DARE Training: Teaching Educators How to Revise Internal Medicine Residency Lectures by Using an Anti-racism Framework.

Introduction: Systemic inequities and provider-held biases reinforce racism and further disparities in graduate medical education. We developed the Department of Medicine Anti-Racism and Equity Educational Initiative (DARE) to improve internal medicine residency conferences. We trained faculty and residents to serve as coaches to support other faculty in delivering lectures. The training leveraged a best-practices checklist to revise existing lectures. Methods: We recruited internal medicine faculty and residents to serve as DARE coaches, who supported educators in improving lectures' anti-racism content. During the training, coaches watched a videotaped didactic presentation that we created about health equity and anti-racism frameworks. DARE coaches then participated in a workshop where they engaged in case-based learning and small-group discussion to apply the DARE best-practices checklist to sample lecture slides. To assess training effectiveness, coaches completed pre- and posttraining assessments in which they edited different sample lecture slides. Our training took 1 hour to complete. Results: Thirty-four individuals completed DARE training. Following the training, the sample slides were significantly improved with respect to diversity of graphics (p < .001), discussion of research participant demographics (p < .001), and discussion of the impact of racism/bias on health disparities (p = .03). After DARE training, 23 of 24 participants (96%) endorsed feeling more prepared to bring an anti-racist framework to lectures and to support colleagues in doing the same. Discussion: Training residents and faculty to use DARE principles in delivering internal medicine lectures is an innovative and effective way to integrate anti-racism into internal medicine residency conferences.

An Anti-Racism and Equity Initiative Improves Residency Educational Conferences.

Background: Graduate medical education curricula may reinforce systemic inequities and bias, thus contributing to health disparities. Curricular interventions and evaluation measures are needed to increase trainee awareness of bias and known inequities in health care. Objective: This study sought to improve the content of core noontime internal medicine residency educational conferences by implementing the Department of Medicine Anti-Racism and Equity (DARE) educational initiative. Methods: DARE best practices were developed from available anti-racism and equity educational materials. Volunteer trainees and faculty in the department of medicine of a large urban academic medical center were recruited and underwent an hourlong training to utilize DARE best practices to coach faculty on improving the anti-racist and equity content of educational conferences. DARE coaches then met with faculty to review the planned 2021-2022 academic year (AY) lectures and facilitate alignment with DARE best practices. A rubric was created from DARE practices and utilized to compare pre-intervention (AY21) and post-intervention (AY22) conferences. Results: Using the DARE best practices while coaching increased the anti-racism and equity content from AY21 to AY22 (total rubric score mean [SD] 0.16 [1.19] to 1.38 [1.39]; P=.001; possible scores -4 to +5), with 75% (21 of 28) of AY22 conferences showing improvement. This included increased diversity of photographs, discussion of the racial or ethnic makeup of research study participants, appropriate use of race in case vignettes, and discussion of the impact of racism or bias on health disparities. Conclusions: Training coaches to implement DARE best practices improved the anti-racism and equity content of existing noontime internal medicine residency educational conferences.

Multimodality Imaging of Progressive Aortic Valve Endocarditis: From Endophthalmitis to Aorto-Atrial Fistula.

Our case highlights an atypical presentation of aortic valve endocarditis after initial presentation with endophthalmitis. This case demonstrates the rapidity of evolution of aortic valve endocarditis through sequential, multimodal imaging, and features the importance of a multidisciplinary approach required for the management of complicated aortic valve endocarditis. A male in his mid-thirties was admitted to the hospital with left endophthalmitis and diabetic ketoacidosis. He was found to have aortic valve endocarditis and severe aortic insufficiency, which progressed to aortic root pseudoaneurysm and subsequently to aorto-atrial fistula in less than 72 hours, as demonstrated by consecutive multimodality imaging studies. After extensive surgical repair, post-operative recovery, and rehabilitation, he was discharged home with a good functional outcome. Sequential and multimodal imaging can be beneficial in diagnosing paravalvular infection early in its evolution, which is crucial for decision-making regarding medical and surgical treatment strategies.

Going Virtual: Objective Structured Teaching Exercises as an Innovative Method for Formative Resident Education.

BACKGROUND: The coronavirus disease 2019 pandemic forced residency programs to adapt teaching to the virtual arena. Objective Structured Teaching Exercises (OSTEs) are a simulation-based session we previously implemented in our in-person pediatric curriculum. We aimed to assess feasibility of and resident satisfaction with the transition to virtual learning for simulation-based OSTEs. METHODS: The pediatrics residency program at our hospital has a weekly academic half-day for residents where the OSTEs were held annually in person 2018 to 2019 and virtually in 2020. Surveys were collected from participating residents and faculty to compare teaching experience, feedback quality, and satisfaction with the session. RESULTS: Over 3 academic years, there were 159 total teaching sessions, 3 of which were OSTEs. The OSTE session was highly rated each year and was the second highest rated virtual session. Residents felt the OSTEs improved their teaching regardless of the virtual versus in-person platform (P = .77), and the quality of feedback as rated by the resident teacher was higher for virtual sessions (P < .001). CONCLUSIONS: Transitioning the OSTE to a virtual platform was both feasible and effective when compared to the in-person OSTE. In the transition to virtual learning, educators should consider opportunities for simulation-based teaching such as OSTEs.

Resident identification of feedback and teaching on rounds.

