Patient survey superior to EMR extraction for eliciting positive symptoms at COVID-19 illness onset.

Context: COVID-19 has ravaged nations around the world, with New York City (NYC) and the NYC suburbs being particular epicenters of COVID-19 infection. Suffolk County, NY, has reported over 200,000 cases and 3,000 deaths to date. Most initial COVID-19 research concerned hospitalized patients. Presenting symptomology in the outpatient setting was poorly characterized, as were the implications of specific presenting symptoms, beyond respiratory distress or hypoxia, for eventual disease severity. This made it difficult for primary care physicians to predict which patients would require hospitalization for COVID-19 disease or decompensate while being managed at home during a time when hospital and ICU beds were limited. Objective: To characterize presenting symptoms of COVID-19 infection in the outpatient setting and evaluate for correlation with severity, duration, and chronicity of disease. Study Design and Analysis: We collected survey data from both patient telephone interviews and electronic medical record (EMR) extraction. Patient characteristics were described using means and percentages when appropriate. Percentage of symptoms by severity level, symptom duration, COVID-19 testing and escalating medical care were calculated. To evaluate association of risk factors with positive testing, severity, duration and chronicity of symptoms, logistic regression was used. Patient characteristics, medications and repeat measures were evaluated as risk factors in logistic regression. Setting or Dataset: 107 patients with suspected and confirmed COVID-19 cases at the 3 primary care practices of Stony Brook University Hospital between March and December, 2020. Population Studied: adult, English speaking primary care patients with suspected or confirmed COVID-19 Intervention/Instrument: patient self report telephone survey, EMR data extraction survey Outcome Measures: symptom duration, symptom severity, persistence of symptoms at 3 month time point Significant Results: Patient self-report survey elicited nearly twice as many symptoms described at illness onset vs. those recorded in the EMR. Conclusions: Early in the setting of newly emerging infectious diseases, particularly those such as COVID-19 which involve multiple organ systems, patient self report of symptoms of illness rather than EMR extraction alone may be crucial both for identifying cases and in order to characterize pathophysiology of disease in real time.

The Art of Observation and the Observation of Art: Zadig in the Twenty-first Century.

Astute observation is a fundamental component of the art of medicine. Yet most schools and residencies offer little formal teaching of this skill, with some outsourcing the entire subject matter to art museums and instructors. Curiously, it was nineteenth century medicine that may have provided the conceptual framework for what is now known as Visual Thinking Strategy, the technique used by many art-based programs in order to teach observation. We suggest that the time is ripe for medicine to regain ownership of the teaching of this skill, not only because it may enhance clinical care but also because only the eyes of a skilled physician can best interpret crucial medical details. To this end, we shall revisit both the method of Zadig, which William Osler practiced and taught to his students, and its application to the observation of art first pioneered by the Italian physician Giovanni Morelli. As an example of this skill, we shall use focused observation to decode a fifteenth century portrait that hangs at the Philadelphia Museum of Art, thus turning a seemingly non-descript Renaissance painting into a treasure trove of personal, social, and medical information.

Patient Self-Report Superior to Electronic Medical Record Abstraction for Identifying Positive COVID-19 Symptoms at Illness Onset.

Introduction: Most initial COVID-19 research focused on hospitalized patients. Presenting symptomatology in the outpatient setting was poorly characterized, making it difficult for primary care physicians to predict which patients would require hospitalization. The purpose of this study was to characterize the presenting symptoms of COVID-19 infection and baseline patient characteristics and evaluate for correlation with disease severity, duration, and chronicity in the outpatient setting. Methods: A total of 107 adult, English-speaking patients with suspected and confirmed COVID-19 cases at the 3 primary care practices of Stony Brook University Hospital were studied between March and December 2020. Survey data were collected from patient telephone interviews and electronic medical record abstraction. The potential risk factors assessed included participant demographics, medical comorbidities, and the number and type of symptoms at illness onset. Outcome measures included symptom duration, hospitalizations, and persistence of symptoms at 12 weeks from study enrollment. Results: Patient self-report survey elicited nearly twice as many symptoms described at illness onset as those recorded in the electronic medical record (p<0.0001). A higher number of symptoms at illness onset was positively associated with symptom duration and chronicity. The presence of fever and hypoxia at the onset of illness were each positively associated with eventual hospitalization for COVID-19 disease. Conclusions: Early in the setting of newly emerging infectious diseases, particularly those such as COVID-19 that involve multiple organ systems, patient self-report of symptoms using a complete review of systems rather than electronic medical record abstraction alone may be key for accurate disease identification and characterization as well as prediction of eventual disease severity, duration, and chronicity.

Needs assessment for a formal emergency medicine residency program in southern Madagascar.

INTRODUCTION: World Health Organization data for Madagascar reveal that the nation's under age five mortality rate is 56/1000, and that its maternal mortality rate is 440/100,000. Malaria, leprosy, plague, and tuberculosis remain significant communicable disease threats. Malnutrition rates are improving but continue to impact negatively on the general health of the Malagasy population, especially in the southern region with its 1.9 million inhabitants. There are no emergency medicine (EM) training programs to serve the southern half of Madagascar, which has a large urban population in Fianarantsoa. This study aimed to assess the need for and potential feasibility of an emergency medicine training program in southern Madagascar. METHODS: We met with the institutional leadership on site at the university hospital in Fianarantsoa. A needs assessment was performed on multiple domains. Domain 1: existing hospital infrastructure and its physical plant and emergency centre (EC) space allotment. Domain 2: existing clinical and technological resources. Domain 3: educational resources and the existing curriculum for EM. Domain 4: medical student educational program and availability of prospective residency candidates. Domain 5: pre-hospital care and emergency medical services. RESULTS: The size of the EC is adequate for the current census. Clinical resources are typical of many developing countries, with significant need for technological advancement and support, which we delineate in the body of our paper. There is an existing curriculum in Antananarivo and in Majanga, as well as one available through the African Federation for Emergency Medicine. The medical school in the area is relatively new, with graduating classes numbering approximately 30. There is no organised pre-hospital care system, no 9-1-1 equivalent, and no pre-hospital treatment from within metropolitan Fianarantsoa. CONCLUSIONS: While the needs assessment indicates substantial need for emergency medicine development in southern Madagascar, the yield (particularly for the metropolitan Fianarantsoa area) would serve the population well.