2013 APDIM Spring Meeting Poster Reception - Alliance for ...

2013 APDIM Spring Meeting 

April 30-May 1, 2013 

Walt Disney World Dolphin 

Lake Buena Vista, FL 

Poster List 

Research Posters 

Poster 

Number 

Submitting Author Submitting Author Email Poster Title 

1 Dean A. Bricker, MD dean.bricker@wright.edu 

Improving Adherence: A Motivational 

Interviewing-Based Curriculum 

2 Alissa J. Brummond, MD brummond.alissa@mayo.edu 

Characteristics and Costs 

of Resident Recruitment: A National 

Survey of Internal Medicine 

Residency Program Directors 

3 Stephanie A. Call, MD scall@mcvh-vcu.edu 

Clinical Competency Committees— 

Need for Change 

4 Stephanie A. Call, MD scall@mcvh-vcu.edu 

The State of the DOM/Chair’s Letter 

and the Need for Reform 

5 Laura A. Carravallah, MD LCarrav1@hurleymc.com 

6 Leonard S. Feldman, MD LF@jhmi.edu 

7 Leonard S. Feldman, MD LF@jhmi.edu 

Comparing an In-Depth Interview on 

the Social Determinants of Health with 

the Social History of Med-Peds 

Senior Adult Continuity Patients 

Do Internal Medicine Interns Practice 

Patient-Centered Communication? 

A Critical Look at the Patient Encounter 

Behind Closed Doors 

In the Wake of the 2003 and 2011 Duty 

Hours Rules, How Do Internal 

Medicine Interns Spend Their Time? 

8 Phuong D. Ho, MD phuong.d.ho@medstar.net 

Do Teaching Styles Matter in Internal 

Medicine Residency Training? 

9 Tresa M. McNeal, MD tmcneal@sw.org 

Resident Advising: A Three-Year 

Follow-Up 

10 Jason A. Post, MD post.jason@mayo.edu 

An Ambulatory Clinic Intervention 

to Improve Resident Physician 

Confidence with the 

Advance Care Planning Process

11 Ruby P. Shah, MD ruby.shah@ucdmc.ucdavis.edu 

12 Sara L. Swenson, MD swensosl@sutterhealth.org 

13 Kris G. Thomas, MD thomas.kris@mayo.edu 

Generalist Career Outcomes 

of University of California Davis 

Graduates: A Longitudinal Study 

Thinking of Quitting: Predictors 

of Considering Resignation Among 

Internal Medicine Program Directors 

The Educational Innovations Project 

(EIP)—Association Between Residency 

Program Participation and 

Medical Education Publications 

14 Heather A. Thompson Buum, MD thomp057@umn.edu 

Duty Hours Monitoring Revisited: 

Self-Report May Not Be Adequate 

15 Laurel Fick, MD lbfick@stvincent.org 

Patient Census: What is Optimal 

for Educational Satisfaction 

and Quality of Care Balance? 

Programmatic Innovation Posters 

Poster 

Number 

Submitting Author Submitting Author Email Poster Title 

16 Laurel Fick, MD lbfick@stvincent.org 

The Triple Threat—Novel 

Hospitalist-Track Electives 

17 Alisa Duran-Nelson, MD duran012@umn.edu 

Procedural Competence: 

From See One, Do One, Teach One 

to an Entrustable Professional Activity 

18 Ola Al Sous, MD alsouso@trinity-health.org 

Transition of Care: A New Curriculum 

to Enhance Safer Hospital Discharges 

19 Sandy Balwan, MD sbalwan@NSHS.edu 

Transitional Care: A Novel, 

Narrative Initiative 

20 Poonam Beniwal-Patel, MD pbeniwal@mcw.edu 

Night Float Cards: 

An Educational Endeavor 

21 Christina R. Bergin, MD christina.bergin@bannerhealth.com 

22 Steffanie R. Campbell, MD Steffanie.Campbell@bcm.edu 

Improving Patient Satisfaction 

Outcomes, Resident Interpersonal 

Communication Skills, 

and Resident Feedback 

Does the Time 

of Educational Conference Impact 

Patient Discharge Times? 

2013 APDIM Spring Meeting Poster List Page 2

23 Amy F. Matthews amatthews@uchc.edu 

24 Brian M. Cohee, MD brian.m.cohee.mil@health.mil 

25 Jennifer A. Corbelli, MD corbellija@upmc.edu 

Incorporating a Longitudinal 

Subspecialty Continuity Clinic 

into Internal Medicine Training 

Achieving Balance on the Inpatient 

Internal Medicine Wards: 

A Performance Improvement Project 

to Restructure Resident Work Hours 

at a Tertiary Care Center 

Breast Cancer Screening and Prevention 

in Primary Care: A Novel Curricular 

Intervention for Medicine Housestaff 

26 Nathan E. Derhammer, MD nderhammer@lumc.edu Chief Resident Leadership Academy 

27 Christopher Dittus, DO cdittus@nshs.edu 

28 Scott R. Friedstrom, MD friedstrom@yahoo.com 

29 Brian J. Hanson, MD hans3829@umn.edu 

“The Chief’s Seminar”: 

Motivating New Residents 

to Master Clinical Reasoning 

Objectification and Meaningful 

Implementation of a Medicine 

Curriculum Designed to Produce the 

Next Generation of Physician Leaders 

Innovative and Successful 

Evidence-Based Morning Report 

Linked to Resident-Led Journal Club 

30 Katherine Harris, MD harriski@healthcare.uiowa.edu 

Tea(ch) Time: An Afternoon Approach 

to Morning Report 

31 Saba A. Hasan, MD shasan@capitalhealth.org 

“You Must Be the Change You Wish 

to See in the World.” -Mahatma Gandhi 

32 Stephen J. Knaus, MD sjknaus@stvincent.org 

33 Tasha Kouvatsos, MD tasha.kouvatsos@gmail.com 

Ambulatory Case Conference— 

A Novel Approach 

to Outpatient Education 

Morbidity and Mortality Conference 

Working Group— 

Resident Driven Change 

34 Gina Luciano, MD gina.luciano@baystatehealth.org The July Transition—Making It Easier 


35 Srikrishna V. Malayala, MD varun_msk@yahoo.com 

36 Jared Moore, MD jared.moore@osumc.edu 

A Refined Patient Safety and Quality 

Improvement Curriculum for Internal 

Medicine Residents—Based 

on a Six-Year Feedback and Review 

Preparing Residents for Team-Based 

Patient Care: The Development 

and Implementation 

of a Resident Leadership 

and Management Training Program 

37 Brandon R. Murguia, MD Brandon.Murguia@dignityhealth.org 

The Next Step in Collaborative Care: 

Medical-Legal Partnerships 

38 Moyna H. Ng, MD mng3@nshs.edu 

Improving Resident Documentation: 

Coding and Billing Practices 

with a Practical Tutorial 

39 Kerri L. Palamara, MD kpalamara@partners.org 

Ambulatory Clinician-Educator 

Rotation for Primary Care Residents 

40 Kerri L. Palamara, MD kpalamara@partners.org 

41 David Paje, MD DPAJE1@hfhs.org 

42 Anne G. Pereira, MD anne.pereira@hcmed.org 

43 Seth Politano, DO politano@usc.edu 

44 Patrick A. Rendon, MD prendon@salud.unm.edu 

45 Eileen E. Reynolds, MD ereynold@bidmc.harvard.edu 

46 Lloyd Rucker, MD lrucker@uci.edu 

Less Sinking and More Swimming: 

Resident Primary Care 

Immersion Blocks 

Training Residents for Independent 

Inpatient Practice (TRIIP): Ongoing 

Development of a Novel Clinical 

Rotation Using PDCA 

and Milestones to Improve 

Education in Hospital Medicine 

Remediating Residents in Transition: 

Individualizing the 

Learner-Manager-Teacher Model 

Training Homework: Does a Structured 

Reading and Testing Program 

Improve Performance 

on the ABIM In-Training Exam? 

“Intern Boot Camp”: 

Case-Based Interactive Curriculum 

for the New Intern 

Hospital Practice Profiles: 

Improving Training by Linking Patient 

Outcomes to Resident Practice 

Best Cases Create Best Case Scenario: 

Educational Competition 

to Improve Resident Experience 


47 Lloyd Rucker, MD lrucker@uci.edu 

Cost Awareness Curriculum 

for Residents 

48 Bindu K. Swaroop, MD bkswaroop@yahoo.com 

49 Adam Sawatsky, MD sawatskyap@upmc.edu 

A Resident-Driven 

Mini-Lecture Curriculum 

for Inpatient Internal Medicine 

The Last Lecture? Uniting Resident 

Preferences and Principles 

of Adult Learning to Improve 

the Noon Conference Lecture Series 

50 Michael P. Stevens, MD mstevens@mcvh-vcu.edu 

It’s All in the Execution: Description 

of a Duty Hours Monitoring Process 

51 Vishnu Laalitha Surapaneni, MD 

VishnuLaalitha.Surapaneni 

@UHhospitals.org 

Optimizing Resident Handoffs 

52 Tabassum Salam, MD tsalam@christianacare.org 

53 David B. Sweet, MD sweetd@summahealth.org 

54 Hailey Vincent, MD hvincent@sw.org 

Raising Resident Awareness of Their 

Role in Quality and Safety 

Through Patient Safety Discussions 

Resident-Led Decision Support 

Huddles to Improve Risk Factors 

for Patients with Diabetes 

Hands-On Quality Improvement: 

A Curriculum for Team-Based, 

Resident-Led Projects Training 

Residents in Quality Improvement 

Using Small Groups 

and Resident-Initiated Projects 

55 Bennett S. Vogelman, MD bsv@medicine.wisc.edu 

Outcomes from a Three-Year QI 

Residency Education Program 

56 Ekterina A. Vypritskaya, MD evypritskaya@capitalhealth.org 

57 Eric J. Warm, MD warmej@ucmail.uc.edu 

“If You Listen Carefully to the Patient, 

They Will Tell You the Diagnosis.” 

-Sir William Osler 

A Novel Assessment System Created 

by Mapping Milestones 

to Entrustable Professional Activities 


Research Poster Abstracts 

Poster Number: 1 

Poster Title: Improving Adherence: A Motivational Interviewing-Based Curriculum 

Authors and Affiliate Institutions: Dean Bricker, Paul Hershberger, Wright State University Boonshoft School of 

Medicine 

Submitting Author 

Dean A. Bricker, MD 

Associate Program Director 

Department of Internal Medicine 

Wright State University Boonshoft School of Medicine 

Weber CHE Building, Second Floor 

128 East Apple Street 

Dayton, OH 45409-2902 

Telephone: (937) 510-2663 

Email: dean.bricker@wright.edu 

Background: Nonadherence to prescribed treatments is both common and costly. With a prevalence of 50% or 

greater, residents encounter nonadherence multiple times each day, yet few programs provide specific training on 

this topic. The patient-provider relationship affects medication adherence. Thus we sought train providers to 

engage patients in a more patient-centered fashion emphasizing how medications are discussed. We targeted 

understanding motivational interviewing, use of open-ended questions and reflective statement as a means to have 

patients talk about their barriers to adherence. 

Aim: To develop and evaluate a motivational interviewing-based curriculum designed to enhance resident 

knowledge and skills for promoting patient adherence. 

Methods: The curriculum consisted of 4 half-day training modules that occurred once per week during an 

ambulatory block rotation. Each block typically included 6 learners: 2 IM R1, 2 FM R1, and 2 sixth year pharmacy 

students. The first session involved interactive discussion of factual content: 1) the scope of the adherence 

problem, 2) barriers to adherence, 3) collaborative care principles, 4) self-management plans, and 5) motivational 

interviewing philosophy/techniques. The second module emphasized skills practice utilizing role plays. In the third 

module, learners interviewed a standardized patient and the interviews were video recorded. The group also 

reviewed video of each learner with one of her/his real patients. The final session included review of the 

standardized patient videos. We used a 20-question quiz to assess learner’s knowledge and a 6-item survey to 

assess skills confidence. We evaluated our video review form for inter-rater reliability and used it to assess videorecorded 

interviews. 

Results: Fifty-nine learners completed the curriculum in 2011-12. Knowledge scores improved from 11.6 (58% 

correct) to 16.1 (80.0% correct) at course completion (p < 0.001). Confidence improved for all items surveyed (p < 

0.001) at course completion. We demonstrated good inter-rater reliability for our interview skills assessment form 

with regard to use of open-ended versus closed questions. Learner’s showed improvements in the open-question: 

closed-question ratios from early rotation compared with scores for interviewing a standardized patient at course 

completion (ratio 1.14 vs. 1.84; p = 0.023). 

Discussion or Conclusion: Learners demonstrated improvements in knowledge and confidence as well as some 

elements of motivational interviewing skills. 

2013 APDIM Spring Meeting Poster Abstract Summaries Page 1

2013 Mayo Foundation for Medical Education and Research 

Characteristics and Costs of Resident Recruitment: A National Survey of 

Internal Medicine Residency Program Directors 

Alissa Brummond MD, 1 Susan Sefcik MD, 2 Andrew J. Halvorsen MS, 1 Saima Chaudhry MD MSHS, 3 Vineet Arora MD MAPP, 4 Mike Adams MD, 5 Maria Lucarelli MD, 6 Furman S. McDonald MD MPH, 1 Darcy A. Reed, MD MPH 1 

1 Department of Medicine, Mayo Clinic College of Medicine, 2 St. Lukes University Health Network, 3 North Shore-Long Island Jewish Hofstra School of Medicine, 4 University of Chicago Prtizker School of Medicine, 

5 Georgetown University School of Medicine, 6 Ohio State University Medical Center 

Background 

• Interest in internal medicine is declining and 

resources for residency recruitment are limited. 

• New regulations requiring programs to place all, or 

none, of their positions within NRMP are anticipated 

to increase recruitment costs; yet, costs of 

recruitment to U.S. residency programs have not 

been comprehensively examined. 

• The objective of this study was to describe 

recruitment to U.S. internal medicine residency 

programs and to estimate associated costs. 

Methods 

Cross-sectional survey of 353 U.S. categorical internal 

medicine residency program directors. Recruitment 

costs were estimated as the sum of the annual 

recruitment budget (food, hotels, supplies, etc.) and the 

percentage effort dedicated to recruitment by residency 

personnel multiplied by national salary data. 

Results 

• Surveys were returned by 270 (76.5%) program 

directors. 

• Programs received a mean (SD) of 2,314 (1579) 

applications and conducted 10 (4) interviews per 

resident position. 

• The estimated median (IQR) total cost of 

recruitment was $148,345 ($95,966-234,704) per 

program and $9,899 ($6,494-13,271) per 

matriculate. 

• In multivariate analysis, PGY1 class size (β= 

+$6,073; p


Poster Title: Characteristics and Costs of Resident Recruitment: A National Survey of Internal Medicine 

Residency Program Directors 

Authors and Affiliate Institutions: Alissa Brummond, Andrew Halvorsen, Furman McDonald, Darcy Reed, 

Mayo Clinic College of Medicine; Susan Sefcik, St. Luke’s of Bethlehem; Saima Chaudhry, Hofstra North Shore- 

LIJ School of Medicine at Hofstra University; Vineet M Arora, University of Chicago Pritzker School of Medicine; 

Mike Adams, Georgetown University School of Medicine; Stephanie Call, Virginia Commonwealth University 

Medical College of Virginia; Maria Lucarelli, Ohio State University College of Medicine 


Alissa J. Brummond, MD 

PGY 2 Resident 


Mayo Clinic College of Medicine 

200 First Street, SW 

Rochester, MN 55905 

Telephone: (507) 284-6391 

Email: brummond.alissa@mayo.edu 

Background: Interest in internal medicine is declining and resources for residency recruitment are limited. New 

regulations requiring programs to place all, or none, of their positions within National Resident Matching Program 

(NRMP) are anticipated to increase recruitment costs, yet costs of recruitment to U.S. residency programs have not 

been comprehensively examined. 

Aim: To describe recruitment to U.S. internal medicine residency programs and to estimate associated costs. 

Methods: Design: Cross-sectional survey Setting: U.S. categorical internal medicine residency programs 

Participants: 353 program directors Measures: Recruitment costs were estimated as the sum of the annual 

recruitment budget (food, hotels, supplies, etc.) and the percentage effort dedicated to recruitment by residency 

personnel multiplied by national salary data. 

Results: Surveys were returned by 270 (76.5%) program directors. Programs received a mean (SD) of 2,314 

(1579) applications and conducted 10 (4) interviews per resident position. The estimated median (IQR) total cost 

of recruitment was $148,345 ($95,966-234,704) per program and $9,899 ($6,494-13,271) per matriculate. In 

multivariate analysis, postgraduate year one (PGY1) class size (β= +$6,073; p


Poster Title: Clinical Competency Committees—Need for Change 

Authors and Affiliate Institutions: Stephanie Call, Virginia Commonwealth University; Jessica Salt, Gregory 

Kane, Jefferson Medical College of Thomas Jefferson University; Sapna Kuehl, St. Agnes Hospital; Vineet Arora, 

University of Chicago Pritzker School of Medicine 


Stephanie A. Call, MD 

Program Director 


Virginia Commonwealth University Medical College of Virginia 

PO Box 980509 

1200 East Broad Street 

Richmond, VA 23298 

Telephone: (804) 828-9726 

Email: scall@mcvh-vcu.edu 

Background: Internal medicine is implementing the Accreditation Council for Graduate Medical Education’s 

(ACGME) Next Accreditation System (NAS) in July of 2013 and is moving toward a more transparent 

competency-based advancement model. Despite the importance of the CCC, little is known of the best structure, 

authority lines, and approach to competency decisions. 

