives innovation in the experiential curriculum, enables comparison across practice sites, and lays the groundwork to test associations between individual clinical exposure and competency-based outcomes, which, in turn, will allow medical educators to draw conclusions regarding how clinical experience reflects clinical competency.

Rhythm control strategies in patients with esophageal varices and atrial arrhythmias pose a unique challenge. The left atrium should be imaged for a thrombus prior to attempting cardioversion or ablation, but the presence of varices is a relative contraindication for transesophageal echocardiography. We present a safe, novel technique of evaluating for left atrial thrombus with simultaneous transesophageal echocardiography and esophagogastroduodenoscopy using slim probes in a patient with large, high-risk esophageal varices, and symptomatic atrial flutter with rapid ventricular rates despite medical therapy.

The COVID-19 pandemic has dramatically disrupted the educational experience of medical trainees. However, a detailed characterization of exactly how trainees' clinical experiences have been affected is lacking. Here, we profile residents' inpatient clinical experiences across the four training hospitals of NYU's Internal Medicine Residency Program during the pandemic's first wave. We mined ICD-10 principal diagnosis codes attributed to residents from February 1, 2020, to May 31, 2020. We translated these codes into discrete medical content areas using a newly developed "crosswalk tool." Residents' clinical exposure was enriched in infectious diseases (ID) and cardiovascular disease content at baseline. During the pandemic's surge, ID became the dominant content area. Exposure to other content was dramatically reduced, with clinical diversity repopulating only toward the end of the study period. Such characterization can be leveraged to provide effective practice habits feedback, guide didactic and self-directed learning, and potentially predict competency-based outcomes for trainees in the COVID era.

The COVID-19 pandemic has presented countless new challenges for healthcare providers including the challenge of differentiating COVID-19 infection from other diseases. COVID-19 infection and acute endocarditis may present similarly, both with shortness of breath and vital sign abnormalities, yet they require very different treatments. Here, we present two cases in which life-threatening acute endocarditis was initially misdiagnosed as COVID-19 infection during the height of the pandemic in New York City. The first was a case of Klebsiella pneumoniae mitral valve endocarditis leading to papillary muscle rupture and severe mitral regurgitation, and the second a case of Streptococcus mitis aortic valve endocarditis with heart failure due to severe aortic regurgitation. These cases highlight the importance of careful clinical reasoning and demonstrate how cognitive errors may impact clinical reasoning. They also underscore the limitations of real-time reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2 testing and illustrate the ways in which difficulty interpreting results may also influence clinical reasoning. Accurate diagnosis of acute endocarditis is critical given that surgical intervention can be lifesaving in unstable patients.