Faculty Bibliography

LEARNING OBJECTIVES 1: Describe a longitudinal curriculum to train internal medicine (IM) residents in point-of-care ultrasound (POCUS). LEARNING OBJECTIVES 2: Recognize the impact of decreased patient contact on residents' retention of POCUS skills. SETTINGAND PARTICIPANTS:Despite thewell-documented benefits of POCUS, internal medicine residents receive little formal training. We implemented a curriculumin the 2019 academic year to train 55 PGY-2 IMresidents in POCUS across four urban teaching hospitals and a method to evaluate its efficacy. As the COVID pandemic hit, we additionally sought to understand the impact of COVID on the efficacy of our curriculum and to ascertain from IM residents their barriers to using POCUS during the COVID pandemic. DESCRIPTION: The curriculum was composed of three workshops, consisting of lectures and hands-on practice covering lung, cardiac, abdominal, and lower extremity vascular views. Following the workshops, we sought to consolidate learners' knowledge with a subsequent year-long skill building phase. The skill-building phase was truncated due to the pandemic.A hands-on assessment was performed prior to the course and not repeated at course conclusion due to social distancing concerns. An online knowledge test was administered before the course, immediately following the course, and at one year. A survey assessing attitudes and barriers to POCUS was administered before the course and at one year. EVALUATION: No resident passed the pre-course hands-on assessment. Prior to the course, the average resident score was 54% on the online knowledge quiz; directly after the workshop series, the average rose to 78%. At one year, the average score on the online knowledge quiz was 74%, a statistically significant decrease (p=0.04). Ninety-one percent of residents reported performing POCUS at least once/month prior to the pandemic. During the pandemic, scanning activity decreased; 67% residents reported they scanned rarely or never. DISCUSSION/ REFLECTION / LESSONS LEARNED: Our course led to significant improvement of knowledge regarding ultrasound technology and image interpretation, however this decayed at one year, likely due to lack of skill reinforcement. Though POCUS was widely used prior to the pandemic, usage dropped at the pandemic's peak, despite its utility as both a diagnostic and therapeutic tool. The most commonly cited reason for lack of use was concern regarding contamination and infectious exposure. While the COVID pandemic disrupted our curriculum, it also highlighted opportunities to incorporate POCUS into clinical practice and reinforced the importance of continued longitudinal practice to retain learned skills

The initial phase of the SARS-CoV-2 pandemic in the United States saw rapidly-rising patient volumes along with shortages in personnel, equipment, and intensive care unit (ICU) beds across many New York City hospitals. As our hospital wards quickly filled with unstable, hypoxemic patients, our hospitalist group was forced to fundamentally rethink the way we triaged and managed cases of hypoxemic respiratory failure. Here, we describe the oxygenation protocol we developed and implemented in response to changing norms for acuity on inpatient wards. By reflecting on lessons learned, we re-evaluate the applicability of these oxygenation strategies in the evolving pandemic. We hope to impart to other providers the insights we gained with the challenges of management reasoning in COVID-19.