Aim: We describe the current variability in CCC characteristics. 

Methods: Questions regarding structure, function, authority and perceived effectiveness of Internal Medicine 

program CCCs were included on the 2011 annual APDIM Program Director (PD) survey. Data from the survey 

was merged in a de-identified database with publicly available data from the ACGME and ABIM. Descriptive 

statistics were performed using SPSS; chi-squared tests were used to assess for differences. 

Results: The survey response rate was 68.5% (n=261). The average size of a CCC was 12.3 members; this varied 

with program characteristics. PD was most frequent chair of the CCC (59%), followed by Associate PD (23%), 

core faculty (12%), other (5%). PDs appointed the chair in 89.7% of programs; this varied by program size. A 

large majority of programs (79%) did not require formal training of the CCC faculty. PDs reported the following 

CCC roles: remediation of residents (97.3%), advancement decisions (92.7%), assessment development (54.4%), 

biannual review process (49.8%), remediation of faculty (28.7%). Only 19% of programs reported a formal process 

for granting residents more autonomy; this did not vary by program characteristics. The PD completed the ABIM 

tracking form in 84% of programs, determined by PD alone in 40%. Only 11% of programs reported that the CCC 

made these decisions alone. One fourth of all programs reported that “every year I graduate at least one resident 

about whom I have concerns regarding their ability to practice independently.” Half of all programs reported that 

“each year I advance at least one resident about whom I have concerns regarding their ability to handle additional 

responsibility.” 

Discussion or Conclusion: Based on this data, it is clear that the structure, format, function, authority and 

effectiveness of these committees must change in order to enhance our ability to effectively evaluate, train, and 

ensure that every Internal Medicine residency graduate is ready for independent practice. 



Poster Title: The State of the DOM/Chair’s Letter and the Need for Reform 

Authors and Affiliate Institutions: Ryan Vega, Georgia McIntosh, Maia LaVallee, Stephanie Call, Virginia 

Commonwealth University School of Medicine; Valerie Lang, University of Rochester School of Medicine and 

Dentistry 


Stephanie A. Call, MD 




PO Box 980509 

1200 East Broad Street 


Telephone: (804) 828-9726 

Email: scall@mcvh-vcu.edu 

Background: Internal Medicine Program Directors regard the Department of Medicine (DOM) letter as a valuable 

piece of information in a residency applicant’s portfolio. An AAIM joint task force of Clerkship Directors and 

Program Directors recently developed a proposed set of guidelines for letter content. 

Aim: Our aim in this survey was to assess current variability in content and format of DOM letters. 

Methods: We identified DOM letters from our program’s pool of US LCME-accredited allopathic school 

graduating applicants in the NRMP 2012 and 2013 match seasons. We randomly selected one letter from each 

school for review. Letters were de-identified and then reviewed for content. We extracted data on 14 variables 

regarding length, structure, and content, including variables identified by the recently proposed guideline for DOM 

letter content. Data was managed and analyzed in Microsoft Excel. Descriptive statistics were performed. 

Results: From our applicant pool, we accessed 116 of the 141 currently LCME accredited or provisionally 

accredited US allopathic schools (82%). There was significant variability in the content and quality of the letters. 

Regarding clerkship and letter descriptions, 89% met the recommended length; 37% contained a statement 

regarding letter preparation; 37% described the clerkship structure and content; 22% contained information on 

grading policies; 23% contained a grade distribution for the clerkship. Regarding individual performance, 68% 

included the final clerkship grade; 19% included NBME shelf exam score; 78% contained some form of detailed 

narrative on performance or verbatim comments. Only 11% of letters included a summary paragraph with student’s 

comparative rank. Only 20% of the letters included information about students’ performance on the sub-internship 

rotation. Approximately 65% of letters included personal or historical information which is not recommended in the 

guidelines. In total, only 44% of letters reviewed contained at least 5 of the criteria from the proposed guidelines. 

Discussion or Conclusion: There is significant variability in the content of the DOM letter. Based on 

recommendations of a national organization, key pieces are missing in a large proportion of letters. As this 

document is considered a critical piece of information for program directors in the review of Internal Medicine 

candidates, there is a significant need for reform in and standardization of letter content. 


Comparing an In-Depth Interview on the Social Determinants of Health 

with the Social History of Med-Peds Senior Adult Continuity Patients 

Laura Carravallah, Jowhara Zindani, Sunil Meruga, Gopesh K Singh, Nick Lecea, Vijay Naraparaju 

Hurley Medical Center, Flint, Michigan 

Michigan State University College of Human Medicine, East Lansing, Michigan 

BACKGROUND 

The impact of socioeconomic factors on health status is well 

delineated in the literature, and while estimates vary, most agree 

that social determinants may in fact play a greater role than biology, 

medical care and health behaviors combined. (Tarlov,1999) 

Determinants of Health 

Source: Dahlgren, G and Whitehead, M. 1991 

Literature Search 

Only one study (Griffith, et a, 1995) addressed the content and adequacy of 

the collection of social history by residents. 

Griffith and colleagues found that the residents had an answer for only 29% 

of the basic social history (excluding health habits) of their inpatients – 

residents who had primary responsibilty for the patient had slightly better 

recall.. 

No studies compared a comprehensive independent patient interview with 

resident documentation and recall. 

No studies evaluated the adequacy and the relevance of social history 

obtained in the ambulatory setting by residents 

It is possible that increased contact and “ownership” of patients in 

continuity clinic may afford better resident knowledge of these social 

determinants. 

ACGME - Internal Medicine Milestones 

We believe that the knowledge skills and attitudes required of the 

residents to successfully collect a history of social determinants is 

pertinent to the following Milestones: 

11. Transitions patients effectively within and across health delivery systems. (SBP4) 

Aspirational: Anticipates needs of patient, caregivers and future care providers and takes 

appropriate steps to address those needs 

18. Responds to each patient’s unique characteristics and needs. (PROF-3) 

Ready for Unsupervised Practice: Recognizes and accounts for the unique characteristics 

and needs of the patient/ caregiver; Appropriately modifies care plan to account for a 

patient’s unique characteristics and needs 

20. Communicates effectively with patients and caregivers. (ICS-1) 

Ready for Unsupervised Practice: Quickly establishes a therapeutic relationship with 

patients and caregivers, including persons of different socioeconomic and cultural 

backgrounds 

PURPOSE 

Source: Tarlov, 1999, also cited by CDC 

The “Social History” is a required part of the medical history, but the 

items are not standardized, and often include little more than the 

health habits of the patient. 

Estimate the prevalence of various social health 

determinants in our underserved adult continuity clinic 

population 

Determine the concordance of resident documentation and 

knowledge with this information 

Determine resident and preceptor rating of the importance 

of these factors for patient’s care 

METHODS 

Setting 

Med-Peds Continuity Clinic situated in a federally subsidized 

Federally Qualified Health Center (FQHC) located in the northern 

part of Flint, MI. 

Subjects 

Patients – adult continuity clinic patients 

• Age ≥ 30 years with ≥ 1 chronic disease 

• Seen by same resident for > 3 times in 2 years 

• No active malignancy 

Residents – Med-Peds senior residents – PGY-3 & -4 

Study Procedure 

Study Interview Tool 

Sources for patient questionnaire 

Southwest Baltimore Community Health Survey (SWB) 

Multilevel Assessment Instrument (MAI) 

California Health Interview Survey (CHIS-2009) 

Psychosocial Adjustment to Illness Scale (PAIS) 

Instrument Activities of Daily Living Scale (IADL) 

Bright Futures 

Rapid Estimate of Adult Literacy in Medicine (REALM-R) 

Categories 

physical environment 

activities of daily living 

social support systems 

spirituality and faith 

community 

adequate finances 

access to health care 

dependent care 

recreation 

transportation 

housing 

police, fire and 

security 

employment 

opportunity 

RESULTS 

occupational health 

education, including 

health literacy 

substance use 

mental health 

legal concerns 

Nutrition 

Residents 

8 senior residents (4 PGY-3 & 4 PGY-4) completed the interview. 

25% Female and 75% Male, all International Medical Graduates 

Patients 

25 adult continuity clinic patients 

60% Female and 40% Male, Ages 30-66 years (mean 49 years) 

56% Black, 40% White, and 4% Other 

80% HTN, 32% COPD, 28% DM, 20% arthritis, 12% CAD/CHF, 

8% CKD, 4% asthma 

Resident Knowledge and Importance of 

“Traditional” Social History > 90%: 

marital status 

social support 

employment 

insurance 

prescription 

drug coverage 

tobacco 

alcohol abuse 

prescription drug 

abuse 

street drug abuse 

Prevalence 

History of Abuse 

56% 

Unemployment 

56% 

Lack of 

Transportation 

46% 

Cannot Afford 

Dental Care 

46% 

Financial Issues 

40% 

Discrimination 

40% 

Poor Health 

Literacy 

33% 

Lack of Sidewalks / 

Street Lights 

33% 

Legal Problems 

32% 

Cannot Afford 

Eye Care 

56% 

Resident 

Documentation / 

Knowledge 

48% 

Chart 

76% 

Chart 

48% 

Chart 

60% 

Chart 

28% 

Chart 

16% 

Chart 

20% 

Chart 

0% 

Chart 

32% 

Chart 

76% 

Resident 

100% 

Resident 

76% 

Resident 

40% 

Resident 

72% 

Resident 

40% 

Resident 

48% 

Resident 

24% 

Resident 

72% 

Resident 

80% 80% 

Chart 

Resident 

Resident & Faculty 

Perceived Clinical 

Importance for the 

Specific Patient 

100% 100% 

Resident 

Faculty 

92% 100% 

Resident 

Faculty 

100% 100% 

Resident 

80% 

Resident 

84% 

Resident 

Faculty 

36% 

Faculty 

100% 

Faculty 

76% 80% 

Resident 

Faculty 

96% 100% 

Resident 

48% 

Resident 

Faculty 

80% 

Faculty 

64% 60% 

Resident 

Faculty 

84% 80% 

Resident 

Faculty 

DISCUSSION 

This pilot study shows that continuity patients seen by our 

residents in an FQHC face considerable health stress stemming 

from socioeconomic condition. 

Traditional social history questions provided very narrow 

information. Similar to the study by Griffith, et al (1995), issues 

considered important in managing the patient were often missed. 

Residents in this study have improved their collection of social 

history as compared to the 1995 Griffith, et al study both in 

breadth and depth (vs. 30%). This may relate to the continuity 

clinic venue, as Griffith found that the accuracy residents 

improved with their level of primary responsibility for that patient. 

For the majority of the social determinants missed, residents and 

faculty rated the importance similarly 

Limitations of this pilot include: small sample size, single 

institution, semi-qualitative analysis, social desirability bias (both 

patients and residents), and lack of a comprehensive validated 

questionnaire for all categories. 

Conclusion and Next Steps 

We believe that we have gained valuable insight about the patient 

population we serve. Residents felt that most of these issues are 

important, but were unaware of many of these barriers affecting 

adherence and outcomes. It is clearly not feasible to do an hourlong 

interview on social determinants on every patient, but this 

study will allow us to prioritize our social history to those issues 

that are most prevalent and important for our patients. 

We have now converted to an EHR and we will be able to use this 

information to develop templates that may allow us to obtain a 

more efficient and effective history. Current planned areas to 

improve education and data collection include: health literacy, 

transportation, nutrition (including food security) and 

environmental factors. We will re-audit after implementation. 

We also plan to have our residents do a comprehensive interview 

on one of their continuity patients and write a reflection as a 

method to enhance empathy. Correlation of accuracy of social 

history and scales measuring resident empathy may also give 

further insights. 

REFERENCES 

1. Griffith, C.H., Rich, E. C., and Wilson, J.F. (1995). Housestaff’s Knowledge of Their 

Patients’ Social Histories. Acad Med, 70(1), 64-66. 

2. Griffith, C.H., Wilson, J.F., and Rich, E.C., A Randomized Trial of Providing House Staff 

with Patient Social History Information: Effect on Patient Outcomes. Eval Health Prof, 

21(3), 362-376. 

3. Morgan-Hopkins Center for Health Disparities Solutions. SOUTH WEST BALTIMORE 

COMMUNITY HEALTH SURVEY (SWB). Rev. 4/2/2004. Johns Hopkins Bloomberg 

School of Public Health, Baltimore, MD 

4. Davis TC, Long SW, Jackson RH, et al. Rapid Estimate of Adult Literacy in Medicine 

(REALM-R) in Rapid estimate of adult literacyin medicine: a shortened screening 

instrument. Fam Med. 1993;25:391–5 

5. Lawton, MP, Moss, M, Fulcomer, M, Kleban M.Multi-Level Assessment Instrument (MAI) 

Manual for Full-length MAI. Madlyn and Leonard Abramson Center for Jewish Life 

6. Accreditation Council on Graduate Medical Education (ACGME). Program Requirements 

for Graduate Medical Education in Internal Medicine. July 1, 2009, pg. 18 

7. TarlovTARLOV, A. R. (1999), Public Policy Frameworks for Improving Population Health. 

Annals of the New York Academy of Sciences, 896: 281–293. doi: 10.1111/j.1749- 

6632.1999.tb08123 

8. CDC http://www.cdc.gov/socialdeterminants/FAQ.html accessed 4/24/2013


Poster Title: Comparing an In-Depth Interview on the Social Determinants of Health with the Social History of 

Med-Peds Senior Adult Continuity Patients 

Authors and Affiliate Institutions: Laura Carravallah, Sunil Meruga, Gopesh K Singh, Nick Lecea, Vijay 

Naraparaju, Hurley Medical Center/Michigan State University; Jowhara Zindani, Michigan State University 

College of Human Medicine; Gergana Kodjebacheva, University of Michigan Medical School 


Laura A. Carravallah, MD 


Department of Internal Medicine and Pediatrics 

Hurley Medical Center/Michigan State University College of Human Medicine 

3AW Combined Med-Peds Education 

One Hurley Plaza 

Flint, MI 48503 

Telephone: (810) 262-9283 

Email: LCarrav1@hurleymc.com 

Background: The impact of socioeconomic factors on health status is well delineated in the literature, but it is 

unknown how often residents elicit a comprehensive social history, nor the impact of any omissions on patient 

outcomes. While Griffith et al (1995) found that social histories in the inpatient setting were inadequate; this has 

not been studied in continuity clinic. 

Aim: To examine the resident recognition and assessment of importance of key psychosocial variables that may 

impact on the management our continuity patients. 

Methods: Senior resident adult continuity patients with chronic disease were invited to participate in a detailed 

interview on the social determinants of health compiled from questionnaires in the literature. After all interviews 

were completed, a chart audit assessed adequacy of documentation and the continuity resident was also quizzed 

about positive findings found in the interview. The resident and a faculty preceptor were asked to rate the clinical 

importance of that information for that individual patient. 

Results: Twenty-five patients of 8 senior residents completed the interview. Major social problems identified 

include difficulties with employment (56%), transportation (46%), abuse (44%), finances (40%), medications 

(40%), discrimination (36%), health literacy (33%), legal system (32%), and health care access, particularly dental 

and eye. Documentation and resident knowledge was deficient, especially in the areas of physical environment 

(24%), discrimination (40%) and health illiteracy (48%). The greatest discrepancy between resident rating of 

importance vs. resident knowledge was around health illiteracy (96% vs.48%), discrimination (76% vs. 40%), and 

transportation and abuse (both 100% vs. 76%). Faculty ratings of importance were within 10% of the residents’ 

with the exception of lack of streetlights/sidewalks (80% vs. 48%) and dental care (36% vs. 80%). 

Discussion or Conclusion: This pilot study shows that continuity patients seen by our residents face considerable 

health stress stemming from socioeconomic conditions. Traditional social history questions provided very narrow 

information. While knowledge and documentation was better than in the inpatient sample in Griffith’s study, room 

for improvement remains. This study will help to focus education and screening protocols on important areas most 

often missed. Next steps will be to embed these protocols into our electronic health record. 


Do internal medicine interns practice etiquette-based communication? 

A critical look at the inpatient encounter 

Lauren Block, MD, MPH, Lindsey Hutzler, Robert Habicht, MD, Albert W. Wu, MD, MPH, Sanjay V. Desai, MD, Kathryn Novello Silva, 

MD, Timothy Niessen, MD, MPH, Nora Oliver, MD, and Leonard Feldman, MD 

Background 

• Institute of Medicine patient-centered care definition: 

• “Care that is respectful of and responsive to individual patient preferences, needs, and 

values, and ensuring that patient values guide all clinical decisions” 

• Etiquette-based medicine definition: 

• Term coined by Kahn 

• Subset of patient-centered communication 

• Includes simple behaviors that convey professionalism and respect to patients 

• Patient-centered communication may improve patient outcomes: 

• Make it easier for patients to disclose illness-related information 

• May impact patient perceptions of safety, patient anxiety, patient satisfaction, functional 

status, and compliance with medical recommendations 

Behavior 

Introducing self 

Introducing role 

Sitting down 

Touching the patient 

Providing a name 

Results 

Observed behaviors and definitions 

Uses term “doctor”, “resident”, “intern”, or “medical team” 

Definition 

Sitting on the bed, in a chair, or crouching if no chair was available during at least part of the encounter 

Any form of physical contact that occurred at least once during the encounter including shaking a patient’s hand, touching a 

patient on the shoulder, or performing any part of the physical exam. 

