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Experience and Education in Residency Training: Capturing the Resident Experience by Mapping Clinical Data

Rhee, David W; Chun, Jonathan W; Stern, David T; Sartori, Daniel J
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.
PMID: 33983144
ISSN: 1938-808x
CID: 4867652

Standardizing Quality of Virtual Urgent Care: Using Standardized Patients in a Unique Experiential Onboarding Program

Sartori, Daniel J; Lakdawala, Viraj; Levitt, Heather B; Sherwin, Jason A; Testa, Paul A; Zabar, Sondra R
Introduction/UNASSIGNED:Virtual urgent care (VUC) provides real-time evaluation, triage, and treatment of low-acuity medical problems; however, VUC physicians have varying levels of telemedicine training. We created a workplace-based experiential onboarding program that deployed standardized patients (SPs) into a VUC clinic to evaluate and deliver feedback to independently practicing physicians, providing quality assurance and identifying areas for improvement. Methods/UNASSIGNED:SPs evaluated communication, disease-specific, and telemedicine skills by observing behaviors. We surveyed participants to evaluate the program. Results/UNASSIGNED:= 34%) well done-highlighting specific behaviors most ripe for improvement. All queried participants indicated that this simulation improved communication and telemedicine skills. Discussion/UNASSIGNED:This workplace-based experiential onboarding program uncovered knowledge gaps within telemedicine skills and patient education domains. Identification of these gaps can help drive new virtual care curricula.
PMID: 35497680
ISSN: 2374-8265
CID: 5215832

Mapping the Clinical Experience of a New York City Residency Program During the COVID-19 Pandemic

Rhee, David W; Pendse, Jay; Chan, Hing; Stern, David T; Sartori, Daniel J
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.
PMID: 34129487
ISSN: 1553-5606
CID: 4911612

Telemedicine Training in the COVID Era: Revamping a Routine OSCE to Prepare Medicine Residents for Virtual Care

Boardman, Davis; Wilhite, Jeffrey A; Adams, Jennifer; Sartori, Daniel; Greene, Richard; Hanley, Kathleen; Zabar, Sondra
Background/UNASSIGNED:During the rapid onset of the pandemic, clinicians transitioned from traditional outpatient practice to virtual modalities for providing routine care to patient panels. Like training programs nationwide, telemedicine training and assessment had not been systematically incorporated into our residency. In response, a scheduled Internal Medicine (IM) Objective Structured Clinical Examination (OSCE) was adapted to a remote modality to become virtual care-focused learning experience for trainees and to provide valuable feedback to educators. Methods/UNASSIGNED:Standardized Patients (SPs) rated residents on their communication (including information gathering, relationship development and patient education), patient activation and satisfaction, and telemedicine skills. Analyses included a comparison of domain scores for residents who participated in both the 2020 remote and 2019 in-person OSCEs, and a review of written resident comments about the virtual OSCE. Results/UNASSIGNED: = .008). Conclusion/UNASSIGNED:Our reformulated OSCE accomplished 3 goals including; (1) physically distancing residents from SPs per COVID regulations, (2) providing residents with the opportunity to practice critical virtual visit skills, and (3) alerting our educators to curricular improvement areas. Our methods are useful for other institutions and have applications to the larger medical education community.
PMID: 34189270
ISSN: 2382-1205
CID: 4950972

Telemedicine training in the covid era: Adapting a routine osce and identifying new core skills for training [Meeting Abstract]