Needs and Objectives: Point-of-care ultrasound (POCUS), when integrated with a physical examination, increases accuracy of diagnosis and decreases procedural complications. However, most hospitalists have not been trained to use this new technology. We developed a year-long curriculum, the Integrated Sonographic Competency at NYU (I-ScaN), to train hospitalists in POCUS. Setting and Participants: Twenty-three hospitalists from across the 4 hospitals affiliated with NYU Langone Health participated. Sixteen of the participants (72%) reported prior ultrasound training, with a range of 2-80 hours (median = 4 hours); 3 reported more than 5 hours of prior training. Three reported active clinical use of POCUS though none of them had more than 5 hours of prior training. The group averaged 4.5 years of clinical practice (range = 1-13 years). Description: The program began with an intensive 2-day course consisting of lectures and hands-on training on human models covering views of the heart, lungs/pleura, abdomen, and leg vasculature. We developed the remainder of the year-long program with the goal of helping participants retain and improve upon the skills acquired during the initial course. Our program included hands-on teaching sessions held at each institution by local experts, presentations at monthly conferences with the course director (HS), and online feedback on uploaded ultrasound images. To facilitate this final item, each participant was given access to portable ultrasound devices with the ability to upload ultrasound clips to a HIPAA-compliant website. Participants provided a clinical interpretation and assessment of image quality for each of their clips. The clips were then reviewed by an expert who provided feedback on both of these domains. Participants could then use these clips to create personal portfolios in accordance with national standards set by the Society of Hospital Medicine. Evaluation: Participants rated the 2-day intensive program as very useful and satisfaction with the individual components of the program ranged from useful to very useful. Participants reported statistically significant increases in their confidence in acquiring images, interpreting images, and performing a clinical evaluation using POCUS for all domains except in performing paracentesis. Knowledge scores increased from a baseline of 58% to 83%; p< 0.001. At 6 months into the program, 2 hospitalists had uploaded > 400 clips each and 7 had uploaded fewer than 20 clips each. Discussion/Reflection/Lessons Learned: I-ScaN is a highly rated and effective program to train hospitalists in core POCUS competencies. The 2-day intensive program significantly improves confidence and knowledge. Monitoring of progress and scanning activity was difficult because few hospitalists uploaded clips regularly. Our focus now is on identifying barriers to using POCUS for new trainees. Future analysis will include frequency of scanning, retention of knowledge and skill, and generation of learning curves for each view

AIM: To assess first-year gastroenterology fellows' ability to address difficult interpersonal situations in the workplace using objective structured clinical examinations (OSCE). METHODS: Two OSCEs ("distracted care team" and "frazzled intern") were created to assess response to disruptive behavior. In case 1, a fellow used a colonoscopy simulator while interacting with a standardized patient (SP), nurse, and attending physician all played by actors. The nurse and attending were instructed to display specific disruptive behavior and disregard the fellow unless requested to stop the disruptive behavior and focus on the patient and procedure. In case 2, the fellow was to calm an intern managing a patient with massive gastrointestinal bleeding. The objective in both scenarios was to assess the fellows' ability to perform their duties while managing the disruptive behavior displayed by the actor. The SPs used checklists to rate fellows' performances. The fellows completed a self-assessment survey. RESULTS: Twelve fellows from four gastrointestinal fellowship training programs participated in the OSCE. In the "distracted care team" case, one-third of the fellows interrupted the conflict and refocused attention to the patient. Half of the fellows were able to display professionalism despite the heated discussion nearby. Fellows scored lowest in the interprofessionalism portion of post-OSCE surveys, measuring their ability to handle the conflict. In the "frazzled intern" case, 68% of fellows were able to establish a calm and professional relationship with the SP. Despite this success, only half of the fellows were successfully communicate a plan to the SP and only a third scored "well done" in a domain that focused on allowing the intern to think through the case with the fellow's guidance. CONCLUSION: Fellows must receive training on how to approach disruptive behavior. OSCEs are a tool that can assess fellow skills and set a culture for open discussion.

Over half of patients with human immunodeficiency virus (HIV) experience diarrhea that contributes negatively to quality of life and adherence to antiretroviral therapy (ART). Opportunistic infectious agents that cause diarrhea in patients with HIV span the array of protozoa, fungi, viruses, and bacteria. With global use of ART, the incidence of diarrhea because of opportunistic infections has decreased; however, the incidence of noninfectious diarrhea has increased. The etiology of noninfectious diarrhea in patients with HIV is multifactorial and includes ART-associated diarrhea and gastrointestinal damage related to HIV infection (i.e., HIV enteropathy). A basic algorithm for the diagnosis of diarrhea in patients with HIV includes physical examination, a review of medical history, assessment of HIV viral load and CD4+ T cell count, stool microbiologic assessment, and endoscopic evaluation, if needed. For patients with negative diagnostic results, the diagnosis of noninfectious diarrhea may be considered. Pharmacologic options for the treatment of noninfectious diarrhea are primarily supportive; however, the use of many unapproved agents is based on unstudied and anecdotal information. In addition, these agents can be associated with treatment-limiting adverse events (AEs), such as drug-drug interactions with ART regimens, abuse liability, and additional gastrointestinal AEs. Currently, crofelemer, an antisecretory agent, is the only therapy approved in the USA for the symptomatic relief of noninfectious diarrhea in patients with HIV on ART.