Faculty Bibliography

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.

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.

Introduction: Educators have theorized that interventions grounded in dual process theory (DPT) and script theory (ST) may improve the diagnostic reasoning process of physicians but little empirical evidence exists. Methods: In this quasi-experimental study, we assessed the impact of a clinical reasoning (CR) curriculum grounded in DPT and ST on medicine residents participating in one of three groups during a 6-month period: no, partial, or full intervention. Residents completed the diagnostic thinking inventory (DTI) at baseline and 6 months. At 6 months, participants also completed a post-survey assessing application of concepts to cases. Results: There was a significant difference between groups in application of concepts (no intervention 1.6 (0.65) compared to partial 2.3 (0.81) and full 2.2 (0.91), p = 0.05), as well as describing cases in problem representation format (no intervention 1.2 (0.38) and partial 1.5 (0.55) compared to full 2.1 (0.93), p = 0.004). There was no significant difference in change in DTI scores (no intervention 7.0 (16.3), partial 8.8 (9.8), full 7.8 (12.0)). Conclusions: Residents who participated in a CR curriculum grounded in DPT and ST were effective in applying principles of CR in cases from their practice. To our knowledge, this is the first workplace-based CR educational intervention study showing differences in the reasoning process residents apply to patients.

Background: Diagnostic errors have a significant impact on our health care system with cognitive errors contributing to the majority of cases. Educators have theorized that interventions grounded in dual process theory (DPT) may improve the clinical reasoning (CR) process of physicians but little empirical evidence of this theory exists.
Method(s): This study was a quasi-experimental design in the New York University Internal Medicine Residency Program from June 2017- January 2018. We implemented two educational interventions in CR grounded in DPT during this 6-month period, leading to a natural experiment with three groups: no intervention (N = 25), partial intervention (received part 1, N = 23), and full intervention (received part 1 and part 2, N = 23). The educational interventions covered the concepts of DPT, impact of diagnostic errors, and case-based discussions introducing techniques to develop fast and slow thinking. We used the diagnostic thinking inventory (DTI) at baseline (a 41 item self-assessment questionnaire to assess one's approach to CR). At 6 months, participants completed a follow-up DTI and a post-survey assessing their ability to apply concepts to cases as well as workplace experiences of CR teaching. Participants who completed pre- and post-surveys were included in the analysis. Case examples were scored by two independent reviewers blinded to group status (Table). Differences between groups were analyzed using a one-way analysis of variance.
Result(s): Those in the full intervention group reported more teaching of DPT on attending rounds and in conference than the partial intervention and no intervention groups (60% often or always taught compared to 25% and 8.3%, p = 0.002; 73.3% often or always taught compared to 58.3% and 33.3%, p = 0.033, respectively). Otherwise workplace experiences were not significantly different between the groups. There was a significant difference between groups in ability to apply concepts to cases with a medium to large effect size (Table). There was also a significant difference in giving case examples in problem representation format with a large effect size (Table). There was no significant difference in change in DTI scores (mean change in score no intervention 7.0 (SD 16.3), partial intervention 8.8 (SD 9.8), full intervention 7.8 (SD 12.0), p = 0.946).
Conclusion(s): This study provides evidence that interns who participated in a CR curriculum grounded in DPT were effective in applying principles of CR in cases from their own clinical practice and supports the argument that we should be designing educational interventions in CR grounded in DPT. Subsequent studies would need to assess further impact on patient outcomes. (Figure Presented)

PURPOSE: The authors sought to develop a conceptual framework of the factors that most influence medical students' development of humanism and to explore students' opinions regarding the role these factors play in developing or inhibiting humanism. METHOD: In 2006-2007, the authors conducted 16 focus groups with fourth-year students and first-year residents at four universities to design a conceptual framework. They used the framework to develop a survey, which they administered to fourth-year medical students at 20 U.S. medical schools in 2007-2008. RESULTS: Data from 80 focus-group participants suggested that the key influences on students' development of humanism were their authentic, unique, and participatory experiences before and during medical school, and the opportunity to process these experiences. Students who completed the survey (N = 1,170) reported that experiences of greatest intensity (e.g., being involved in a case where the patient dies), participatory learning experiences (e.g., volunteer work, international clinical rotations), and positive role models had the greatest effect on their development of humanism, whereas stressful conditions, such as a busy workload or being tired or postcall, inhibited their humanism. Women and students going into primary care placed significantly greater importance on experiences promoting humanism than did men and those not going into primary care. In addition, students with lower debt burdens viewed such experiences as more important than did those with higher debt burdens. CONCLUSIONS: Students viewed a variety of factors as influencing their development of humanism. This research provides a starting point for enhancing curricula to promote humanism.