Boardman, D; Wilhite, J; Adams, J; Sartori, D; Greene, R E; Hanley, K; Zabar, S
BACKGROUND: During the rapid onset of the pandemic, clinicians transitioned from traditional outpatient practice to telemedicine for triaging COVID-19 patients and providing routine care to patient panels. Telemedicine training and assessment had not been systematically incorporated into most residencies. In response, a scheduled Internal Medicine (IM) Objective Structured Clinical Examination (OSCE) was adapted to a telemedicineemphasized, virtual modality to become a just-in- time learning experience for trainees.
METHOD(S): Remote cases deployed on common web-based video conference platform included; (1) a potential COVID-19 triage, (2) educating on buprenorphine maintenance, (2) counselling on mammogram screening, and (3) addressing frustration with electronic health record documentation. Simulated Patients (SPs) rated residents on communication skills, patient activation and satisfaction, and case-specific telemedicine items. Analyses included a comparison of domain scores (mean % well done) for residents who participated in both the 2020 remote and 2019 in-person OSCEs, and a review of written resident feedback.
RESULT(S): Fewer than half (46%) of 2020's residents (n=23) performed well on the COVID-19 case's telemedicine skill domain. Residents excelled in using nonverbal communication to enrich on-camera communication (100%), but struggled with virtual physical exams (13%), gathering information (4%), and optimizing technology (4%). Residents expressed interest in more opportunity to practice telemedicine skills going forward. Residents' overall COVID-19 knowledge was fair (54% of items were rated as 'well done'). Fewer than half (45%) advised the SP that testing was not available at the time, but that he should call the city hotline for information, and about half (55%) provided quarantine/ home care instructions. In comparing 2020 (virtual) to 2019 (in-person) OSCE scores, residents who participated in both assessments (n=9) performed similarly on communication skills including information gathering (84% vs. 83%), and relationship development (93% vs. 92%), patient satisfaction (72% vs. 80%) and activation (65% vs. 66%). Patient education scores were significantly lower during the virtual OSCE (40% vs. 76%, P=.008).
CONCLUSION(S): Our reformulated OSCE accomplished three goals: (1) physically distancing residents from SPs, (2) providing residents the opportunity to practice critical telemedicine skills, and (3) alerting our educators to curricular improvement areas in virtual physical exam, patient education, gathering information and optimizing technology. Our methods are scalable at other institutions and have applications to the larger medical and clinical education community. LEARNING OBJECTIVE #1: Describe challenges and barriers to effective communication and clinical skill utilization during televisits. LEARNING OBJECTIVE #2: Understand resident physician practice patterns and communication regarding infectious disease
ISSN: 1525-1497
CID: 4985002

Continuous care: Implementation of a virtual and in person transitional care management(TCM) clinicby internal medicine residents [Meeting Abstract]

Li, P; Kassapidis, V; Pandey, A; Bharadwaj, K; Moussa, M; Hayes, R; Sartori, D; Jervis, R
STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): The transition between hospital and home is a vulnerable time for patients, who are at risk for readmission, medication reconciliation errors, and lack of follow up. LEARNING OBJECTIVES 1: Introduce a new type of visit to improve continuity of care for patients recently discharged from acute care LEARNING OBJECTIVES 2: Apply data from TCMvisits to identify areas for improvement in the hospital discharge process DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The time between hospital discharge and primary care follow-up has historically been a vulnerable period for patients. The COVID-19 pandemic has exacerbated this transitional period, as patients have been forgoing their routine healthcare visits, losing touch with their primary care providers (PCPs), and not having a point of contact for their health needs after they leave the hospital. We launched a new resident-led virtual and in-person post-discharge clinic at an urban academic hospital connected in order to address the increasing need for follow-up care after hospital discharge. Patients admitted to the hospital who did not have a PCP or could not schedule a PCP visit within 10 days after being discharged were given the option of either an in-person or video TCM visit with an internal medicine resident. Each visit consisted of a templated set of questions, including whether medications were reconciled, and if follow-up appointments were scheduled. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICHWILL BE USEDTOEVALUATE PROGRAM/INTERVENTION): The primary endpoint for this pilot program was the total number of completed TCM visits. Secondary endpoints included the number of visits where there was a discrepancy in medications or follow-up appointments after hospital discharge. FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): Between October and December 2020, there were a total of 79 scheduled TCM visits (28 virtual visits and 51 in-person visits) and 51 (67%) completed visits. For the virtual visits, there was a 86% (24/28) completion rate. For in-person visits, there was a 53% (27/51) completion rate. In 31% (16/51) of the visits, subspecialty appointments were not scheduled at the time of discharge. In 12% (6/51) of the visits, there was a discrepancy with the medications patients were discharged with, with 50% (3/6) due to misprescribed antihyperglycemic agents. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY): The increased completion rate of virtual visits as compared to in-person visits (86%vs. 57%, respectively) suggests virtual visits may be a more convenient and preferable mode of follow-up for patients after hospital discharge. This pilot also shows how TCMvisit data can offer insights about the hospital discharge process that would otherwise go unnoticed. The data on discrepancies in medications reveals antihyperglycemic medication reconciliation may be a potential area of focus to improve the hospital discharge process. More data is needed to determine the effectiveness of this resident-led TCMinitiative, including its effects on hospital readmission rates. The preliminary data suggests that TCM visits, especially virtual visits, may effectively bridge gaps in care from the time patients leave the hospital until they establish more permanent care
ISSN: 1525-1497
CID: 4986522

Mapping clinical data to characterize residents' diverse educational experiences [Meeting Abstract]