Frequency of performing behaviors during patient encounters by intern gender and shift type 

Total encounters N (%) Introduced self Introduced role Sat down Touched patient 

Conclusions 

•Internal medicine residents did not routinely practice behaviors comprising etiquettebased 

communication 

•Interns introduced themselves to patients in fewer than half of all observed encounters 

•Interns sat down with patients in fewer than 10% of encounters 

•Residents did not touch the patient in one third of visits, including during admitting 

shifts 

•We observed a high degree of variation between interns in performance of these 

behaviors 

•While interns believed they were practicing etiquette-based communication, as 

defined by Kahn, only a minority actually were 

Limitations 

• We sought to understand whether etiquette-based communication behaviors are practiced 

by trainees. 

• Study design and setting 

Specific hypotheses 

Methods 

• Cross-sectional prospective inpatient study incorporating direct observation of 

residents 

Overall 732 (100%) 40% 36% 9% 64% 

JHH 373 (51%) 35%*† 29%*† 10% 62%* 

UMD 359 (49%) 45% 44% 8% 69% 

Male 284 (39%) 39% 35% 9% 64% 

Female 448 (61%) 41% 38% 10% 67% 

Day shift 551 (75%) 37%* 34%* 9% 65% 

Night shift 181 (25%) 48% 45% 12% 67% 

Admitting shift 377 (52%) 46%* 42%* 10% 63% * 

Non-admitting shift 355 (48%) 34% 30% 9% 69% 

* 

•Study limited to two institutions in Baltimore, which limits external validity 

•Using non-medical observers may have caused measurement error 

•All 732 patient encounters were assessed, regardless of whether the resident had 

seen the patient previously or was leading the discussion on rounds 

•Hawthorne effect, change in behavior due to observation, is also possible 

•Survey was conducted 6 months after observations and limited to only 1 program 

Implications 

• PGY-1 residents in two internal medicine programs in Baltimore during January, 2012 

• Total of 29 interns observed (27% of interns in the two programs) 

• * p


Poster Title: Do Internal Medicine Interns Practice Patient-Centered Communication? A Critical Look at the 

Patient Encounter Behind Closed Doors 

Authors and Affiliate Institutions: Leonard Feldman, Lauren Block, Albert W Wu, Sanjay V Desai, Timothy 

Niessen, Lindsey Hutzler, Johns Hopkins University School of Medicine; Robert Habicht, University of Maryland 

School of Medicine 


Leonard S. Feldman, MD 

Assistant Professor 

Division of General Internal Medicine 


Johns Hopkins University School of Medicine 

600 North Wolfe Street 

Nelson 215 

Baltimore, MD 21287 

Telephone: (443) 287-3135 

Email: LF@jhmi.edu 

Background: Patient-centered communication strategies are associated with positive outcomes, including patient 

satisfaction. 

Aim: We sought to understand whether such behaviors are practiced by residents. 

Methods: Cross-sectional study design using direct observation of twenty-nine first-year medicine residents at two 

internal medicine programs who were observed during clinical encounters over one month of patient care. We 

evaluated how often four key “etiquette-based” communication strategies are practiced: introducing one’s self; 

introducing one’s role in the patient’s care; touching the patient; and sitting down with the patient. 

Results: A total of 732 patient encounters were observed during 118 intern shifts. Overall, interns introduced 

themselves 40% of the time and their role 36% of the time. Interns sat down with patients during 9% of visits, and 

touched patients on 64% of visits. All four behaviors were performed during 5% of encounters. Ten percent of the 

interns almost always practiced the behaviors, averaging three or more behaviors per encounter, while 14% 

averaged less than one. 

Discussion or Conclusion: Resident physicians introduced themselves to patients, explained their role, and sat 

down with patients infrequently during observed inpatient encounters. Interns touched patients during a majority of 

visits, but rarely performed all four behaviors in the same encounter. There was a high degree of variability among 

interns in performance of these behaviors. These behaviors, termed “etiquette-based medicine,” are easy to perform 

yet are not widely practiced. Since trainee behaviors may persist when they enter independent practice, 

interventions to facilitate etiquette-based communication during residency are warranted. 


Background 

In the Wake of the 2003 and 2011 Duty Hours Regulations, 

How Do Internal Medicine Interns Spend Their Time? 

Lauren Block MD, Kevin Wang, Timothy Niessen MD, Sanjay Desai MD, Albert Wu MD, Robert Habicht MD, Leonard Feldman MD 

Johns Hopkins University and University of Maryland Medical Center, Baltimore MD 

Results 

Conclusions 

• New ACGME requirements highlight importance of interaction with patients: 

• “For the resident, the essential learning activity is interaction with patients under the 

guidance and supervision of faculty members who give value, context, and meaning to 

those interactions” 

• New work hour rules may reduce time spent with patients 

• Efficiency may be prioritized over quality care 

• More frequent handoffs could increase medical errors 

• Health system changes may improve efficiency and safety but require more “screen” time 

• Expansion of electronic medical records and allied health professional teams may ease 

some resident clinical burden 

• Shorter hospital shifts could mean increased wakefulness and efficiency 

• Prior time motion studies in 1989 and 1997 found that residents spent more time charting 

than they do with patients; findings upheld in meta-analysis 

• Residents spent significant time engaging in basic activities: sleeping and eating 

Specific hypotheses 

• Relative to prior time motion studies, internal medicine residents will spend: 

• Less face-to-face time directly interacting with patients, and less time sleeping 

• More indirect patient care time: patient handoffs, accessing the medical record, and 

discussing patients with other physicians 

Methods 

Time spent by activity category 

63.6% 

9.3% 

12.3% 

• Nearly 2/3 of time spent in indirect patient care 

• Only 12.3% of time spent in direct patient care 

14.7% 

Comparison to historical studies 

Patient care 

Education 

Indirect pt care 

Misc 

Study Shift Direct pt care Indirect pt care Education Basic 

schedule 

Lurie, 1989 Night 22-31% 20-34% n/a 34-46% 

Lurie, 1993 Day/night 27-39% 20-42% n/a 11-40% 

Moore, 2000 Night 14% 43% n/a 42% 

Current study Day/night 12% 64% 15% 9% 

Percent of time spent in each activity by institution 

Total JH UMD 

Total time (hours) 873 439 (50.3%) 434 (49.7%) 

Activity 

Direct patient care 12.3% 11.4% 13.3%* 

Initial patient evaluation 3.8% 3.6% 4.1% 

Follow-up patient visit 7.2% 6.5% 7.8%*+ 

Patient education 0.1% 0.1% 0.1% 

Family meeting 0.5% 0.4% 0.6% 

Procedures 0.7% 0.8% 0.6% 

Procedure consent 0.04% 0.05% 0.03% 

Education 14.7% 18.8% 10.6%* 

Educational conferences 2.3% 2.8% 1.8% 

Reading about medicine 2.1% 2.8% 1.3%*+ 

Rounds 9.7% 12.2% 7.3%*+ 

Teaching students 0.6% 1% 0.3% 

Indirect patient care 63.6% 61.2% 66.1%* 

Reviewing patient chart 14.5% 14.7% 14.3% 

Writing notes 16.1% 13.1% 19.1% 

Talking with providers 20% 20.5% 19.5% 

Paperwork 3.8% 1.5% 6.1%*+ 

Writing orders 6.4% 7.3% 5.4% 

Handoffs 2.9% 4% 1.7%*+ 

Transport


Poster Title: In the Wake of the 2003 and 2011 Duty Hours Rules, How Do Internal Medicine Interns Spend Their 

Time? 

Authors and Affiliate Institutions: Leonard Feldman, Lauren Block, Albert W Wu, Sanjay V Desai, Timothy 

Niessen, Kevin Wang, Johns Hopkins University School of Medicine; Robert Habicht, Kathryn Novello Silva, 

Nora Oliver, University of Maryland School of Medicine 


Leonard S. Feldman, MD 




Johns Hopkins University School of Medicine 

600 North Wolfe Street 

Nelson 215 

Baltimore, MD 21287 

Telephone: (443) 287-3135 

Email: LF@jhmi.edu 

Background: The 2003 and 2011 ACGME common program requirements compress busy inpatient schedules and 

increase intern supervision at the same time that residents wrestle with the effects of electronic medical record 

systems, including documentation needs and availability of an ever-increasing amount of stored patient data. 

Aim: In light of this environment, we conducted a time motion study to determine how internal medicine residents 

spend their time in the hospital. 

Methods: Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs 

at large academic medical centers in Baltimore, MD during January, 2012. Twenty-nine interns from the two 

residency programs participated. The primary outcome was percent of time spent in direct patient care (talking with 

and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and 

miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis 

adjusted for clustering at the observer and intern levels. 

Results: Interns were observed for a total of 439 hours at Site 1 and 434 hours at Site 2. Interns spent 12% of their 

time in direct patient care, 64% in indirect patient care, 15% in educational activities, and 9% in miscellaneous 

activities. Computer utilization occupied 40% of their time. There was no significant difference in time spent in 

these activities between the two sites. 

Discussion or Conclusion: Interns today spend a minority of their work time in direct contact with patients. 

Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient 

care and sleeping, and proportionally more time talking with other providers and documenting. Reduced work 

hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased 

supervision may limit the amount of time interns spend with patients. 



Poster Title: Do Teaching Styles Matter in Internal Medicine Residency Training? 

Authors and Affiliate Institutions: Phuong Ho, Burton Lee, Sailaja Pindiprolu, Washington Hospital Center 


Phuong D. Ho, MD 

Fellow 

Division of Pulmonary and Critical Care 

Department of Medicine 

MedStar Washington Hospital Center 

110 Irving Street, NW 

Washington, DC 20010 

Telephone: (202) 877-7856 

Email: phuong.d.ho@medstar.net 

Background: Deslauriers et al. demonstrated that a model that included pre-class reading assignments and quizzes, 

small group active learning, and targeted in-class instruction and feedback increased learning1. This has been the 

teaching model in our MICU for the past 10 years. The same attendings also taught on the pulmonary elective 

using traditional daily rounds with bedside teaching and ad hoc talks. This is supplemented by traditional didactic 

noon conferences. 

Aim: To assess whether these different styles affected In-Training Exam (ITE) scores. 

Methods: Retrospective review of 1st and 3rd year ITE results for the past five years. We collected each 

resident’s % of overall questions and combined pulmonary/critical care (PCC) questions answered correctly. Using 

the objectives, we divided the PCC questions into pulmonary and critical care, and determined the % correct for 

each. We reviewed their schedules to determine whether they had MICU and pulmonary rotations. We compared 

the % of questions answered correctly (overall, PCC, pulmonary only, and critical care only) with their exposure to 

the MICU and pulmonary electives. 

Results: A total of 95 residents (190 ITE score reports) were included. While all residents had at least 2 MICU 

rotations, only 43% had a pulmonary rotation by their 3rd year ITE. Overall ITE, PCC, pulmonary only and 

critical care only scores all significantly improved from year 1 to year 3. There was a greater improvement in 

critical care only scores vs. pulmonary only scores (17.0% vs. 8.3%, p= 0.004) and this difference was statistically 

significant. In addition, the improvement in critical care only scores was greater than the improvement in the 

overall scores (17.0% vs. 9.2%, p=0.001). There was no difference in 3rd year ITE overall, PCC, pulmonary 

only or critical care only scores between residents who had and did not have a pulmonary elective. In addition, 

having a pulmonary rotation also made no difference on rates of improvement on ITE overall, PCC, pulmonary 

only or critical care only questions between the 1st year and 3rd year ITEs. 

Discussion or Conclusion: These results suggest that pre-assigned reading, small group interactive problem 

solving and direct feedback is more effective than rounds and conferences. We hope to change the educational 

structure on pulmonary to emulate the MICU model. 


Resident Advising: A Three-Year Follow-Up 

Tresa M McNeal, MD 1,2 , Austin Metting, MD 1,2 , Maybelline Lezama, MD 1,2 , Curtis Mirkes, DO 1,2 

1 

Texas A&M Health Science Center College of Medicine, 2 Scott & White Healthcare, Temple, Texas 

Introduction 

A resident advising program can serve a useful purpose in providing 

guidance to residents on many potential topics. The July 2009 

ACGME guidelines charged internal medicine residencies with the 

“development of an effective resident advising program.” (II.A.4.t.) 

Residencies throughout the U.S. have instituted advising programs 

within different frameworks at their institutions. 

Background 

The Scott & White Healthcare/Texas A&M Health Science Center 

(S&W/TAMHSC) Internal Medicine Residency pairs incoming 

interns with faculty advisors in the intern’s area of interest. The 

resident advising requirement has now been in effect for 3 years so 

we surveyed internal medicine residents and recent graduates at 

S&W/TAMHSA to determine the effects of the program. 

Suggestions for dealing with 

stressors 

Work‐life balance 

Subspecialty/job application 

Scholarly activity 

What to look for in a practice 

Topics Discussed with 

Advisors 

2012 all respondents 

2012 PGY4 

2012 PGY3 

2012 PGY2 

Results 

26 of 32 (91%) total surveys were returned 

• 10 PGY-2 (63%) 

• 10 PGY-3 (63%) 

• 6 PGY-4 (43%) 

There were 13 male and 13 female responses. 

92% were comfortable contacting their advisor with concerns. 

42% shared interests with their advisor outside of medicine. 

88% stated that most communication with their advisor was in person. 

Most commonly discussed topics were (multiple responses were allowed): 

• Subspecialty or job application (58%) 

• Work-life balance (50%) 

• What to look for in a practice (50%) 

• Scholarly activity (50%) 

15% of all respondents felt that that their interaction with their advisor was not 

adequate. 

Of the recent graduates who responded, 50% reported that they 

changed their career direction based on interactions with their 

advisor. 

Methods 

A 12-question, multiple choice response and free text survey was sent 

to 32 PGY-2 and PGY-3 residents and 14 PGY-4 recent graduates at 

the TAM/HSC Internal Medicine Residency Program in October 

2012 with a goal of program evaluation and improvement. Questions 

centered on discovering resident perceptions regarding the advising 

program in terms of the usefulness of these interactions as well as 

suggestions for improvement. Results were collected and analyzed 

for any trends in responses. 

Board preparation 

0 10 20 30 40 50 60 70 

Percent of Residents Indicating Each Topic Discussed with 

their Advisor (multiple responses allowed) 

Conclusion 

Based on results from this small number of respondents, the resident advising 

program is serving a useful purpose in guiding residents through career 

development. Future directions may include a multi-institutional survey regarding 

resident advising programs.


Poster Title: Resident Advising: A Three-Year Follow-Up 

Authors and Affiliate Institutions: Tresa M McNeal, Maybelline Lezama, Austin Metting, Curtis R Mirkes, 

Texas A&M University College of Medicine 


Tresa M. McNeal, MD 

Assistant Professor, Associate Program Director 

Division of Inpatient Medicine 



2401 South 31st Street 

Temple, TX 76508 

Telephone: (254) 724-8797 

Email: tmcneal@sw.org 

Background: A resident advising program can serve a useful purpose in providing guidance to residents on many 

potential topics. The July 2009 ACGME guidelines charged internal medicine residencies with the “development of 

an effective resident advising program.” (II.A.4.t.) Residencies throughout the U.S. have instituted advising 

programs within different frameworks at their institutions. The Scott & White Healthcare/Texas A&M Health 

Science Center (S&W/TAMHSC) Internal Medicine Residency matches incoming interns with faculty advisors in 

the intern’s area of interest. 

Aim: The resident advising requirement has now been in effect for 3 years so we surveyed internal medicine 

residents and recent graduates at S&W/TAMHSC to determine the effects of the program. 

Methods: A 12-question, multiple choice response and free text survey was sent to 32 PGY-2 and PGY-3 residents 

and 14 PGY-4 recent graduates at the S&W/TAMHSC internal medicine residency program in October 2012 with a 

goal of program evaluation and improvement. Questions centered on discovering resident perceptions regarding 

the advising programs in terms of the usefulness of these interactions as well as suggestions for improvement. 

Results were collected and analyzed for any trends in responses. 

Results: A total of 26 surveys were returned, 10 each of PGY-2 and 3 responses and 6 PGY-4 responses. There 

were an equal number of responses from male and female residents and recent graduates. Overall, only 15% felt 

that the interaction with their advisor was not adequate to meet their career development needs. Ninety-two percent 

would feel comfortable contacting their advisor with a concern. Interestingly, 42% of respondents reported not only 

having similar interests as their advisor within medicine but also outside of medicine. The topic most commonly 

discussed with advisors was subspecialty or job application with 58% of respondents indicating this. The majority 

(88%) indicated that they typically communicated in person although 27% also communicate with text messaging. 

