Bridging the Gap from Student to Doctor: Developing Coaches for the Transition to Residency.

BACKGROUND: A lack of educational continuity creates disorienting friction at the onset of residency. Few programs have harnessed the benefits of coaching, which can facilitate self-directed learning, competency development, and professional identity formation, to help ease this transition. OBJECTIVE: To describe the process of training faculty Bridge Coaches for the Transition to Residency Advantage (TRA) program for interns. METHODS: Nineteen graduate faculty educators participated in a coaching training course with formative skills assessment as part of a faculty development program starting in January 2020. Surveys (n = 15; 79%) and a focus group (n = 7; 37%) were conducted to explore the perceived impact of the training course on coaching skills, perceptions of coaching, and further program needs during the pilot year of the TRA program. RESULTS: Faculty had strong skills around establishing trust, authentic listening, and supporting goal-setting. They required more practice around guiding self-discovery and following a coachee-led agenda. Faculty found the training course to be helpful for developing coaching skills. Faculty embraced their new roles as coaches and appreciated having a community of practice with other coaches. Suggestions for improvement included more opportunities to practice and receive feedback on skills and additional structures to further support TRA program encounters with coaches. CONCLUSIONS: The faculty development program was feasible and had good acceptance among participants. Faculty were well-suited to serve as coaches and valued the coaching mindset. Adequate skills reinforcement and program structure were identified as needs to facilitate a coaching program in graduate medical education.

Mapping hospital data to characterize residents' educational experiences.

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.

Development of a Clinical Reasoning Documentation Assessment Tool for Resident and Fellow Admission Notes: a Shared Mental Model for Feedback.

BACKGROUND: Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the reliability and validity of existing assessment tools. Of the existing tools, the IDEA assessment tool includes a robust assessment of clinical reasoning documentation focusing on four elements (interpretive summary, differential diagnosis, explanation of reasoning for lead and alternative diagnoses) but lacks descriptive anchors threatening its reliability. OBJECTIVE: Our goal was to develop a valid and reliable assessment tool for clinical reasoning documentation building off the IDEA assessment tool. DESIGN, PARTICIPANTS, AND MAIN MEASURES: The Revised-IDEA assessment tool was developed by four clinician educators through iterative review of admission notes written by medicine residents and fellows and subsequently piloted with additional faculty to ensure response process validity. A random sample of 252 notes from July 2014 to June 2017 written by 30 trainees across several chief complaints was rated. Three raters rated 20% of the notes to demonstrate internal structure validity. A quality cut-off score was determined using Hofstee standard setting. KEY RESULTS: The Revised-IDEA assessment tool includes the same four domains as the IDEA assessment tool with more detailed descriptive prompts, new Likert scale anchors, and a score range of 0-10. Intraclass correlation was high for the notes rated by three raters, 0.84 (95% CI 0.74-0.90). Scores ≥6 were determined to demonstrate high-quality clinical reasoning documentation. Only 53% of notes (134/252) were high-quality. CONCLUSIONS: The Revised-IDEA assessment tool is reliable and easy to use for feedback on clinical reasoning documentation in resident and fellow admission notes with descriptive anchors that facilitate a shared mental model for feedback.

Hickam's dictum, Occam's razor, and Crabtree's bludgeon: a case of renal failure and a clavicular mass.

OBJECTIVES: Our discussant's thoughtful consideration of the patient's case allows for review of three maxims of medicine: Occam's razor (the simplest diagnosis is the most likely to be correct), Hickam's dictum (multiple disease entities are more likely than one), and Crabtree's bludgeon (the tendency to make data fit to an explanation we hold dear). CASE PRESENTATION: A 66-year-old woman with a history of hypertension presented to our hospital one day after arrival to the United States from Guinea with chronic daily vomiting, unintentional weight loss and progressive shoulder pain. Her labs are notable for renal failure, nephrotic range proteinuria and normocytic anemia while her shoulder X-ray shows osseous resorption in the lateral right clavicle. Multiple myeloma became the team's working diagnosis; however, a subsequent shoulder biopsy was consistent with follicular thyroid carcinoma. Imaging suggested the patient's renal failure was more likely a result of a chronic, unrelated process. CONCLUSIONS: It is tempting to bludgeon diagnostic possibilities into Occam's razor. Presumption that a patient's signs and symptoms are connected by one disease process often puts us at a cognitive advantage. However, atypical presentations, multiple disease processes, and unique populations often lend themselves more to Hickam's dictum than to Occam's razor. Diagnostic aids include performing a metacognitive checklist, engaging analytic thinking, and acknowledging the imperfections of these axioms.