Sartori, D; Rhee, D
LEARNING OBJECTIVES 1: Characterize internal medicine resident's inpatient clinical exposure across public, private, federal and community hospital settings. LEARNING OBJECTIVES 2: Identify disparities in resident's clinical exposure across sites to guide curriculum development and rational rotation scheduling. SETTING AND PARTICIPANTS: Experiential learning through patient care is the primary means by which Internal Medicine (IM) residents mature. Despite this, there is an unmet need to characterize how residents' diverse patient care activities inform their educational experience. This is especially true at NYU's IM Residency, which comprises over 200 residents across four distinct hospital systems, exposing residents to diverse, and often variable clinical content. We have previously described a 'crosswalk tool' which maps ICD10 diagnosis codes to one of 16 American Board of Internal Medicine (ABIM) medical content areas and one of 178 specific condition categories, to better characterize clinical exposure. Here, we translate resident-attributed principal ICD-10 discharge diagnosis codes from each of our Program's four training hospitals in Quarter 1 of AY2020 to profile the educational experience of residents at each site. DESCRIPTION: From July 1-Sept 30 2020, we mined principal ICD10 discharge diagnosis codes from resident teams at Bellevue Hospital (BH), a large public hospital; NYU Langone Hospital-Brooklyn (NYU-BK), an academic community hospital; NYU Lang one Hospitals-Manhattan (NYUMN), a large quaternary hospital; and VA NY Harbor Healthcare-Manhattan (VA), a Veteran's Affairs Hospital. We then applied diagnosis codes to the crosswalk tool to translate ICD10 codes into broad ABIM content areas and specific condition categories, yielding site-specific clinical content maps. EVALUATION: At each site there was notable enrichment in two specific content areas-Infectious Disease (ID) and Cardiovascular Diseases (CVD). However, there were striking differences in the frequency of these content areas across sites. Roughly 28% of all diagnoses fell under ID at NYU-BK and NYU-MN, with half that frequency at BH and VA. CVD diagnoses represented 40% of diagnoses at VA, while only 20% at NYU-BK, 25% at NYU-MN, and 30% at BH. For reference, CVD represents 14% and ID 9% of content on theABIM Certification Exam. There were uniformly low frequencies (<1%) of several less typical ABIM content areas, namely Optho, Derm, Allergy/ Immuno, OB/GYN, and ENT/Dental Med. The frequency of Psychiatry diagnoses, which houses substance use, was markedly higher at BH and NYU-BK than the other sites. There were several substantial differences in condition categories across sites, most notably within 'bacteremia and sepsis syndromes' and 'ischemic heart disease.' DISCUSSION / REFLECTION / LESSONS LEARNED: In this pilot we translate discharge data from four distinct hospital systems into an educational framework to characterize our resident's educational experience and in doing so unmask disparities in exposure that could drive rational changes in rotation schedules and didactic content selection
ISSN: 1525-1497
CID: 4986552

The TeleHealth OSCE: Preparing Trainees to Use Telemedicine as a Tool for Transitions of Care

Sartori, Daniel J; Hayes, Rachael W; Horlick, Margaret; Adams, Jennifer G; Zabar, Sondra R
Background/UNASSIGNED:Telemedicine holds promise to bridge the transition of care between inpatient and outpatient settings. Despite this, the unique communication and technical skills required for virtual encounters are not routinely taught or practiced in graduate medical education (GME) programs. Objective/UNASSIGNED:To develop an objective structured clinical examination (OSCE) case to assess residents' telemedicine-specific skills and identify potential gaps in our residency program's curriculum. Methods/UNASSIGNED:As part of a multi-station OSCE in 2019, we developed a case simulating a remote encounter between a resident and a recently discharged standardized patient. We developed an assessment tool comprising specific behaviors anchored to "not done," "partly done," and "well done" descriptors to evaluate core communication and telemedicine-specific skills. Results/UNASSIGNED:Seventy-eight NYU internal medicine residents participated in the case. Evaluations from 100% of participants were obtained. Residents performed well in Information Gathering and Relationship Development domains. A mean 95% (SD 3.3%) and 91% (SD 4.9%) of residents received "well done" evaluations across these domains. A mean 78% (SD 14%) received "well done" within Education/Counseling domain. However, only 46% (SD 45%) received "well done" evaluations within the Telemedicine domain; specific weak areas included performing a virtual physical examination (18% well done) and leveraging video to augment history gathering (17% well done). There were no differences in telemedicine-specific skill evaluations when stratified by training track or postgraduate year. Conclusions/UNASSIGNED:We simulate a post-discharge virtual encounter and present a novel assessment tool that uncovers telemedicine-specific knowledge gaps in GME trainees.
PMID: 33391602
ISSN: 1949-8357
CID: 4738482