Of the recent graduates who responded, 50% reported that they changed their career direction based on interactions 

with their advisor. 

Discussion or Conclusion: Based on results from this small number of respondents, the resident advising program 

is serving a useful purpose in guiding residents through career development. Future directions may include a multiinstitutional 

survey regarding resident advising programs. 



Poster Title: An Ambulatory Clinic Intervention to Improve Resident Physician Confidence with the Advance 

Care Planning Process 

Authors and Affiliate Institutions: Ericka Tung, Jason Post, Mark Wieland, John Bundrick, Thomas Jaeger, 

Karen Mauck, Matthew Thomas, Kris Thomas, Mayo Clinic Rochester; Brandon Verdoorn, University of Colorado 



Jason A. Post, MD 

Instructor 


Mayo Clinic Rochester 



Telephone: (507) 284-2511 

Email: post.jason@mayo.edu 

Background: Primary care providers play a key role in advance care planning (ACP), yet studies indicate many 

providers lack ACP training and feel uncomfortable discussing end of life care. 

Aim: To assess internal medicine (IM) residents’ ACP practices and improve resident confidence with ACP 

utilizing a multifaceted educational intervention. 

Methods: During one continuity clinic session in January 2012, residents participated in a quality review of ACP, 

including small group discussion, guided self-reflection, didactic teaching, and ACP chart audit on their patients 

aged ≥65. Patient and provider variables were collected to explore associations between these measures and 

documentation of ACP. A pre- and post-intervention survey assessed resident confidence with ACP activities. 

Descriptive statistics were generated for survey results and chart audits. Fisher’s exact test was utilized to compare 

pre and post-intervention survey results. Multivariate logistic regression models were used to determine 

associations between ACP completion and patient and provider variables. This study was deemed exempt by Mayo 

Clinic’s IRB. 

Results: Of 144 categorical IM residents, 106 (74%) participated in the sessions, of which 92% completed pre-post 

surveys and guided chart audit (873 charts reviewed, mean 8.6 charts per resident). Only 24% of audited patients 

had an advance directive (AD) on file; 11% had ACP documentation at the last comprehensive examination; and 

28% of ACP documentation was reported of “no clinical utility.” Senior residents were less likely to document 

ACP (OR 0.21, p


Poster Title: Generalist Career Outcomes of University of California Davis Graduates: A Longitudinal Study 

Authors and Affiliate Institutions: Ruby Shah, Anthony Bhe, Tonya Fancher, University of California Davis, 



Ruby P. Shah, MD 

Primary Care Outcomes Research Fellow 


University of California, Davis, School of Medicine 

4150 V Street, Suite 2400 

Sacramento, CA 95817 

Telephone: (916) 734-5290 

Email: ruby.shah@ucdmc.ucdavis.edu 

Background: The number of medical school graduates choosing primary care internal medicine (IM) has 

plummeted since 1985. UC Davis School of Medicine (UCDSOM) was founded in 1966 with an overarching goal 

of “maintaining one of the best generalist physician training programs in the country. However, little is known 

about graduates’ career outcomes. 

Aim: 1) To examine the number of UCDSOM graduates practicing in primary care careers or medically 

underserved areas post-residency; and 2) to determine if educational experiences at UCDSOM are associated with 

graduates entering these careers. 

Methods: We conducted a longitudinal cohort study of all UCDSOM graduates from 2004-2008 (N=454) and 

determined their post-residency practice specialty and practice setting. Using logistic regression, we examined the 

association between post-residency career setting or specialty adjusting for research experience during medical 

school, student run clinic participation, gender, race, ability to speak more than one language, total dollar debt at 

graduation, , and performance on the MCAT, USMLE 1 and 2. 

Results: We found that post-residency 27.9% of UCDSOM graduates were practicing primary care and 37.2% 

were in medically underserved areas; 6.6% were in primary care IM and 12% were practicing IM sub-specialties. 

We found that graduates who participated in a student-run clinic (OR 2.15, 95% CI 1.16-3.99) and women 

graduates (OR 1.83, 95% CI 1.09-3.07) were more likely to be in primary care careers post-residency. Graduates 

who participated in research experiences during medical school were less likely to be in primary care careers (OR 

0.52, 95% CI 0.32-0.86). There was no significant association between debt at graduation and eventual practice in 

primary care or medically underserved areas. Graduates who speak more than one language were more likely to 

practice in medically underserved areas (OR 1.91, 95% CI 1.14-3.23). Student race, performance on the MCAT or 

USMLE, research activity or participation in student run clinics during medical school were not associated with 

post-residency practice in medically underserved areas. 

Discussion or Conclusion: Many students participate in UCDSOM student run clinics and go on to practice 

primary care. Gender, ability to speak more than one language, and research experience are also associated with 

career outcomes which is consistent with prior studies. Program directors seeking to identify applicants who are 

likely to enter primary care or medically underserved areas may choose to focus on these characteristics. 


Flight Risk: Predictors of Contemplating Resignation Among Internal Medicine Program Directors 

Sara L. Swenson, MD † , Richard Shaw, PhD † , Vineet M. Arora, MD ‡ , Andrew J. Halvorsen, MS € , Michael Adams, MD*, Kevin T. Hinchey, MD**, Sandhya Wahi‐Gururaj, MD***, Furman S. McDonald, MD, MPH € APDIM Survey Committee 

† California Pacific Medical Center, 

‡ University of Chicago Pritzker School of Medicine, *Georgetown University School of Medicine, **Baystate Medical Center, ***University of Nevada School of Medicine, 

€ Mayo Clinic College of Medicine 

Introduction 

National internal medicine program directors exhibit high 

job turnover with almost 40% of program directors 

reporting three or fewer years in the job in 2010. Fiscal 

constraints and regulatory requirements may heighten 

pressures on program directors. We hypothesized that 

program directors’ perceptions of support by key 

institutional leaders might play an important role in job 

sustainability. 

Discussion 

• large national sample 

Strengths 

Limitations 

• unknown predictive value of primary outcome variable 

• institutional support questions not previously validated 

Methods 

National survey of 365 internal medicine program directors 

in August‐November of 2011 

• Response rate 72% (261/365 IM programs surveyed) 

Implications 

• increasing residency program budget transparency and institutional 

support by key leaders may help to mitigate high turnover among internal 

medicine program directors 

• GME organizations, such as APDIM, should consider ways to support 

program directors at high flight risk 

• Sample size for this data analysis: 244 

Primary outcome variable: “In the past year, have you 

considered resigning as program director?” 

Independent variables: 

Program director characteristics (age, sex, length of tenure, 

salary, time since training, percent protected time) 

Program characteristics (community vs. university, cycle 

length 

Perceptions of key leaders, institutional support, budgetary 

control 

Perspectives on 2011 duty hours requirements 

Duty hours and institutional support assessed using 5‐point Likert 

scale items 

Statistical analyses: 

Bivariate: Kendall’s b‐tau 

Multivariable logistic regression model included statistically 

significant (P


Poster Title: Thinking of Quitting: Predictors of Considering Resignation Among Internal Medicine Program 

Directors 

Authors and Affiliate Institutions: Sara L Swenson, Richard Shaw, California Pacific Medical Center; Michael 

Adams, Georgetown University School of Medicine; Sandhya Wahi-Gururaj, University of Nevada School of 

Medicine (Las Vegas); Kevin Hinchey, Baystate Medical Center; Vineet Arora, University of Chicago Pritzker 

School of Medicine; Furman McDonald, Mayo Clinic College of Medicine 


Sara L. Swenson, MD 

Interim Program Director 


California Pacific Medical Center 

2351 Clay Street, Third Floor 

San Francisco, CA 94115 

Telephone: (415) 600-2767 

Email: swensosl@sutterhealth.org 

Background: Turnover among internal medicine program directors is high. Fiscal constraints and regulatory 

requirements may heighten pressures on program directors. We hypothesized that program directors’ perceptions of 

support by key institutional leaders may have an impact on job sustainability. 

Aim: Our study investigated how many internal medicine program directors had considered resigning from their 

jobs in the past year and the predictors of contemplating resigning. 

Methods: Using the 2011 annual APDIM survey, we asked internal medicine program directors: “in the past year, 

have you considered resigning as program director?” We investigated univariate and multivariable predictors of 

intent to resign, including program and program director characteristics and perceptions of institutional support. 

Institutional support items used 5-point Likert scales to assess perceptions of program director control of their 

budget, key institutional leaders’ valuation of service versus education, disagreements with key leaders, and support 

for 2011 duty hours requirements. For univariate analyses, we employed Kendall’s b-tau and ANOVA for 

categorical and linear variables, respectively. We evaluated multivariable predictors via logistic regression. 

Results: Forty-six percent of respondents considered resigning as program director in 2011-12. Univariate analysis 

demonstrated associations between intent to resign and program director sex (female 61%, male 39%), support of 

duty hours regulations, and perceptions of institutional support. On multivariable analysis, independent predictors 

of contemplating resigning were female sex (AOR 2.37; 95% CI 1.03, 5.43), lack of philosophical support for duty 

hours changes (4.80; 1.36, 16.90), the perception that disagreements with key hospital leaders had a negative 

impact on job satisfaction (2.88; 1.09, 7.60), and lack of transparency regarding residency-related funding (0.34; 

0.14, 0.87). Hospital administrators were more likely to prioritize service over education (56% vs. 9%) than were 

department chairs (40% vs. 12%) (p

The Educational Innovations Project (EIP) - Association between Residency 

Program Participation and Medical Education Publications 

Kris G Thomas 1 , Andrew J Halvorsen 1 , Colin P West 1 , Eric J Warm 2 , Jerry Vasilias 3 , Eileen E Reynolds 4 , John G.Frohna 5 , Furman S McDonald 1 

1 Mayo Clinic, 2 University of Cincinnati, 3 Accreditation Council for Graduate Medical Education, 4 Beth Israel Deaconess Medical Center, 5 University of Wisconsin 

 

 

 

Background 

The Educational Innovations Project (EIP) is an 

Accreditation Council for Graduate Medical 

Education (ACGME) initiative meant to spur 

innovation and dissemination of outcomes 

among participating IM residency programs. 1 

Since its inception in 2006, a collaborative 

community has been established among EIP 

programs that may facilitate innovation and 

scholarship. 

A number of presentations and publications 

have been disseminated from EIP 

programs 2,3,4,5 though it is unclear whether 

education scholarship productivity of EIP 

programs differs from similar non-participating 

programs. 

Study Objectives 

• To determine if the number of education 

publications generated from EIP programs 

differs from that of similar non-EIP programs. 

• To compare the proportion of EIP-participating 

and EIP-eligible programs with at least one 

publication. 

• To determine if the impact factor of journals 

publishing education scholarship generated 

from EIP programs differs from that of similar 

non-EIP programs 

Methods 

Design: 

•Controlled cohort study comparing internal medicine GME 

publications from EIP-participating (n=21) and EIP-eligible (n=80) 

programs, using program director (PD) authorship as a surrogate 

marker. 

•During the study period, 3 programs stopped participating in EIP 

and 5 eligible programs withdrew accreditation, leaving 18 

participating and 75 eligible programs (37 and 129 PDs, 

respectively) for inclusion. 

Search Strategy: 

•The medical literature was searched using Pub Med via a search 

strategy linking all PD names from EIP-participating and EIP-eligible 

programs as authors AND (internal medicine[mesh] OR "graduate 

medical education" OR education, medical, graduate[mesh] OR 

internship and residency[mesh]), limited to publication dates 2002- 

2011. 

•The literature search returned 300 publications, of which 3 were 

excluded due to mismatched author initials, leaving 297 matched 

publications, 239 (80.5%) of which were authored by the PD during 

a year of their tenure at a program (Figure 1). 

Figure 1: GME publications returned by 

the literature search 

28 

Participating 

(1.6/program) 

84 

PRE-initiative 

(2002-2006) 

300 articles returned by 

literature search 

(166 PD names) 

61 excluded 

3 author initial mismatch 

58 outside PD years of 

tenure 

239 articles 

authored during 

PD tenures 

56 

Eligible 

(0.8/program) 

76 

Participating 

(4.2/program) 

155 

POST-initiative 

(2007-2011) 

79 

Eligible 

(1.1/program) 

Demographic Characteristics of EIP- 

Participating and EIP-Eligible Programs 

Number of 

Program 

Directors, Mean 

(SD) 

Years of PD 

Tenure, Mean (SD) 

% ABIM Pass 

Rate, Mean (SD) 

Approved 

Residency 

Positions, Mean 

(SD) 

EIP-Participating 

Programs (N=18) 

EIP-Eligible 

Programs (N=75) 

References 

P Value 

2.1 (0.9) 1.7 (0.8) 0.19 

11.0 (5.1) 11.3 (6.1) 0.86 

91.2 (6.7) 89.6 (7.3) 0.40 

101.4 (49.0) 69.5 (35.3) 0.02 

Region 0.17 

Midwest 10 (55.6%) 24 (32.0%) 

Northeast 4 (22.2%) 31 (41.3%) 

South 1 (5.6%) 12 (16.0%) 

West 3 (16.7%) 8 (10.7%) 

Type Program 0.32 

Community-based 0 (0.0%) 6 (8.0%) 

Community-based, 7 (38.9%) 40 (53.3%) 

University-affiliated 

Military 0 (0.0%) 1 (1.3%) 

University-based 11 (61.1%) 28 (37.3%) 

No government 15 (83.3%) 56 (74.7%) 0.80 

affiliation 

1. Mladenovic J, Bush R, Frohna J. Am J Med. 2009;122(4):398-404. 

2. Warm EJ, Schauer DP, Diers T, et al. Journal of General Internal Medicine. 

2008;23(7):921-6. 

3. Mathis BR, Warm EJ, Schauer DP, et al. Journal of General Internal Medicine. 

2011;26(11):1253-7. 

4. McCoy CP, Halvorsen AJ, Loftus CG, et al. Mayo Clin Proc. 2011;86(3):192-6. 

5. Tess AV, Yang JJ, Smith CC, et al. Academic Medicine. 2009;84(3):326-34. 

6. Nasca TJ, Philibert I, Brigham T, Flynn TC. NEJM 2012. 

Results: Publications from EIP and Eligible 

Programs and Their Program Directors (PD) 

Pre-EIP (2002-2006) 

EIP- 

Participating 

Programs 

(N=18) 

EIP- 

Eligible 

Programs 

(N=75) 

P Value 

Prevalence of Publication 

N (%) Publishing 10 (55.6%) 25 (33.3%) 

OR of Publication 2.5 - 0.09 

Number of Publications 

Maximum Per Program 18 8 

Maximum Per PD 12 8 

Median (IQR) Per Program 1 (0-2) 0 (0-1) 0.13 

Median (IQR) Per PD 0 (0-1) 0 (0-0) 0.25 

2011 Impact Factor, Mean (SD) 5.9 (6.5) 4.8 (6.4) 0.48 

Post-EIP (2007-2011) 

Prevalence of Publication 

N (%) Publishing 15 (83.3%) 25 (33.3%) 

OR of Publication* 10.0 - 0.0007 

Number of Publications 

Maximum Per Program 34 23 

Maximum Per PD 29 23 

Median (IQR) Per Program 2 (1-4) 0 (0-1)


Poster Title: The Educational Innovations Project (EIP)—Association Between Residency Program Participation 

and Medical Education Publications 

Authors and Affiliate Institutions: Kris Thomas, Andrew Halvorsen, Colin West, Furman McDonald, Mayo 

Clinic College of Medicine; Eric Warm, University of Cincinnati College of Medicine; Jerry Vasilias, 

Accreditation Council for Graduate Medical Education; Eileen Reynolds, Harvard Medical School Beth Israel 

Deaconess Medical Center; John Frohna, University of Wisconsin School of Medicine 


Kris G. Thomas, MD 


Division of Primary Care Internal Medicine 


Mayo Clinic College of Medicine 



Telephone: (507) 284-2511 

Email: thomas.kris@mayo.edu 

Background: The Educational Innovations Project (EIP) is an Accreditation Council for Graduate Medical 

Education (ACGME) initiative launched July 1, 2006 to spur innovation and dissemination of outcomes among 

internal medicine residency programs. 

Aim: To determine if the number of education publications generated from EIP- programs differs from similar 

EIP-eligible programs. 

Methods: We compared internal medicine GME publications from EIP-participating and EIP-eligible programs, 

using program director (PD) authorship as a surrogate marker. PDs from EIP-participating and EIP-eligible 

programs were identified using publically available data. PubMed was searched via a strategy linking PD names as 

authors with residency education related publications, limited to publication dates 2002-2011. The mean number of 

publications, median number of publications, and proportion with at least 1 publication (for both programs and 

PDs) were assessed across two 5-year time periods, pre-EIP (2002-06) and post-EIP (2007-11). 