Development and Validation of a Machine Learning-Based Decision Support Tool for Residency Applicant Screening and Review.

PURPOSE: Residency programs face overwhelming numbers of residency applications, limiting holistic review. Artificial intelligence techniques have been proposed to address this challenge but have not been created. Here, a multidisciplinary team sought to develop and validate a machine learning (ML)-based decision support tool (DST) for residency applicant screening and review. METHOD: Categorical applicant data from the 2018, 2019, and 2020 residency application cycles (n = 8,243 applicants) at one large internal medicine residency program were downloaded from the Electronic Residency Application Service and linked to the outcome measure: interview invitation by human reviewers (n = 1,235 invites). An ML model using gradient boosting was designed using training data (80% of applicants) with over 60 applicant features (e.g., demographics, experiences, academic metrics). Model performance was validated on held-out data (20% of applicants). Sensitivity analysis was conducted without United States Medical Licensing Examination (USMLE) scores. An interactive DST incorporating the ML model was designed and deployed that provided applicant- and cohort-level visualizations. RESULTS: The ML model areas under the receiver operating characteristic and precision recall curves were 0.95 and 0.76, respectively; these changed to 0.94 and 0.72, respectively, with removal of USMLE scores. Applicants' medical school information was an important driver of predictions-which had face validity based on the local selection process-but numerous predictors contributed. Program directors used the DST in the 2021 application cycle to select 20 applicants for interview that had been initially screened out during human review. CONCLUSIONS: The authors developed and validated an ML algorithm for predicting residency interview offers from numerous application elements with high performance-even when USMLE scores were removed. Model deployment in a DST highlighted its potential for screening candidates and helped quantify and mitigate biases existing in the selection process. Further work will incorporate unstructured textual data through natural language processing methods.

"I Cannot Take This Any More!": Preparing Interns to Identify and Help a Struggling Colleague.

BACKGROUND: Few programs train residents in recognizing and responding to distressed colleagues at risk for suicide. AIM: To assess interns' ability to identify a struggling colleague, describe resources, and recognize that physicians can and should help colleagues in trouble. SETTING: Residency programs at an academic medical center. PARTICIPANTS: One hundred forty-five interns. PROGRAM DESIGN: An OSCE case was designed to give interns practice and feedback on their skills in recognizing a colleague in distress and recommending the appropriate course of action. Embedded in a patient "sign-out" case, standardized health professionals (SHP) portrayed a resident with depressed mood and an underlying drinking problem. The SHP assessed intern skills in assessing symptoms and directing the resident to seek help. PROGRAM EVALUATION: Interns appreciated the opportunity to practice addressing this situation. Debriefing the case led to productive conversations between faculty and residents on available resources. Interns' skills require further development: while 60% of interns asked about their colleague's emotional state, only one-third screened for depression and just under half explored suicidal ideation. Only 32% directed the colleague to specific resources for his depression (higher among those that checked his emotional state, 54%, or screened for depression, 80%). DISCUSSION: This OSCE case identified varying intern skill levels for identifying and assessing a struggling colleague while also providing experiential learning and supporting a culture of addressing peer wellness.

Warm Handoffs: a Novel Strategy to Improve End-of-Rotation Care Transitions.

BACKGROUND: Hospitalized medical patients undergoing transition of care by house staff teams at the end of a ward rotation are associated with an increased risk of mortality, yet best practices surrounding this transition are lacking. AIM: To assess the impact of a warm handoff protocol for end-of-rotation care transitions. SETTING: A large, university-based internal medicine residency using three different training sites. PARTICIPANTS: PGY-2 and PGY-3 internal medicine residents. PROGRAM DESCRIPTION: Implementation of a warm handoff protocol whereby the incoming and outgoing residents meet at the hospital to sign out in-person and jointly round at the bedside on sicker patients using a checklist. PROGRAM EVALUATION: An eight-question survey completed by 60 of 99 eligible residents demonstrated that 85% of residents perceived warm handoffs to be safer for patients (p < 0.001), while 98% felt warm handoffs improved their knowledge and comfort level of patients on day 1 of an inpatient rotation (p < 0.001) as compared to prior handoff techniques. Finally, 88% felt warm handoffs were worthwhile despite requiring additional time (p < 0.001). DISCUSSION: A warm handoff protocol represents a novel strategy to potentially mitigate the known risks associated with end-of-rotation care transitions. Additional studies analyzing patient outcomes will be needed to assess the impact of this strategy.