Building Telemedicine Capacity for Trainees During the Novel Coronavirus Outbreak: a Case Study and Lessons Learned

Lawrence, Katharine; Hanley, Kathleen; Adams, Jennifer; Sartori, Daniel J; Greene, Richard; Zabar, Sondra
INTRODUCTION/BACKGROUND:Hospital and ambulatory care systems are rapidly building their virtual care capacity in response to the novel coronavirus (COVID-19) pandemic. The use of resident trainees in telemedicine is one area of potential development and expansion. To date, however, training opportunities in this field have been limited, and residents may not be adequately prepared to provide high-quality telemedicine care. AIM/OBJECTIVE:This study evaluates the impact of an adapted telemedicine Objective Structured Clinical Examination (OSCE) on telemedicine-specific training competencies of residents. SETTING/METHODS:Primary Care Internal Medicine residents at a large urban academic hospital. PROGRAM DESCRIPTION/METHODS:In March 2020, the New York University Grossman School of Medicine Primary Care program adapted its annual comprehensive OSCE to a telemedicine-based platform, to comply with distance learning and social distancing policies during the COVID-19 pandemic. A previously deployed in-person OSCE on the subject of a medical error was adapted to a telemedicine environment and deployed to 23 primary care residents. Both case-specific and core learning competencies were assessed, and additional observations were conducted on the impact of the telemedicine context on the encounter. PROGRAM EVALUATION/RESULTS:Three areas of telemedicine competency need were identified in the OSCE case: technical proficiency; virtual information gathering, including history, collateral information collection, and physical exam; and interpersonal communication skills, both verbal and nonverbal. Residents expressed enthusiasm for telemedicine training, but had concerns about their preparedness for telemedicine practice and the need for further competency and curricular development. DISCUSSION/CONCLUSIONS:Programs interested in building capacity among residents to perform telemedicine, particularly during the COVID-19 pandemic, can make significant impact in their trainees' comfort and preparedness by addressing key issues in technical proficiency, history and exam skills, and communication. Further research and curricular development in digital professionalism and digital empathy for trainees may also be beneficial.
PMID: 32642929
ISSN: 1525-1497
CID: 4518942

Standardizing quality of virtual urgent care: An experiential onboarding approach using standardized patients [Meeting Abstract]

Sartori, D; Lakdawala, V; Levitt, H; Sherwin, J; Testa, P; Zabar, S
BACKGROUND: Virtual Urgent Care (VUC) is a now a common modality for providing real-time assessment and treatment of common medical problems. However, most providers have not had formal telemedicine training or clinical experience. Faculty have little experience with this new modality of healthcare delivery. We created an experiential onboarding program in which standardized patients (SPs) are deployed into a VUC platform to assess and deliver feedback to physicians in an effort to provide individual- level quality assurance and identify programlevel areas for improvement.
METHOD(S): We simulated a synchronous urgent care evaluation of a 25- year-old man with lingering upper respiratory tract symptoms refractory to over-the-counter medications. The SP was trained to strongly request an antibiotic prescription. A mock entry in the electronic medical record, available to providers during the visit, provided demographic, prior medical, pharmacy and allergy information. The encounter was scheduled into a regular 30-minute appointment slot during a routine 8-hour shift. We developed a behaviorally- anchored assessment tool to evaluate core communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' SPs provided post-encounter verbal feedback to urgent care providers (UCPs), who received a summary report and had an opportunity provide structured feedback regarding the case. A single SP performed 20 / 21 visits.
RESULT(S): Twenty-one UCPs, with 2 to 23 years of clinical experience, participated in an announced scheduled visit. UCPs performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. All UCPs provided appropriate management plans and did not give antibiotics. In contrast, Education and Counseling skills were less strong (32% 'well done'). Within this domain, few received 'well done' for checking understanding (14%); conveying small bits of information and summarizing to ensure clarity (9%). Most (71% well done) collaborated with the SP in discussing next steps. Specific telemedicine skills were infrequently used: only 19% performed a virtual physical exam, 24% utilized the audio/video interface to augment information gathering, 14% optimized technical aspects by assessing sound, video or ensuring a backup plan should video fail. A subset of UCPs (n=9) provided structured feedback regarding the case. 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improved telehealth skills.
CONCLUSION(S): This experiential virtual urgent care onboarding program utilizing standardized announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. These findings form the basis for dedicated training for virtual urgent care providers to assure quality across the program
ISSN: 1525-1497
CID: 4805262