Results: Twenty-one EIP-participating and 80 EIP-eligible programs were identified. During the study period, 3 

programs stopped participating in EIP and 5 eligible programs withdrew accreditation, so 18 participating and 75 

eligible programs (38 and 136 PDs, respectively) were included. The literature search returned 302 publications, of 

which 3 were excluded due to mismatched author initials, leaving 299 publications for analysis. During the pre- 

EIP, there were 38 publications by participating programs and 68 by eligible (Mean 2.2 vs. 0.9 publications per 

program, p=.22, Mean 1.2 vs. 0.5 publications per program director, p=.11). During the post-EIP, there were 94 

publications by participating programs and 99 by eligible (Mean 5.4 vs. 1.3 publications per program, p=.07, Mean 

3.0 vs. 0.8 publications per program director, p=.02). A significant increase in publications was seen among EIPparticipating 

programs relative to eligible (Mean change of +3.4 publications per program, p=.01, Mean change of 

+1.8 publications per PD, p=.02), while publications from eligible programs remained unchanged (Mean +0.4 

publications per program, p=.20, Mean +0.2 per PD, p=.17). Analysis by medians and proportion with at least 1 

publication (per program and per PD) were similar. 

Discussion or Conclusion: These data support plans by GME leaders to replicate and generalize successful 

elements of EIP in support of innovation and scholarly dissemination throughout residency programs nationally. 



Poster Title: Duty Hours Monitoring Revisited: Self-Report May Not Be Adequate 

Authors and Affiliate Institutions: Heather Thompson Buum, Alisa Duran-Nelson, L James Nixon, Jeremiah 

Menk, University of Minnesota Medical School 


Heather A. Thompson Buum, MD 




University of Minnesota Medical School 

MMC 284 

420 Delaware Street, SE 

Minneapolis, MN 55455 

Telephone: (612) 626-5868 

Email: thomp057@umn.edu 

Background: Monitoring compliance with duty hour regulations requires an accurate method of reporting. While 

self-report is a generally accepted practice, it has not been validated. Only three studies to date have been 

published evaluating the accuracy of self-report compared to another measure of resident activity. These studies 

concluded that self-report was accurate, but were limited by small numbers of residents and relatively brief study 

periods. 

Aim: We sought to verify the accuracy of daily self-reported duty hours data logged via an electronic reporting 

system, the Residency Management Suite (RMS), as well as validate RMS as a tool for tracking duty hours 

violations. 

Methods: Twenty-eight weeks of parking data and self-reported RMS data for 136 resident rotations were 

compared, spanning from December 12, 2011 to June 27, 2012. An intercept-only model with a random effect for 

correlation within person was used to compare the hours parked per day versus self-report hours. The number of 

duty hour violations in the two sets of data was compared using McNemar’s test. 

Results: The daily mean self-report hours was 0.745 longer than the mean hours parked (95% CI: [0.538--0.953], p 

< 0.001), a difference likely accounted for by offsite continuity clinics. No significant difference was detected 

regarding the 80-hour violations in the two sets of data; however, a greater number of 8-hour and 16-hour violations 

were observed in the parking card data compared to self-report data (p


Poster Title: Patient Census: What is Optimal for Educational Satisfaction and Quality of Care Balance? 

Authors and Affiliate Institutions: Megan Ramsey, Laurel Fick, St. Vincent Hospital and Health Care Center 


Laurel Fick, MD 


Division of Internal Medicine 

Department of Medical Education 

St. Vincent Hospital and Health Care Center 

2001 West 86th Street 

Three North, Medical Education 

Indianapolis, IN 46260 

Telephone: (317) 338-7622 

Email: lbfick@stvincent.org 

Background: To our knowledge there have been no previous studies correlating daily patient census with 

educational satisfaction and perceived patient care quality in the teaching hospital setting. 

Aim: The purpose of this study was to determine the teaching census that provides the best balance of quality 

patient care and educational satisfaction as perceived by teaching faculty and resident physicians. 

Methods: This IRB-approved study surveyed hospitalist faculty and Internal Medicine residents at our mediumsized 

community-based training program at a tertiary care hospital in the Midwest. The electronic survey tool 

asked each respondent to identify the daily team patient census at which the quality of patient care/education 

balance is optimal as well as the census at which this balance becomes suboptimal. It then asked the physicians to 

qualify how his or her overall work experience is affected by patient census and to state if they had ever had a poor 

patient outcome they attributed to being overextended from a high census. 

Results: Seventy-two percent of academic hospitalists and 64% of residents completed the survey. Among 

faculty, 95% responded that the census at which the patient care/educational balance is optimal is 12-15 for a team 

consisting of one resident and two interns. Sixty-seven percent of residents agreed that an optimal census is 12-15. 

For teams consisting of 1 resident or intern, 77% of faculty and 65% of residents felt that an optimal census was 12 

or less. In both surveys only 1 respondent felt that a census over 15 was optimal. Nearly one hundred percent of 

hospitalists and residents felt faculty teaching decreased, quality of care decreased, career satisfaction decreased 

when the census was high. Thirty-eight percent of faculty and 51% of residents attributed a poor patient outcome to 

being overextended from a high census. 

Discussion or Conclusion: This pilot study suggests that the current ACGME census caps may be higher than is 

optimal for balancing educational satisfaction and quality patient care. A team census cap of 15 patients (for one 

resident/two intern teams) may be more favorable for training programs of similar size and structure. Most 

concerning is the high percentage of physicians that felt a poor patient outcome was related to high census. It 

would be interesting to objectively study this perception in the future. 


Introduction 

The Triple Threat: Novel Hospitalist‐Track Electives 

Kapil Mehta MD, Teresa Hogue MD, Laurel Fick MD, FACP 

St. Vincent Hospital‐ Indianapolis 

Advanced Hospitalist Medicine 

Results 

Hospitalists are increasingly involved in hospital 

operations, administration, and practicing in distinctive 

areas of medicine. Given this trend, our Curriculum 

Committee created three new electives for our Internal 

Medicine Hospitalist Track to facilitate the development of 

diverse yet uniquely trained physicians. 

Administrative Medicine 

Two to four-week elective that offers senior residents 

exposure to the business and quality aspects of hospital 

leadership. 

Experiences include: 

• Hospital Operations: Quality Assurance, 

Regulatory Compliance, Business Development 

and Lean Methodology, Performance Metrics 

• Patient Safety: Medication Safety, Principles of a 

High Reliability Organization(HRO) 

• Principles of physician leadership 

• Legislative Medicine 

• Hospital Meetings/Committee management 

Four- week elective that offers residents a “menu” of 1-2 

week sub-rotations based on their interest and perceived 

need for additional training. 

Current options for experiences include: 

•Pre-Operative Medicine 

• Observation Unit Medicine 

• Advanced Neurology 

• Inpatient Geriatrics 

• Orthopedic Hospitalist Medicine 

• Inpatient Billing and Coding 

Informatics 

Two to four-week elective with the Chief Informatics Officer 

and Information Technology (IT) team to participate in 

the development and implementation of the electronic 

health record and to learn how IT enables the effective 

collection of data to develop medical knowledge and to 

facilitate the delivery of patient care. 

“This rotation allowed me to get exposure to prepare for 

being a hospitalist. I feel more comfortable with 

billing/coding, and made the transition much smoother. 

Due to this rotation, I also developed interest in preoperative 

medicine and am currently doing pre-operative 

consultations/risk assessment.” 

To date one graduate who completed these electives has 

begun a hospitalist career involving both administrative 

medicine and informatics . 

Conclusions 

These elective rotations are easy to implement and 

customizable based on the facilities, staffing, resident 

interest, and specialty options unique to each residency 

program and/or hospital. Future directions may include 

development of an Administrative Medicine Track.

Programmatic Innovation Poster Abstracts 


Poster Title: The Triple Threat—Novel Hospitalist-Track Electives 

Authors and Affiliate Institutions: Kapil Mehta, Teresa Hogue, Laurel Fick, St. Vincent Hospital and Health 

Care Center 


Laurel Fick, MD 


Division of Internal Medicine 

Department of Medical Education 



Three North, Medical Education 


Telephone: (317) 338-7622 

Email: lbfick@stvincent.org 

Discussion of How the Problem was Identified and Explored: Hospitalists are increasingly involved in hospital 

operations, administration, and practicing in distinctive areas of medicine. Given this trend, in 2011 our Curriculum 

Committee created three new electives for our Internal Medicine Hospitalist Track to facilitate the development of 

diverse yet uniquely trained physicians. 

Description of the Innovation: Administrative Medicine- Two to four-week elective that offers senior residents 

exposure to the business and quality aspects of hospital leadership. Residents rotate with the Hospitalist Director 

and obtain experience in Hospital Operations, Patient and Medication Safety, Leadership, and Legislative 

Medicine. Informatics- Two to four-week elective with the Chief Informatics Officer and Information 

Technology (IT) team to participate in the development and implementation of the electronic health record and to 

learn how IT enables the effective collection of data to develop medical knowledge and to facilitate the delivery of 

patient care. Advanced Hospitalist Medicine (AHM)- Four- week elective that offers residents a “menu” of 1-2 

week sub-rotations based on their interest and perceived need for additional training. Current options for 

experiences include: o Pre-Operative Medicine o Observation Medicine o Advanced Neurology o Inpatient 

Geriatrics o Orthopedic Hospitalist Medicine o Inpatient Billing and Coding. 

Results to Date: Post-rotation surveys were administered to all rotators with positive results. Administrative 

medicine (2 rotators to date) and Informatics (1 rotator to date) each had an average of 5 (on a 5 point Likert scale) 

when asked if this rotation was valuable for the resident’s medical education, 4 out of 5 when asked if the rotation 

was organized sufficiently. To date, one rotator for both of the above rotations has since completed residency has 

entered into a career including both administrative and informatics responsibilities. AHM (10 rotators to date)- 

All sub-rotations achieved at least a 5 (on 1-6 Likert scale) when asked “The components of this rotation provided 

knowledge and experiences missing in other rotations of the required residency curriculum.”. There were no 

negative comments or scores for any sub-rotation or the rotation as a whole. Free text comments were extremely 

positive for all three novel rotations. 

Discussion/Reflection/Lessons Learned: Our program identified a need for advanced experiences in 

administrative medicine, informatics, and hospitalist medicine and created three novel electives with very positive 

results to date. These elective rotations are easy to implement and customizable based on the facilities, staffing, 

resident interest, and specialty options unique to each residency program and/or hospital. 



Poster Title: Procedural Competence: From See One, Do One, Teach One to an Entrustable Professional Activity 

Authors and Affiliate Institutions: Alisa Duran-Nelson, Sophia P Gladding, L James Nixon, University of 

Minnesota Medical School 


Alisa Duran-Nelson, MD 



University of Minnesota Medical School 

420 Delaware Street, SE 

MMC 284 


Telephone: (612) 626-4603 

Email: duran012@umn.edu 

Discussion of How the Problem was Identified and Explored: The ACGME’s Outcome Project launched a 

transition from focusing on the processes to the outcomes of training. The ACGME competencies have been refined 

to program specific developmental milestones to be achieved by trainees during their training. Educational leaders 

have looked to Entrustable Professional Activities (EPAs) as a framework to tie these concepts together. We have 

been challenged with creating EPAs that support the development and assessment of our trainees in areas of 

essential clinical practice. 

Description of the Innovation: Our educational committee, composed of educators with expertise in competencybased 

education and assessment, developed a Procedural EPA. Using levels of entrustment described previously by 

Ten Cate (reference), we defined criteria for advancement to each level of entrustment. The criteria included: 

assessment environment (simulated vs. actual), assessment by procedural checklist and/or knowledge test, level of 

assistance required of instructor (hands on, verbal, no assistance), and resident’s self-assessment of confidence for 

each procedure. We piloted this EPA with 32 interns in our Beside Ultrasound Course. In this course, we train 

residents in simulated ultrasound-guided procedures including: central venous catheters, arterial lines, paracentesis 

and thoracentesis. For advancement to level 2 entrustment, each intern had to pass the knowledge test at the end of 

the course, and correctly complete all four procedures under the supervision of instructors. 

Results to Date: One hundred percent of our interns correctly completed the required procedures in the simulation 

environment and passed the knowledge assessment at the end of the course. Consequently, all of the interns 

advanced to level 2 entrustment (able to perform in actual practice under full supervision) for the procedures. 

Discussion/Reflection/Lessons Learned: Residents’ ability to perform common procedures independently by 

graduation is a critical outcome of residency training. Until now little has been done to assess residents’ procedural 

competence beyond logging of procedures. Our Procedural EPA demands careful observation and assessment of 

residents’ skills, and purposeful entrustment as skills develop. While we only piloted initial advancement to Level 

2 entrustment, time will yield more information on the number of procedures needed for advancement, rates of 

progression for residents to higher levels of entrustment, as well as patient outcomes and complications reported for 

residents at different levels of entrustment. 


Transitions of Care: A New Curriculum to Promote Safer Hospital Discharges 

O. Al Sous, K. Ramdeen *, V. Abiraj, M. Akce, J. Hopper 

St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA 

*University of North Dakota 

Introduction 

Background 

Objectives 

Process Description 

Results 

Care coordination, 

including transitions 

of care, has been 

recognized by the 

Institute of 

Medicine as a 

national priority 

area for quality 

improvement. (1) 

Ineffective 

handovers at 

hospital discharge 

seriously impede the 

quality and safety of 

patient care, as well 

as pose a significant 

financial burden. (2) 

Safe hospital 

discharge is always a 

major concern, 

particularly in the 

early academic year 

when new interns 

and residents are 

practicing their roles 

for the very first 

time. The potential 

for error is high 

during this period; 

we developed a onemonth 

Transitions 

of Care (TOC) 

rotation for the 

early PGY-2 year. 

The St. Joseph 

Mercy Hospital 

Internal Medicine 

Residency is a 

community program 

in a 537-bed 

tertiary care 

hospital in Ann 

Arbor, Michigan. 

There are 61 

residents including 

categorical and 

preliminary internal 

medicine and 

transitional year 

residents. 

Our Medicine 

Teaching Service 

(MTS) hospital 

ward team consists 

of one supervising 

physician, one 

senior resident, 

three interns and 

one or two medical 

students. Clinical 

rounds are preceded 

by brief case 

management 

rounds; where early 

discharge planning 

takes place. 

• To deliver high quality care to hospital patients. 

• To avoid preventable re-admissions. 

• To ensure resident reflective learning on transitions of care. 

• To incorporate ACGME requirement for systems-based practice. 

Expectations 

• Work within the MTS team and lead case management rounds 

and early discharge planning. 

• Provide patients with in-depth education about disease processes, 

preventive measures, medication changes and vaccination updates. 

• On admission, ensure accurate medication reconciliation and 

primary care physician (PCP) notification. 

• Assess appropriateness of discharge location. 

• Provide one on one intern supervision of the discharge process, 

including medication reconciliation, informative concise discharge 

summaries, patient counseling about new medications and follow 

up tests and appointments. 

• Follow up on any pending tests on discharge 

• Coordinating communication with primary care physicians and 

case managers regarding discharge plan. 

• For patients who do not have primary care physician, set up follow 

up appointments with the TOC resident in the resident continuity 

clinic. 

Prior to the start of the rotation, TOC residents attend an 

orientation led by a chief resident and informatics specialist. 

Expectations, curriculum and goals are reviewed. TOC residents 

taught how to keep an electronic log of primary care contacts. 

Near the end of rotation, the TOC resident facilitates a meeting 

with the MTS team, attending and chief resident to discuss 

readmissions and analyze preventability of at least one of them. 

Evaluation 

Based on ACGME milestones using Entrustable Professional 

Activities (EPA): 

• Recognize need to advocate 

for individual patient needs 

• Provide appropriate 

preventive care and teach 

patient regarding self-care 

• Effectively communicate 

plan of care to all members 

of the health care team 

• Utilize patient-centered 

education strategies 

• Manage and coordinate 

care and care transitions 

across multiple delivery 

systems 

• Engage in collaborative 

communication with all 

members of the health 

care 

Response from residents, faculty and 

interdisciplinary staff has been positive. 

Residents commented: “Good learning 

experience as a bridge between relentless 

inpatient physician efforts and outpatient 

long term health care providers. Ensuring 

more patient safety by all means”, “I will 

be utilizing this training to incorporate 

in my future role as team leader”, “Made 

sure the inpatient plans continue in 

the outpatient world”, “I learnt a lot 

regarding coordination care plans after 

discharge to make sure that patients are 

living in a safe environment in order 

to prevent relapse or readmission” 

Conclusion 

Multiple transitions of care innovations have been studied but it has been 

difficult to draw conclusions regarding best practice. (2) As more structured 

modalities are explored, residency programs should prepare physicians 

in training to practice safe discharges and adapt concise and consistent 

communication between the inpatient and the outpatient settings. For the next 

academic year, we are planning to continue TOC training for all second year 

residents prior to starting their roles as team leaders. As the ward team structure 

evolves, the hospital ward curriculum will continue to incorporate the new 

ACGME transition of care competencies. 

References 

1. Priority Areas for National Action, Transforming Health 

Care Quality. Adams K, Corrigan JM, eds. 2003, The 

National Academies Press. Accessed at: http://www. 

nap.edu/openbook.php?record_id=10593 

2. Transitional Care: Focusing on Patients-Centered 

Outcomes and Simplicity. Bray-Hall, Susan T. 6, 

s.l.: Annals of Internal Medicine, 2012, Vol. 157. 

