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.

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

PROBLEM: Internal medicine training programs operate under the assumption that the 3-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: 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: This pilot study has provided proof of principle that the crosswalk tool can effectively map 1 year of resident-attributed diagnosis codes to both the broad content category level (e.g., "cardiovascular disease") and to the more specific condition category level (e.g., "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: The crosswalk tool introduced here translated residents' patient care activities into discrete, measurable educational content and enabled 1 internal medicine residency 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.

Endoscopy-guided transesophageal echocardiography for large esophageal varices: Use of the "Double Barrel" technique.

Rhythm control strategies in patients with esophageal varices and atrial arrhythmias pose a unique challenge. The left atrium should be imaged for a thrombus prior to attempting cardioversion or ablation, but the presence of varices is a relative contraindication for transesophageal echocardiography. We present a safe, novel technique of evaluating for left atrial thrombus with simultaneous transesophageal echocardiography and esophagogastroduodenoscopy using slim probes in a patient with large, high-risk esophageal varices, and symptomatic atrial flutter with rapid ventricular rates despite medical therapy.

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

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.

Reevaluating the psychometric properties of symptom measures within longitudinal contexts: The Yale-Brown Obsessive Compulsive Scale and Dimensional Obsessive-Compulsive Scale.

As research and clinical settings increasingly emphasize questions of change, it is crucial that our mechanistic and outcome variables are established as reliable and valid measures of such change. However, there is often a mismatch between the purposes for which symptom measures were developed and validated versus their application. Traditional psychometric theory has focused largely on between-person change, whereas increasingly research and clinical questions concern within-person change. We examined the psychometric properties of two commonly used measures of obsessive-compulsive symptoms (Yale-Brown Obsessive Compulsive Scale, YBOCS; Dimensional Obsessive-Compulsive Scale, DOCS) within a longitudinal treatment context (N = 570). Regarding reliability, we applied traditional (i.e., internal consistency at each week) and novel methods that allow for examination of the reliability of both within- and between-person change (i.e., variance partitioning based on generalizability theory). We examined longitudinal concurrent validity by correlating per-person slopes of obsessive-compulsive and depression symptom measures obtained via mixed-effects models. Within-person change reliability was acceptable or good for the YBOCS and DOCS total scores (.77, .83), suggesting that these measures are capable of capturing meaningful changes that exist within persons over time, and between-person change reliability was excellent (.99-1.0). Per-person slopes analyses supported the longitudinal concurrent validity of both measures. Our data support the continued use of the YBOCS and DOCS as measures of obsessive-compulsive symptoms for the purpose of many longitudinal research questions. The current study provides a template for reestablishing the psychometric properties of other commonly used measures in the context of longitudinal investigations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Two cases of acute endocarditis misdiagnosed as COVID-19 infection.

The COVID-19 pandemic has presented countless new challenges for healthcare providers including the challenge of differentiating COVID-19 infection from other diseases. COVID-19 infection and acute endocarditis may present similarly, both with shortness of breath and vital sign abnormalities, yet they require very different treatments. Here, we present two cases in which life-threatening acute endocarditis was initially misdiagnosed as COVID-19 infection during the height of the pandemic in New York City. The first was a case of Klebsiella pneumoniae mitral valve endocarditis leading to papillary muscle rupture and severe mitral regurgitation, and the second a case of Streptococcus mitis aortic valve endocarditis with heart failure due to severe aortic regurgitation. These cases highlight the importance of careful clinical reasoning and demonstrate how cognitive errors may impact clinical reasoning. They also underscore the limitations of real-time reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2 testing and illustrate the ways in which difficulty interpreting results may also influence clinical reasoning. Accurate diagnosis of acute endocarditis is critical given that surgical intervention can be lifesaving in unstable patients.

Quantification of peripapillary sparing and macular involvement in Stargardt disease (STGD1).

PURPOSE: To quantify and compare structure and function across the macula and peripapillary area in Stargardt disease (STGD1). METHODS: Twenty-seven patients (27 eyes) and 12 age-similar controls (12 eyes) were studied. Patients were classified on the basis of full-field electroretinogram (ERG) results: Fundus autofluorescence (FAF) and spectral domain-optical coherence tomography (SD-OCT) horizontal line scans were obtained through the fovea and peripapillary area. The thicknesses of the outer nuclear layer plus outer plexiform layer (ONL+), outer segment (OS), and retinal pigment epithelium (RPE) were measured through the fovea, and peripapillary areas from 1° to 4° temporal to the optic disc edge using a computer-aided, manual segmentation technique. Visual sensitivities in the central 10° were assessed using microperimetry and related to retinal layer thicknesses. RESULTS: Compared to the central macula, the differences between controls and patients in ONL+, OS, and RPE layer thicknesses were less in the nasal and temporal macula. Relative sparing of the ONL+ and/or OS layers was detected in the nasal (i.e., peripapillary) macula in 8 of 13 patients with extramacular disease on FAF; relative functional sparing was also detected in this subgroup. All 14 patients with disease confined to the central macula, as detected on FAF, showed ONL+ and OS layer thinning in regions of normal RPE thickness. CONCLUSIONS: Relative peripapillary sparing was detected in STGD1 patients with extramacular disease on FAF. Photoreceptor thinning may precede RPE degeneration in STGD1.

Toward a clinical protocol for assessing rod, cone, and melanopsin contributions to the human pupil response.

PURPOSE. To better understand the relative contributions of rod, cone, and melanopsin to the human pupillary light reflex (PLR) and to determine the optimal conditions for assessing the health of the rod, cone, and melanopsin pathways with a relatively brief clinical protocol. METHODS. PLR was measured with an eye tracker, and stimuli were controlled with a Ganzfeld system. In experiment 1, 2.5 log cd/m(2) red (640 ± 10 nm) and blue (467 ± 17 nm) stimuli of various durations were presented after dark adaptation. In experiments 2 and 3, 1-second red and blue stimuli were presented at different intensity levels in the dark (experiment 2) or on a 0.78 log cd/m(2) blue background (experiment 3). Based on the results of experiments 1 to 3, a clinical protocol was designed and tested on healthy control subjects and patients with retinitis pigmentosa and Leber's congenital amaurosis. RESULTS. The duration for producing the optimal melanopsin-driven sustained pupil response after termination of an intense blue stimulus was 1 second. PLR rod- and melanopsin-driven components are best studied with low- and high-intensity flashes, respectively, presented in the dark (experiment 2). A blue background suppressed rod and melanopsin responses, making it easy to assess the cone contribution with a red flash (experiment 3). With the clinical protocol, robust melanopsin responses could be seen in patients with few or no contributions from the rods and cones. CONCLUSIONS. It is possible to assess the rod, cone, and melanopsin contributions to the PLR with blue flashes at two or three intensity levels in the dark and one red flash on a blue background.