Feedback and teaching occur regularly on teaching hospital wards. Although feedback has important implications for resident learning, residents often report that they receive little feedback. The significant overlap of teaching and feedback in clinical education may contribute to resident difficulty with feedback identification. We sent a survey with seven scenarios to internal medicine residents across the country. Two of the scenarios contained teaching, two contained feedback, and three contained combined teaching and feedback. From October 2017 to April 2018, 17% of residents (392/2346) from 17 residency programs completed the survey. Participating residents correctly identified both feedback scenarios 89% of the time, both teaching scenarios 64% of the time, and all three combined teaching and feedback scenarios 38% of the time. Interns were less likely than upper-level residents to correctly identify combined teaching and feedback scenarios (P = 0.005). Residents may have difficulty identifying feedback in the context of teaching. This confusion may contribute to residents' perceptions that they receive little feedback.

Health Literacy and Hospital Length of Stay: An Inpatient Cohort Study.

BACKGROUND: Associations between low health literacy (HL) and adverse health outcomes have been well documented in the outpatient setting; however, few studies have examined associations between low HL and in-hospital outcomes. OBJECTIVE: To compare hospital length of stay (LOS) among patients with low HL and those with adequate HL. DESIGN: Hospital-based cohort study. SETTING: Academic urban tertiary-care hospital. PATIENTS: Hospitalized general medicine patients. MEASUREMENTS: We measured HL using the Brief Health Literacy Screen. Severity of illness and LOS were obtained from administrative data. Multivariable linear regression controlling for illness severity and sociodemographic variables was employed to measure the association between HL and LOS. RESULTS: Among 5540 participants, 20% (1104/5540) had low HL. Participants with low HL had a longer average LOS (6.0 vs 5.4 days, P < 0.001). Low HL was associated with an 11.1% longer LOS (95% confidence interval [CI], 6.1%-16.1%; P < 0.001) in multivariate analysis. This effect was significantly modified by gender (P = 0.02). Low HL was associated with a 17.8% longer LOS among men (95% CI, 10.0%-25.7%; P < 0.001), but only a 7.7% longer LOS among women (95% CI, 1.9%-13.5%; P = 0.009). CONCLUSIONS: In this single-center cohort study, low HL was associated with a longer hospital LOS. The findings suggest that the adverse effects of low HL may extend into the inpatient setting, indicating that targeted interventions may be needed for patients with low HL. Further work is needed to explore these negative consequences and potential mitigating factors.

Screening Hospitalized Patients for Low Health Literacy: Beyond the REALM of Possibility?

As patient-centered education efforts increase, assessing health literacy (HL) becomes more salient. The verbal Brief Health Literacy Screen (BHLS) may have clinical and feasibility advantages over written tools, including the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) and Short Test of Functional Health Literacy in Adults (S-TOFHLA); however, the BHLS's utility among inpatients remains unresolved. Hospitalized adults were enrolled; HL was assessed using three tools. Categorical comparisons used chi-square; area under the receiver operating characteristic curve was calculated (reference: REALM-R). The prevalence of low HL among participants ( n = 260) was higher for the BHLS than S-TOFHLA (29% vs. 17%, p < .001) and higher for the REALM-R than both the BHLS (44% vs. 29%, p = .004) and S-TOFHLA (44% vs. 17%, p < .001). The areas under the receiver operating characteristic curve were .58 for BHLS and .66 for S-TOFHLA. The different prevalence of low HL among the participants based on each tool likely reflects the complexity of measuring HL and differing domains captured by each tool. The BHLS can be considered a viable inpatient HL screening tool, given its increased feasibility and verbal administration.

Postdischarge Falls and Readmissions: Associations with Insufficient Vision and Low Health Literacy among Hospitalized Seniors.

The role of patient-level risk factors such as insufficient vision has been understudied. Because insufficient vision may interfere with health literacy assessments, the full impact of low health literacy among older patients with impaired vision is unknown. We sought to determine whether senior inpatients' insufficient vision and low health literacy are associated with adverse outcomes postdischarge, specifically falls and readmissions. We conducted an observational study of adult medicine inpatients at an urban hospital. Visual acuity and health literacy were screened at bedside. Outcomes data were collected by telephone 30 days postdischarge. Among 1,900 participants, 1,244 (65%) were reached postdischarge; 44% had insufficient vision and 43% had low health literacy. Insufficient vision was associated with postdischarge falls among participants ≥65 years (adjusted odds ratio [AOR] 3.38, 95% confidence interval [CI] 1.42-8.05), but not among participants <65 years (AOR 1.44, 95% CI 0.89-2.32). Low health literacy was associated with readmissions among participants ≥65 years (AOR 3.15, 95% CI 1.77-5.61), but not among participants <65 years (AOR 0.78, 95% CI 0.56-1.09). The results suggest the need to implement screening for older inpatients' vision and health literacy. Developing effective interventions to reduce these risks is critical given national priorities to reduce falls and readmissions.

Insights into inpatients with poor vision: A high value proposition.

BACKGROUND: Vision impairment is an under-recognized risk factor for adverse events among hospitalized patients, yet vision is neither routinely tested nor documented for inpatients. Low-cost ($8 and up) nonprescription "readers" may be a simple, high-value intervention to improve inpatients' vision. We aimed to study initial feasibility and efficacy of screening and correcting inpatients' vision. METHODS: From June 2012 through January 2014 we began testing whether participants' vision corrected with nonprescription lenses for eligible participants failing a vision screen (Snellen chart) performed by research assistants (RAs). Descriptive statistics and tests of comparison, including t tests and χ(2) tests, were used when appropriate. All analyses were performed using Stata version 12 (StataCorp, College Station, TX). RESULTS: Over 800 participants' vision was screened (n = 853). Older (≥65 years; 56%) participants were more likely to have insufficient vision than younger (<65 years; 28%; P < 0.001). Nonprescription readers corrected the majority of eligible participants' vision (82%, 95/116). DISCUSSION: Among an easily identified subgroup of inpatients with poor vision, low-cost readers successfully corrected most participants' vision. Hospitalists and other clinicians working in the inpatient setting can play an important role in identifying opportunities to provide high-value care related to patients' vision.