REMARKABLE MEDICINE. REMARKABLE CARE. 

Designed and Produced by: Debi Nichols, Graphic Designer 

St. Joseph Mercy Hospital – Ann Arbor, Michigan 

Printing Services and Graphic Design Department


Poster Title: Transition of Care: A New Curriculum to Enhance Safer Hospital Discharges 

Authors and Affiliate Institutions: Ola Al Sous, Khris Ramdeen, Vishal Abiraj, Mehmet Akce, John Hopper, St. 

Joseph Mercy Hospital 


Ola Al Sous, MD 

Third-Year Resident 


St. Joseph Mercy Hospital 

5333 McAuley Drive 

Suite 3009 

Ann Arbor, MI 48106 

Telephone: (904) 651-6443 

Email: alsouso@trinity-health.org 

Discussion of How the Problem was Identified and Explored: Care coordination including transition of care has 

been recognized by the Institute of Medicine as a national priority area for quality improvement. Ineffective 

handovers at hospital discharge seriously impede the quality and safety of patient care. Safe discharge is always a 

major concern; in particular early in the academic year when new interns and second year residents are practicing 

their roles for the first time. Due to the high potential for error during this period, a one-month Transition of Care 

(TOC) rotation was developed in the PGY-2 year, July through October. The purpose is to deliver high quality 

hospital discharges allowing improved patient care and reducing rate of preventable readmissions. 

Description of the Innovation: TOC residents work within the Medicine Teaching Service (MTS) team and lead 

interdisciplinary rounds. Prior to the rotation, residents attend an orientation led by a chief resident and informatic 

specialist. The roles of TOC residents are to ensure: contact with primary care physicians, early discharge planning, 

and in-depth patient education. The TOC resident educates interns on the discharge process including medication 

reconciliation and informative concise discharge summaries. The TOC resident ensures contact with primary care 

physicians as well as case managers at patients discharge. Patients who do not have primary care physicians are 

seen by the TOC resident in the resident continuity clinic. Near the end of rotation, the TOC resident facilitates a 

meeting with the MTS team, attending and chief resident to analyze preventability of at least one readmission. 

Results to Date: Response from residents, faculty and interdisciplinary staff has been positive. Data from the first 

month of the rotation show improved communication with doctors and admission medication reconciliation. 

Discussion/Reflection/Lessons Learned: Multiple transition of care innovations have been studied but it has been 

difficult to draw conclusion regarding best practice. As more structured modalities are explored, residency 

programs should prepare physicians in training to practice safe discharges and adapt concise and consistent 

communication between the inpatient and the outpatient settings. 



Poster Title: Transitional Care: A Novel, Narrative Initiative 

Authors and Affiliate Institutions: Sandy Balwan, Sean LaVine, Saima Chaudhry, Steven Savella, Alexandria 

Atuahene, Hofstra NorthShore-LIJ School of Medicine at Hofstra University 


Sandy Balwan, MD 



Hofstra North Shore-LIJ School of Medicine at Hofstra University 

300 Community Drive 

Manhasset, NY 11030 

Telephone: (516) 562-2587 

Email: sbalwan@NSHS.edu 

Discussion of How the Problem was Identified and Explored: More than two-thirds of sentinel events in 

hospitals are caused by communication breakdowns, half during transitions. The ACGME requires residency 

programs to instruct trainees in care transitions. Traditionally the focus has been placed on intra facility transitions 

and less emphasis has been placed on transitions between inpatient and rehabilitation settings on discharge. 

Description of the Innovation: In July 2011, The Hofstra NSLIJ Residency introduced a unique transition of care 

experience as an alternative to classroom based education. Interns followed a patient they discharged to a 

rehabilitation center or skilled nursing facility (SNF). At the facility the intern reconciled discharge medications 

with SNF medications, identified new medical issues, and verified follow-up of pending tests or recommendations. 

Additionally, interns wrote a narrative on how the experience altered their understanding of transitional care, 

patient safety, and how it may impact their future practice. Two hospitalists evaluated each narrative and provided 

feedback. 

Results to Date: Fifty out of 60 interns participated. Interns identified a large number of changes to medications 

including 62% of patients having a new medication, 47% having a medication discontinued, and 28% having a 

change in dose or frequency. Thirty percent of patients had pending tests, 50% had new medical issues identified, 

and 60% required a specialty consultation. Sixty percent of interns reported their experience was very valuable in 

their understanding of the fragmentation in healthcare. Hospitalist evaluators identified two major themes in the 

intern’s reflections. First, interns reported they more fully understood the importance of handoff between facilities 

and identified procedures to improve it; second, interns reported more comfort in discussing nursing facilities with 

their patients. 

Discussion/Reflection/Lessons Learned: The experience provided an inexpensive, effective method of teaching 

transitional care that differed from traditional methods and was well received. The activity fulfills teaching in all 

six ACGME competencies and the entrustable professional activity (EPA) of safely discharging a patient. 

Hospitalist core faculty are uniquely qualified to assess and provide feedback on transitional care teaching activities 

in resident programs. 



Poster Title: Night Float Cards: An Educational Endeavor 

Authors and Affiliate Institution: Poonam Beniwal-Patel, Kathlyn E Fletcher, Medical College of Wisconsin 


Poonam Beniwal-Patel, MD 

Chief Resident 


Medical College of Wisconsin 

9200 West Wisconsin Avenue 

Cancer Center—Fifth Floor 

Milwaukee, WI 53226 

Telephone: (414) 917-2046 

Email: pbeniwal@mcw.edu 

Discussion of How the Problem was Identified and Explored: Since the implementation of the Accreditation 

Council for Graduate Medical Education (ACGME)’s new work hour policies in July 2011, more internal medicine 

residency programs have had to utilize a night float system to comply with restricted hours. With night float 

comprising a larger proportion of residency requirements, attention should be paid to its contribution to resident 

education. 

Description of the Innovation: We gave night float cards to each intern during their weeks as a night float. We 

asked interns to enter the following information on each card: patient name, question to address, source of answer, 

answer. The cards also had a space for the question to be answered. Each night float intern was instructed to 

complete at least one card per night. They could give the card to someone from a team that they had cross-covered 

or admitted to during the previous night or they could find the answer on their own. The cards were turned into the 

chief resident at the end of each month. 

Results to Date: A total of sixty-two night float cards were collected. We analyzed the interns’ questions by 

identifying the content area (i.e. cardiology) and type of question (i.e. diagnostics). The most common content 

areas were: cardiology (25%), general internal medicine (15%), pain (11.3%) and nephrology (11.3%). Interns 

most commonly asked about how to manage conditions (72%) but also commonly had questions about diagnosis 

(28%). There was a wide range of complexity in the interns’ questions. An example of a straightforward question 

was how to treat hospital acquired pneumonia in a patient with a penicillin allergy. An example of a complex 

question was how to insert an arterial line. Interns used a variety of resources to find the answer to questions: on 

call medicine resident (74%), UpToDate/Online Source (15%), consult resident/fellow (7%) and a pharmacist (4%). 

Interestingly not all of the answers provided by on-call residents were correct. 

Discussion/Reflection/Lessons Learned: We designed a simple intervention to facilitate learning while on night 

float. These data identify common questions that interns encounter while on night float rotations. There is an 

opportunity to construct an educational tool for night float interns that incorporates the most commonly-asked 

questions and also encourages independent investigation into questions using different resources. 


Improving Patient Satisfaction Outcomes, Resident Interpersonal 

Communication Skills, and Resident Feedback 

Christina R. Bergin, Cheryl W. O'Malley, Karen Alonso, Douglas Eckhardt, and Richard Gerkin 

Banner Good Samaritan Medical Center/Phoenix VA Medical Center Internal Medicine Residency Program, Phoenix AZ 

Background 

• The concept of patient satisfaction is becoming increasingly important in medicine today. 

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 

survey has standardized the assessment and public reporting of patient satisfaction. In 

addition, the ValueBased Purchasing Program by the Centers for Medicare and Medicaid 

Services links various outcomes, including patient satisfaction, to reimbursement. 

• Such public attention stems from evidence that difficulties in physicianpatient 

communication contribute to patient dissatisfaction with medical care, malpractice suits, 

discontinuity of care, and reduced compliance with treatment regimens. 

• Conversely, improved communication and increased patient satisfaction have been 

linked to improved continuity of care and patient compliance, decreased readmission 

rates, and even improvement in various health outcomes. 

• To help identify members of the teaching service, an information sheet describing the 

teaching service is provided to patients (Figure 4), and a monthly picture roster is 

distributed to nursing staff. 

• Every four months, a comprehensive report is compiled for each resident with their 

survey results, enabling them to identify strengths and to address any identified 

deficiencies, with the goal of improving performance (Figure 5). 

• A high percentage of residents reported "always" or "usually" utilizing several key 

strategies that can enhance patient satisfaction (Figure 9). However, other techniques 

remain underemployed despite discussion of their merits (Figure 10). 

Figure 9. Frequency of Commonly Utilized Strategies by Residents 

How the Problem was Identified and Explored 

• Residents are important providers of patient care on the inpatient teaching service, and 

therefore they create opportunities for directly impacting patient satisfaction. 

• In addition, the ACGME requires training programs to teach about systems of care and 

to assess trainees using multiple sources of feedback, including patients. 

• Our Internal Medicine residency program identified 

the need for more formal resident training in patient 

satisfaction and interpersonal communication after a 

quarter in which the inpatient teaching service's 

score was suboptimal on the HCAHPS 

Communication with Doctors composite (Figure 1). 

• Due to HCAHPS methodology, no concrete 

explanation for our low score was available; nor was 

there specific provider feedback to help us focus our 

efforts. We therefore recognized there was an 

opportunity to obtain 360degree patient and nursing 

feedback about resident performance in the inpatient 

setting as well. 

Figure 1. Q4 2010 HCAHPS “Top Box” Scores, 

Communication with Doctors Composite 

Description of the Innovation 

• A patient satisfaction and feedback project was initiated in June 2011. Patient and 

nursing surveys were developed as residencyspecific feedback tools. Questions were 

based on both the HCAHPS Communication with Doctors composite and on several other 

satisfaction factors that were felt to be useful feedback items. 

• At the beginning of each ward month, a faculty member leads residents in an interactive 

session about HCAHPS and key concepts in patient satisfaction. Strategies to enhance 

physicianpatient communication and patient satisfaction are discussed in detail. 

• Residents rotating on wards distribute the surveys to patients and nurses requesting 

their anonymous feedback (Figures 2 and 3). Selfaddressed envelopes are also included 

to preserve anonymity. 

Figure 4. Patient Information Sheet 

• After the first year of the project, a survey was conducted assessing resident attitudes 

and frequency of use of suggested behaviours shown to improve patient satisfaction. 

Results to Date 

• The Internal Medicine residency service's HCAHPS top box scores improved from 52% 

in the fourth quarter of 2010 to 78% in the second quarter of 2012 (Figure 6). 

• Resident scores on the distributed programspecific patient surveys also have 

increased, three of these significantly (Figure 7). 

Figure 6. HCAHPS "Top Box" Scores, Communication with 

Doctors Composite 

• While not statistically significant, there is a trend towards residents placing more value 

on patient satisfaction since the inception of this project. Sixty percent of residents 

agreed or strongly agreed that 

patient satisfaction was important 

to them prior to the project's 

initiation, whereas 72% did so after 

participating (Figure 8). 

• Residents also place a priority on 

multisource feedback. Over 90% 

of residents felt it is valuable to 

obtain feedback from patients; 

84% felt it is valuable to obtain 

feedback from nurses (Figure 8). 

Figure 5. Resident Feedback Report 

Figure 7. Scores on Residency Program's Patient Surveys 

• With progression in PGY level, there was a trend towards an increased rate of: 

explaining their role on the team 

using whiteboards in patient rooms 

sitting down at the bedside during H&P, daily assessment, and on day of discharge 

Discussion 

• The implementation of this project has led residents to place more value on patient 

satisfaction than they did previously. 

• This program innovation has also filled a prior void in multisource feedback in the 

inpatient setting within our residency program. The addition of individualized patient and 

nursing feedback from their time on the wards has allowed for more targeted interventions 

to assist in the continued maturation of resident interpersonal communication skills. 

• Combining focused education about patient satisfaction with individualized resident 

feedback and the regular discussion of techniques shown to enhance communication and 

patient satisfaction seems to have been effective at improving patient satisfaction scores 

for the Internal Medicine teaching service. 

• This initial project has also identified other 

areas for focused initiatives. We added five 

new questions to the patient feedback tool to 

enhance the quality and quantity of feedback 

received by residents (Figure 11). We are 

working to improve distribution and return rates 

of the two feedback tools. We have added 

more formal opportunities for residents to 

review and discuss their feedback, including a 

monthly small group activity for wards residents, 

in order to promote selfreflection, goalsetting, 

and peertopeer sharing of successful 

techniques. 

References 

Figure 10. Frequency of Less Commonly Utilized Strategies by 

Residents 

Boulding, W et al. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17:4148. 

Brinkman, WB et al. Effect of multisource feedback on resident communication skills and professionalism. Arch Pediatr Adolesc Med. 2007;161:4449. 

Cope, DW et al. Modification of residents’ behavior by preceptor feedback of patient satisfaction. J Gen Intern Med. 1986;1:394398. 

DiMatteo, MR. Enhancing patient adherence to medical recommendations. JAMA. 1994; 271:7983. 

Figure 11. New Patient Survey 

Reinders, ME et al. Does patient feedback improve the consultation skills of general practice trainees? A controlled trial. Medical Education. 2010;44:156164. 

Stewart, MA. Effective physicianpatient communication and health outcomes: a review. Can Med Assoc J. 1995;152:14231433. 

Figure 2. Patient Survey 

Figure 3. Nursing Survey 

Figure 8. Resident Attitudes About Patient Satisfaction and Multisource 

Feedback 

Swayden, KJ et al. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Education and Counseling. 2012;86:166171. 

Tan, SY. Issues in medical malpractice IX. Hawaii Medical Journal. 2007;66:7879.


Poster Title: Improving Patient Satisfaction Outcomes, Resident Interpersonal Communication Skills, and 

Resident Feedback 

Authors and Affiliate Institutions: Christina R Bergin, Cheryl W O’Malley, Karen Alonso, Douglas Eckhardt, 

Richard Gerkin, Banner Good Samaritan Medical Center 


Christina R. Bergin, MD 

Faculty/Academic Hospitalist 


Banner Good Samaritan Medical Center 

1111 East McDowell Road 

Medical Education, LL2 

Phoenix, AZ 85006 

Telephone: (602) 839-6301 

Email: christina.bergin@bannerhealth.com 

Discussion of How the Problem was Identified and Explored: Our Internal Medicine residency program 

identified the need for more formal resident training in patient satisfaction after a quarter in which the inpatient 

teaching service’s score was suboptimal on the Hospital Consumer Assessment of Healthcare Providers and 

Systems (HCAHPS) survey’s Communication with Doctors composite. Due to HCAHPS methodology no concrete 

explanation for this or specific feedback was available. We therefore felt there was opportunity to obtain 360- 

degree patient and nursing feedback about resident performance in the inpatient setting as well. 

Description of the Innovation: A patient satisfaction and nursing survey project was initiated in June 2011. At 

the beginning of each ward month, a faculty member leads a discussion about HCAHPS and strategies to enhance 

patient satisfaction. Residents rotating on wards distribute surveys to patients and nurses requesting their 

anonymous feedback. Every four months, a comprehensive report is compiled for each resident with their survey 

results, enabling them to identify strengths and to address any identified deficiencies. After the first year of the 

project, a survey was conducted assessing resident attitudes and frequency of use of suggested behaviors shown to 

improve patient satisfaction. 

Results to Date: The Internal Medicine residency service’s HCAHPS scores improved from a mean of 52% in the 

fourth quarter of 2010 to a mean of 73% in the first quarter of 2012. Resident scores on the distributed patient 

surveys also have increased, some significantly. While not statistically significant, there is a trend towards 

residents placing more value on patient satisfaction since the inception of this project. Sixty percent of residents 

agreed or strongly agreed that patient satisfaction was important to them prior to the project’s initiation, whereas 

72% did so after participating. Additionally, over 90% of residents felt it is valuable to obtain feedback from 

patients; nearly 84% felt it is valuable to obtain feedback from nurses. A high percentage of residents reported 

“always” or “usually” utilizing several key strategies that enhance patient satisfaction. However, other techniques 

are underemployed, including sitting down at the bedside, using whiteboards in patient rooms, and distributing 

information describing the teaching service. 

Discussion/Reflection/Lessons Learned: The implementation of this project has led residents to place more value 

on patient satisfaction and provided them with individualized patient feedback allowing for more targeted 

interventions. Combining these methods with the regular discussion of techniques shown to enhance patient 

satisfaction seems to have been effective at improving patient satisfaction scores. We would like to continue to 

optimize patient satisfaction and to enhance rates of patient and nursing feedback. These goals may be achieved in 

part by addressing the satisfaction strategies currently still underutilized, together with interventions to augment the 

quantity of feedback obtained. 


Does the time of educational conference impact patient discharge times? 

Steffanie Campbell, MD; Alexander M Djuricich, MD 

Department of Medicine, Baylor College of Medicine; 

Department of Medicine, Indiana University School of Medicine 

Introduction 

Background 

Resident workload is continually compressed due to decreasing length of 

stay, increasing admission acuity and overall nationwide increase in hospital 

admissions. 

This is further exacerbated by the 2003 and 2011 work hour limitations. 

Recent research surrounding the 2003 and 2011 work hour changes have 

found that residents believe the quality of their education has suffered. 

Despite this compression, we must still try and find time for our residents to 

learn the necessary medical knowledge. 

One patient care task vital to throughput and hospital quality measures is 

discharge time. 

It has been hypothesized that morning conferences delay patient discharge 

times by procuring resident working time. 

The purpose of this study was to determine whether moving the time of day 

an educational conference is scheduled impacts the time to completion of 

patient discharges by internal medicine teaching services. 

Methods 

Setting and participants 

Wishard Hospital is a county hospital in downtown Indianapolis. It has 340 

beds, 90 of these are dedicated to medicine patients. Wishard Hospital serves 

an indigent population with multiple medical comorbidities and increasingly 

difficult social situations. These factors make discharges for patients extremely 

complex and difficult. 

Internal Medicine Interns and Residents assigned to Wishard Hospital 

inpatient teaching teams during the study period. Our residency consists of 36 

categorical medicine residents, 14 Medicine-Pediatrics residents, and 12 

preliminary residents per year, for a total of 177 during the 2010-2011 academic 

year. 

Our interns and residents train at four different hospitals, to include: a county 

hospital – Wishard, a tertiary care hospital – University, a private hospital – 

Methodist and the Veterans Administration Hospital. 

On average each intern and resident does 3-4 months per year of inpatient 

medicine wards at Wishard hospital. There are five teaching teams with one 

resident and two interns each. There are two additional teaching teams with 

one resident or one intern each. The overnight admissions are done by a 

nightfloat team. 

During the three month study period during the year 2010-2011, 51 interns 

and residents rotated through Wishard Hospital. 

Discharge Times for Each Morning Report 

Number of Discharges 

Study Design 

Morning report-style conference for all internal medicine interns and residents 

at Wishard Hospital was shifted from 8:30am to 2pm during 8/23/2010 

through 12/12/2010. 

This shift occurred at the midpoint of a month long inpatient rotation in an 

attempt to eliminate potential differences conferred by individual resident 

efficiency. 

Teaching service medicine patient discharge times, defined as the time the 

discharge order set was signed, were compared during the three-months the 

conference time was shifted. 

Resident attendance was measured with resident sign-in sheets placed at 

each conference time. 

Resident satisfaction and time preference was measured using an 

electronically delivered survey. 

Conference 

Time 

Time of Day 

Results 

Discharge time for 1493 medicine patients discharged during the 8:30 am 

was compared to 1506 medicine patients discharged during the 2pm report 

time. 

Dependent variable was educational conference time. The independent 

variables were medicine patient discharge times and resident satisfaction 

scores. The discharge times during the 8:30am educational conference and 

the 2pm educational conference were graphically compared. The discharge 

times were also analyzed using a T-Test method with a significant P-value 

defined as less than 0.05. 

It was noted there was no significant difference in discharge time with a P 

value of 0.3. 

Mean discharge time during both designated conference times was between 

4:30 and 5:00 pm. 

All residents were sent a link to participate in the electronic survey. 42 of 51 

residents (82% response rate) completed the survey 

74% of the interns and residents that completed the survey felt the 8:30am 

conference time was better for rounding and education. 56% of the interns 

and residents that completed the survey felt the 8:30am conference time 

was better for patient care tasks. 

Conclusions 

As shown through our study, medical patient discharge time was not 

significantly influenced by time of educational conference. 

Educating residents when time constraints and workload continue to increase 

is fraught with challenges. 

Our data suggest that Program Directors should resist the urge from hospital 

administration to change educational conference times in order to maximize 

throughput via earlier discharge times. 

References 

Goitein L, Ludmerer K. Resident Workload-Let’s Treat the Disease, Not Just the Symptom. JAMA Intern 

Med, online, 3/25/2013 

Healthcare Cost and Utilization Project net. Available at: http://hcupnet.ahrq.gov/ 

Meyer MH, Jekowsky E, Crane FG. Applying platform design to improve the integration of patient services 

across the continuum of care. Managing Service Quality 2007; 17:23. 

Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a 

systematic review. Arch Intern Med 2012; 172:1057. 

O'Leary KJ, Liebovitz DM, Feinglass J, et al. Creating a better discharge summary: improvement in quality 

and timeliness using an electronic discharge summary. J Hosp Med 2009; 4:219.


Poster Title: Does the Time of Educational Conference Impact Patient Discharge Times? 

Authors and Affiliate Institutions: Steffanie Campbell, Baylor College of Medicine; Alexander Djuricich, 

Indiana University School of Medicine 


Steffanie R. Campbell, MD 



Baylor College of Medicine 

One Baylor Plaza 

BCM 285 

Houston, TX 77030 

Telephone: (713) 798-6724 

Email: Steffanie.Campbell@bcm.edu 

Discussion of How the Problem was Identified and Explored: Changes in direct patient care time caused by the 

duty hour changes in 2003 and 2011 have compressed medical resident daily workload. Despite this compression, 

residents must still learn the necessary medical knowledge and patient care management. Thus, the timing of 

educational activities is imperative to optimize attendance while also assuring completion of necessary patient care 

tasks. One task vital to throughput is the time of discharge. The purpose of this study was to determine whether 

moving the time of day an educational conference is scheduled impacts the time to completion of patient discharges 

by internal medicine teaching services. 

Description of the Innovation: Morning report-style conference for internal medicine residents was shifted from 

8:30am to 2pm during a five-month period. This shift occurred at the midpoint of the rotation in an attempt to 

eliminate potential differences conferred by individual resident efficiency. Teaching service medicine patient 

discharge times, defined as the time the discharge order set was signed, were then obtained via the electronic 

medical record for this same time period. The discharge times recorded were compared for the two different 

educational conference times. Resident attendance and satisfaction was also measured. 

Results to Date: Discharge times for 1495 medicine teaching service patients demonstrated a mean discharge time 

between 4:30 and 5pm. The timing of the educational conference had no effect on the discharge time. There were 

222 discharges around 5pm during the 8:30am conference time and 201 discharges at 5pm during the 2pm 

conference time. Resident attendance was approximately 50% for both conference times. Satisfaction survey 

results for 42 residents demonstrated that 64% preferred the 8:30 am report time, and 74% felt this time was also 

better for education and rounding. 

Discussion/Reflection/Lessons Learned: Medical patient discharge time was not significantly influenced by time 

of educational conference. Educating residents when time constraints and workload continue to increase is fraught 

with challenges. Our data suggest that there are other factors beyond the timing of educational conference that may 

influence discharge times. 



Poster Title: Incorporating a Longitudinal Subspecialty Continuity Clinic into Internal Medicine Training 

Authors and Affiliate Institutions: Amy F Matthews, Steven V Angus, University of Connecticut School of 

Medicine 


Amy F. Matthews 

Administrative Program Coordinator 


University of Connecticut School of Medicine 

263 Farmington Avenue 

Farmington, CT 06030 

Telephone: (860) 679-6297 

Email: amatthews@uchc.edu 

Discussion of How the Problem was Identified and Explored: The number of Internal Medicine Residency 

graduates choosing to pursue further subspecialty training in Internal Medicine has risen nearly 25% over the last 

10 years. Although elective block rotations and inpatient subspecialty experiences are available, these brief 

encounters fail to give residents true insight into what it would be like to practice in that profession. Most elective 

time is spent rounding on the inpatient service and performing subspecialty consults with different attendings, 

impairing the development of a true mentoring relationship between resident and attending. Additionally, patients 

seen on subspecialty rotations are typically seen only in the hospital with no continuity of care provided by the 

residents. 

Description of the Innovation: In an attempt to overcome these barriers, a weekly longitudinal ambulatory-based 

subspecialty clinic was developed as part of the PGY2/3 year curriculum. During non-call rotations, residents may 

elect to spend one half-day each week working with the same subspecialty mentor and seeing the same panel of 

patients for the duration of their ambulatory-based subspecialty continuity clinic. The typical resident attends 

approximately 40-50 half-day sessions in their longitudinal clinic, in addition to their 130 half-day primary care 

continuity clinic sessions. 

Results to Date: Ninety out of 155 graduates (58%) from the Internal Medicine program opted to participate in the 

longitudinal ambulatory-based subspecialty clinic. We found residents participating in the second clinic experience 

were significantly more likely to match into a fellowship than residents who did not (p=.001). Satisfaction surveys 

targeting residents who selected the second continuity experience and their faculty preceptors were administered 

anonymously and overall, residents agreed that the second clinic was a valuable component of their training (100%) 

and helpful in their decisions about pursuing fellowship training (93%) while 100% of faculty reported the 

experience was valuable to residents considering fellowships, in helping them craft stronger letters of 

recommendation, and choosing suitable candidates for their fellowship programs. 

Discussion/Reflection/Lessons Learned: A longitudinal continuity clinic based in a specialty clinic was 

associated with higher rates of matching into fellowships and high satisfaction ratings by faculty and residents 

alike. Future research should explore the experience’s clinical impact on patient care and patient satisfaction. 



Poster Title: Achieving Balance on the Inpatient Internal Medicine Wards: A Performance Improvement Project 

to Restructure Resident Work Hours at a Tertiary Care Center 

Authors and Affiliate Institutions: Brian M Cohee, Joshua D Hartzell, William T Shimeall, Walter Reed 

National Military Medical Center 


Brian M. Cohee, MD 

Pulmonary and Critical Care Medicine Fellow 


Walter Reed National Military Medical Center 

Pulmonary Clinic, Building Nine 

8901 Wisconsin Avenue 

Bethesda, MD 20889 

Telephone: (301) 295-4191 

Email: brian.m.cohee.mil@health.mil 

Discussion of How the Problem was Identified and Explored: Verbal reports from residents working under a 

night-float system were that on-call teams were routinely violating work hours. Also, because the majority of 

admissions were occurring late in the day, the night float was admitting more patients than the day teams, and these 

patients had rushed initial evaluations and poor continuity. Additionally, the emergency department expressed 

frustration over prolonged wait times for admissions. 

Description of the Innovation: We report the results of a quality improvement project designed to enhance our 

ward structure to improve continuity and better align resident resources with institutional demands. Data collection 

on the details of admitting intensity, disposition times, and continuity were collected during an 8-day period before 

and a 12-day period after an intervention that changed the ward team structure from a night-float system to a senior 

resident long-call system with a graded transition of responsibility to a night team. All housestaff and attendings 

that rotated on the new structure during an eight-week period were surveyed after implementation. 

Results to Date: The new structure improved patient continuity and resident satisfaction and sense of patient 

involvement. Disposition times from the emergency department were substantially improved. Survey respondents 

reported subjective improvements in quality of patient care and handoffs, as well as improved adherence to dutyhour 

regulations. The changes also resulted in a decrease of one resident on night-float responsibility without 

increasing other ancillary support. 

Discussion/Reflection/Lessons Learned: A growing body of literature exists describing how fatigue, handoffs, 

and work intensity affect the quality of patient care and the educational experience of residents. While many 

studies have examined each of the factors independently, there remains little understanding as to how these factors 

interplay and the best ways to optimize rotation structure to achieve the best balance. Reports of interventions 

designed to improve care at specific centers have occasionally yielded unexpected results, and are probably highly 

dependent on local factors. Designing a ward admission system around a brief but intensive assessment of the 

intensity of work was associated with better alignment of resident resources with work load, and resulted in 

improvements in continuity, emergency department disposition times, adherence with duty hours, and transitions in 

care. 



Poster Title: Breast Cancer Screening and Prevention in Primary Care: A Novel Curricular Intervention for 

Medicine Housestaff 

Authors and Affiliate Institutions: Jennifer Corbelli, Melissa McNeil, University of Pittsburgh School of 

Medicine 


Jennifer A. Corbelli, MD 

Faculty 

Department of General Internal Medicine 

University of Pittsburgh School of Medicine 

230 McKee Place 

Suite 600 

Pittsburgh, PA 15213 

Telephone: (585) 781-4177 

Email: corbellija@upmc.edu 

Discussion of How the Problem was Identified and Explored: Women’s health content accounts for 

approximately 6% of the American Board of Internal Medicine certifying examination. Yet national studies have 

shown that residents do not receive sufficient training in women’s health. Furthermore, prior survey research by the 

submitting author found that breast health knowledge among housestaff is poor: for example, fewer than 10% had 

ever calculated a Gail score. This educational intervention targets interns’ knowledge and skills surrounding breast 

health. 

Description of the Innovation: The curriculum is multimodal and takes place over a half-day session. Interns first 

take a knowledge-based pre-test. Next, they work through a 30-minute interactive web-based virtual patient case 

and a team-based learning session, both of which focus on a variety of breast health topics including the 

controversies in screening mammography, the Gail model, chemoprevention, and management of high-risk women. 

They then take a knowledge-based post-test. To target skill development, interns perform a pre- and post- breast 

exam on the Mammacare® breast simulator, which uses specialized software to generate scores for completeness 

and accuracy. 

Results to Date: Data collection is ongoing. With existing data, interns’ pre- and post- test scores on both the 

knowledge assessment and the Mammacare simulator were compared. Furthermore, PGY-2s, who have not 

received this curriculum, took the same knowledge-based assessment, with scores compared to interns’ postcurriculum 

scores. A repeated measures Analysis of Covariance (ANCOVA) will be calculated, to control for 

length of time in the program as a potential confounder. Preliminary data shows a significant improvement in 

interns’ post-test scores on both knowledge and skills assessments. Furthermore, data shows that interns who 

received this curriculum perform significantly better on a knowledge-based assessment than PGY-2s who do not. 

Discussion/Reflection/Lessons Learned: Housestaff serve as the primary care physician for a panel of patients 

during their residency training, many of whom have numerous barriers to care. As such, housestaff are responsible 

for optimization of their patients’ breast health, as the majority of these patients see no other physician for 

preventive health measures. Results to date suggest that a low-cost, low-time investment curriculum can result in a 

significant improvement the knowledge and skills necessary for interns to meet their patients’ breast health needs. 

Furthermore, interns’ superior performance to PGY-2s demonstrates that this topic is not being adequately 

delivered elsewhere in their training. 



Poster Title: Chief Resident Leadership Academy 

Authors and Affiliate Institutions: Nathan E Derhammer, Loyola University Medical Center 


Nathan E. Derhammer, MD 


Division of Hospital Medicine 


Loyola University Medical Center 

2160 South First Avenue 

Maywood, IL 60304 

Telephone: (708) 216-5674 

Email: nderhammer@lumc.edu 

Discussion of How the Problem was Identified and Explored: The role of chief resident is a time-honored 

tradition and formative experience, as well as one that brings with it lofty expectations from program directors, 

residents-at-large, and individual chief residents alike. Chief residents typically lack formal training for this 

uniquely challenging and important position. Our institution identified a need for preparation of incoming chief 

residents from all departments to refine and develop leadership skills with respect to their applicability in this 

multifaceted role. 

Description of the Innovation: Using a learner-centered curriculum driven by a leadership skills inventory 

completed by participants, the Chief Resident Leadership Academy is comprised of five weekly discussion-based 

sessions. Although conversations are guided by brief preparatory reading assignments, involvement of both 

educational leaders and current chief residents provides insight and expertise at a number of levels. The 

participation of leaders and chief residents (both active and incoming) from a variety of residency programs at our 

institution addresses the hidden curriculum of building professional interdepartmental relationships. 

Results to Date: Pilot data collected by survey demonstrated that 100% of participants in the 2012 Chief Resident 

Leadership Academy found the program to be both personally and professionally beneficial, relevant to their chief 

residency, and enhanced by the interdepartmental scope of involvement. Importantly, participants reported that the 

climate of the sessions promoted non-judgmental discussion and all respondents indicated that they would 

recommend the program to future chief residents. 

Discussion/Reflection/Lessons Learned: The philosophy behind the Chief Resident Leadership Academy is 

simple: leaders-in-training deserve the opportunity to develop their skills and identify challenges BEFORE 

assuming a highly regarded and highly scrutinized position such as chief resident. The individuals benefit from a 

heightened sense of awareness and confidence and a decreased sense of isolation when faced with the multitude of 

unique but recurrent issues related to chief residency. Program directors benefit from chief residents who have been 

imparted some degree of “institutional memory” and also offered the opportunity to reflect on strengths and 

weaknesses as they pertain to their role as an educational leader. Residents benefit from cohesive, confident, 

emotionally-intelligent leadership. Future directions of the Chief Resident Leadership Academy will include 

enhancing interdepartmental participation and collecting data to support the above assertions. 



Poster Title: “The Chief’s Seminar”: Motivating New Residents to Master Clinical Reasoning 

Authors and Affiliate Institutions: Christopher Dittus, Vanya Grover, Georgia Panagopoulos, Lenox Hill 

Hospital; Kenar Jhaveri, Hofstra North Shore-LIJ School of Medicine at Hofstra University 


Christopher Dittus, DO 



Lenox Hill Hospital 

100 East 77th Street 

New York, NY 10075 

Telephone: (917) 754-0887 

Email: cdittus@nshs.edu 

Discussion of How the Problem was Identified and Explored: Postgraduate medical education is primarily 

lecture-based learning, which has been unchanged for decades. Identification of multiple learning styles has 

modified undergraduate medical education. This has not been adequately adapted in the postgraduate medical 

education setting. To accommodate these changes, we propose a reproducible, interactive teaching curriculum led 

by chief residents. 

Description of the Innovation: This innovative clinical reasoning curriculum is based on three concepts – “who, 

what, and how.” First, the program is led by chief residents (i.e. “who”). Second, topics are presented based on the 

chief complaint, and not the disease itself (e.g. “dyspnea,” not “pneumonia”). This allows the resident to generate a 

differential and arrive at the diagnosis through structured clinical reasoning (i.e. “what”). Third, the information 

must be conveyed using an innovative approach to engage and motivate residents (i.e. “how”). Incentives and 

competition are excellent motivators for residents. Specifically, each module begins with a topic-based crossword 

puzzle competition followed by three weekly, small-group, interactive sessions using concept maps. Data were 

collected via pre- and post-course five-item quizzes. The Wilcoxon Signed-Rank Test was used for statistical 

analysis. A six point resident survey was also distributed for evaluation of each module. 

Results to Date: To date, four one-month modules have been completed – Dyspnea (N=15), Chest Pain (N=13), 

Fever (N=14), and Abdominal Pain (N=10). Results showed a statistically significant increase in quiz scores for the 

Chest Pain (pre-, post-test means: 1.77, 3.08; p=0.007), Fever (2.21, 3.21; p=0.008), and Abdominal Pain (3.5, 4.3; 

p=0.011) modules, and a trend towards statistical significance for the Dyspnea module (2.93, 3.67; p=0.053). 

Additionally, the six-point resident survey demonstrated overall resident satisfaction with each instructed module. 

Discussion/Reflection/Lessons Learned: The results of this pilot study reveal a statistically significant increase in 

five-item quiz scores after attending the Chest Pain, Fever, and Abdominal Pain teaching modules. The evolving 

nature of this curriculum allows us to adapt the subsequent modules to improve resident education. This 

curriculum, based on the “who, what and how” concepts, is a novel and effective way to enhance resident education 

and satisfaction. 



Poster Title: Objectification and Meaningful Implementation of a Medicine Curriculum Designed to Produce the 

Next Generation of Physician Leaders 

Authors and Affiliate Institutions: Scott R Friedstrom, Helen Koselka, Good Samaritan Hospital; Curtis A 

Sheldon, Cincinnati Children’s Hospital 


Scott R. Friedstrom, MD 


Division of Medicine 


Good Samaritan Hospital 

375 Dixmyth Avenue 

Cincinnati, OH 45220 

Telephone: (513) 862-3306 

Email: friedstrom@yahoo.com 

Discussion of How the Problem was Identified and Explored: The need for program change became obvious 

when our board pass rate recently dropped dramatically. Using the techniques of SWOT analysis, key driver 

diagrams, and mind mapping, we realized that this was a symptom of a bigger problem, rather than a bump in the 

road. Our analysis helped us to conclude that a curriculum change was needed, but also, and more fundamentally, a 

culture change was necessary. This can be especially challenging for a community based program. The didactic 

curriculum was renovated and re-invigorated. Key faculty were identified, and a “buy-in” to this change was 

obtained. Support of the GME office, as well as highly placed hospital administrators, was solicited and obtained. 

Description of the Innovation: The didactic curriculum has been individualized for each post-graduate year. A 

first year interactive lecture series called “Foundations of Professionalism and Continuous Learning” has been 

implemented. Interns have been taught how to use mind-maps, and they are now mind-mapping “The Hitchhiker’s 

Guide to Internal Medicine”. These maps can be continuously updated, and are being shared on the cloud. 

Beginning at week 1 of PGY year 2, and continuing for 78 weeks, a theme has been chosen. In successive noon 

conferences during each week, the relevant chapter from a major medicine text is discussed, the same topic from a 

major board review book is discussed, the relevant subspecialist brings it to the bedside in a lecture, and 2-3 case 

scenarios are discussed to teach clinical reasoning. For each week of this curriculum, mind-maps are created. The 

last six months of the PGY3 year are spent in an intensive board review effort. We predict the mind maps will be 

very useful in board preparation. 

Results to Date: It is still early. However, our resident team placed second in the “Doctor’s Dilemma Quiz Bowl” 

competition of the most recent Ohio ACP chapter meeting. Last year they did not escape the first round. We have 

one-third more resident research projects being conducted this year when compared to last year. Before and after 

quizzes are measuring real performance improvement. Scores on ITEs and ABIM exams will be compared when 

available. But most importantly, a palpable change is in the air. Most of our residents now exhibit what Sam Keen 

called “fire in the belly.” 

Discussion/Reflection/Lessons Learned: Change is usually daunting and foreboding; this change has been 

exhilarating. Our new curriculum is based on fundamental principles of education, systems theory, bioethical 

principles, variance analysis using Donald Wheeler’s work, process improvement based on Demmings’ work, the 

study of conflict management based on Pues’ work, and much more. And a bonus of this effort is that much of this 

change is helping us to prepare for and implement the NAS. It has been a lot of work, but in the words of Thomas 

Jefferson: “I’m a great believer in luck, and I find the harder I work, the more I have of it.” We’re feeling lucky. 



Poster Title: Innovative and Successful Evidence-Based Morning Report Linked to Resident-Led Journal Club 

Authors and Affiliate Institutions: Brian Hanson, Jerrod Quarles, Anita Udayamurthy, Alison Wing, Sarah Lee, 

Laura Broder, Kirstin Juhl, Justin Howard, Steve Powell, Matt Lehnert, Colin Turner, Jonathan Koffel, Nacide 

Ercan-Fang, Minneapolis VA Medical Center 


Brian J. Hanson, MD 



Minneapolis VA Medical Center 

One Veterans Drive 

111 Hanson 


Telephone: (612) 467-7141 

Email: hans3829@umn.edu 

Discussion of How the Problem was Identified and Explored: Practice-based learning and improvement is a 

part of the Accreditation Committee for Graduate Medical Education’s (ACGME) core competencies. The 

evidence-based medicine (EBM) milestones include asking answerable questions, acquiring the best evidence, 

appraising the validity and usefulness, as well as applying the evidence to decision-making for individual patients. 

Our goal was to improve residents’ EBM skills by implementing an EBM morning report and a resident-led journal 

club tied directly to patient care. 

Description of the Innovation: We implemented an EBM morning report linked to a resident-led journal club at 

our institution. A clinical question in the PICO format is generated from the care of a current patient. A research 

librarian aids in the search while teaching search techniques. An article is selected to answer the clinical question 

and the resident critically appraises the article with the aid of an EBM mentor. Standardized instructions guide the 

resident through the appraisal and presentation process. A chief resident reviews presentation skills and techniques. 

At a subsequent morning report, the resident presents their findings and teaching points. Care is taken to apply the 

findings directly to patient care. The EBM mentor in addition to a clinical expert are present to guide discussion 

and answer questions. A questionnaire using a Likert scale from 1-5 was used to the rate quality of the journal 

club. A score of “5” indicated the evaluator strongly agreed with the statement and the presentation far exceeded 

expectations. A score of “1” indicated the evaluator strongly disagreed with the statement and the presentation was 

unacceptable. 

Results to Date: The curriculum addressed the development of a clinical question, the acquisition of relevant 

evidence, critical appraisal, and patient application. Over the course of three years, 38 residents led an EBM journal 

club. Overall, residents found EBM report to be helpful and educational. Based on the six questions, the average 

presenter scores were 4.53, 4.79, 4.82, 4.68, 4.62, and 4.71 for clinical relevance, coherency, presenter 

understanding, identifying study strengths and weaknesses, applicability, and overall presentation respectively. 

Discussion/Reflection/Lessons Learned: Our EBM linked resident-led journal club meets ACGME practicebased 

learning and improvement milestones. In addition, it has created high quality presentations. Residents present 

relevant information in a coherent, clear, interesting and dynamic way while addressing key components of EBM. 

In addition, the sessions have be well attended and participation excellent. We propose that a resident driven, 

mentor-assisted, EBM morning report linked to a resident-led journal club can be a successful way to address 

current ACGME milestones. 



Poster Title: Tea(ch) Time: An Afternoon Approach to Morning Report 

Authors and Affiliate Institutions: Katherine Harris, Manish Suneja, University of Iowa Carver College of 

Medicine 


Katherine Harris, MD 


Division of General Medicine 


University of Iowa Carver College of Medicine 

200 Hawkins Drive 

E 327-1 GH 

Iowa City, IA 52242 

Telephone: (319) 384-8512 

Email: harriski@healthcare.uiowa.edu 

Discussion of How the Problem was Identified and Explored: In this era of increasingly hectic time schedules 

and duty hour restrictions, our residency program struggled with balancing didactic teaching and traditional 

morning report based case presentations. Additional challenges included finding a time and venue for case based 

learning which would enable maximum participation of the residents/students on the inpatient wards. The goal of 

this project was to introduce daily case-based learning sessions to enhance diagnostic reasoning at a time and venue 

which would maximize inpatient resident/student participation. Initial needs assessment was done by a survey of 

all Internal Medicine Residents (respondents: 30/82). 

Description of the Innovation: Based on the survey results we piloted an afternoon session called “Tea (ch) 

Time” which took place at 3:00 pm in the individual team room of the presenting resident/students. At each 

conference a resident team presented one of their current patients selected on the basis of: 1) diagnostic dilemmas; 

2) interesting findings; 3) common diseases with uncommon presentations; 4) notable radiologic findings; 5) rare 

diagnoses. These sessions were informal and were moderated by two faculty members. At the end of the session the 

group was asked to identify two teaching points. The teaching points focused more on general principles with 

emphasis placed on the cognitive process behind clinical decision making. 

Results to Date: The resident/student attendance and participation was excellent. Feedback from the 

residents/students pertaining to the sessions was gathered. The major themes from comments gathered were that the 

learners liked the exposure to more cases, it helped them develop diagnostic reasoning skills and a systematic 

approach to patient care. An important and unanticipated finding was noted with the medical students surveyed. 

The medical students were asked if they were more likely to enter the field of Internal Medicine because of these 

teaching sessions and 80% replied “yes.” 

Discussion/Reflection/Lessons Learned: Based on the results of the survey, we plan on implementing “Tea 

Time” as a learning curriculum in November 2012. The Chief residents will play a large role in moderating the 

sessions, along with key clinical faculty on the Inpatient Wards. This will make the curriculum sustainable, as the 

two faculty initiating this project are unable to facilitate the meeting daily. We will be gathering data regularly to 

further assess resident/medical student satisfaction and gain more insight regarding the session’s effectiveness in 

teaching clinical reasoning on the inpatient wards. 


“You Must Be The Change You Wish To See In The World”- Mahatma Gandhi 

An Innovative Approach to Performance Improvement Curriculum 

Saba A. Hasan, MD, FACP; Ekaterina Vypritskaya, MD, FACP 

Abstract 

Methods 

Results 

Conclusion 

ACGME requires each resident to 

“evaluate performance data for their 

panels related to both chronic 

disease management and 

preventive health care, receiving 

faculty guidance for developing a 

data-based action plan and evaluate 

the plan at least twice a year” 

Objectives 

To develop an innovative approach 

to the existing Performance 

Improvement Curriculum by having 

residents work on their projects with 

an attitude of ownership and 

commitment. 

•In the past three years, residents 

have worked on a number of different 

projects, which have enhanced the 

care of their patients and improved 

patient satisfaction 

•The presentations have led to 

evidence based discussions among 

residents and faculty 

•Through the work on PI projects, the 

program has been able to recruit 

institutional resources in the clinic 

system 

•Some examples include: 

•introduction of weight loss clinic 

•appointment reminder phone 

calls 

•improved medication 

reconciliation 

•increased number of influenza 

and pneumovax vaccinations 

given 

•improved overall care of diabetic 

patients through the introduction 

of focused diabetic visits and a 

resident designed diabetic visit 

progress note template 

•Residents feel a sense of pride 

regarding their success with 

interventions and are motivated to 

change their strategies when faced 

with barriers hindering change 

In order to maximize the impact of 

the residents' Performance 

Improvement experience, the 

program implemented the following: 

•Residents make a twice yearly 

formal presentation of their data to 

their peers and faculty 

•The presentation includes a brief 

overview of the problem, the most 

recent evidence based 

recommendations for preventive 

and chronic disease care, the reason 

the resident chose to address it in his 

panel of patients, review of data 

collected, summary of results and 

future plans for the project 

•These presentations stimulate 

discussions on medical care and 

systems based issues encountered 

in the continuity clinic 

•Through the process, the residents 

optimize the care of clinic patients 

and identify systems barriers, 

which are discussed with peers and 

clinic leadership, exploring ideas and 

solutions 

•Residents receive written 

feedback from faculty using an 

evaluation form, which is also filed 

along with their project in their 

portfolio 

•In our program, the PI project 

exercise not only helps develop the 

competency of PBLI, but also 

Medical Knowledge, 

Communication and Interpersonal 

Skills and Systems Based Practice 

•It provides a forum for discussion of 

‘best practices’, review of recent 

literature/guidelines 

• Collaboratively develop innovative 

ideas to overcome the challenges 

to providing quality care to our clinic 

patients. 

Healthy Weight Project 

References: 

•ACGME Outcome Project. General competencies. 

http://www.acgme.org/outcome/comp/compmin.asp. Last accessed- May 5, 2011. 

•Holmboe ES, Prince L, Green M. Teaching and Improving Quality of Care in a 

Primary Care Internal Medicine Residency Clinic. Acad Med. 2005;80:571–73. 

•Djuricich AM, Ciccarelli M, Swigonski NL. A Continuous Quality Improvement 

Curriculum for Residents: Addressing Core Competency, Improving Systems. 

Acad Med. 2004;79:65–75.


Poster Title: “You Must Be the Change You Wish to See in the World.” -Mahatma Gandhi 

Authors and Affiliate Institutions: Saba A Hasan, Ekaterina Vypritskaya, Capital Health Regional Medical 

Center 


Saba A. Hasan, MD 



Capital Health Regional Medical Center 

750 Brunswick Avenue 

Trenton, NJ 08638 

Telephone: (609) 394-6031 

Email: shasan@capitalhealth.org 

Discussion of How the Problem was Identified and Explored: ACGME requires each resident to “evaluate 

performance data for their panels related to both chronic disease management and preventive health care, receiving 

faculty guidance for developing a data-based action plan and evaluate the plan at least twice a year.” 

Description of the Innovation: In order to maximize the impact of the resident’s Performance Improvement 

experience, the program implemented the following: •Residents make a twice yearly formal presentation of their 

data to their peers and faculty •The presentation includes a brief overview of the problem, the most recent evidence 

based recommendations for preventive and chronic disease care, the reason the resident chose to address it in his 

panel of patients, review of data collected and summary of results and future plans for the project. •These 

presentations stimulate discussions on medical care and systems based issues encountered in the continuity clinic. 

•Through the process the residents optimize the care of clinic patients and identify systems barriers, which are 

discussed with peers and clinic leadership, exploring ideas and solutions. •Residents receive written feedback from 

faculty using an evaluation form, which is also filed along with their project in their portfolio. 

Results to Date: In the past three years residents have worked on a number of different projects, enhancing the 

care of their patients, improving patient satisfaction and held evidence based discussions on the topics. Residents 

feel a sense of pride regarding their success with interventions and are motivated to change their strategies when 

faced with barriers hindering change. 

Discussion/Reflection/Lessons Learned: In our program, the Performance Improvement Project exercise not only 

helps develop the competency of PBLI, but also Medical Knowledge, Communication and Interpersonal Skills and 

Systems Based Practice. It provides a forum for discussion of ‘best practices’, review of recent literature/guidelines 

and collaboratively develop innovative ideas to overcome the challenges to providing quality care to our clinic 

patients. 


Ambulatory Case Conference—A Novel Approach to Outpatient Education 

Stephen J. Knaus MD, FACP and Laurel Fick MD, FACP 

St. Vincent Indianapolis Hospital 

Introduction 

Description of Innovation 2011-12 ACC Schedule Results Conclusion 

Evidence-based discussion of 

common ambulatory disease states 

is often missing in traditional internal 

medicine didactic conferences. 

Many institutions have successfully 

implemented Ambulatory Morning 

Report as a way to improve 

ambulatory education and cover 

ambulatory topics not covered in 

other parts of the conference 

curriculum. Our program developed 

an Ambulatory Case Conference to 

improve our resident training in 

common conditions encountered in 

ambulatory general internal 

medicine. 

Percent of Cases (n=56) 

Graph 1 

16 

14 

12 

10 

8 

6 

4 

2 

0 

14 

Ambulatory Case Conference (ACC) is a 

30-45 minute resident-led case 

presentation and evidence-based 

discussion of an outpatient topic of the 

resident’s choosing—typically based on 

a case encountered in the resident’s 

ambulatory experience. This is usually 

followed by faculty-led topic-related 

MKSAP questions with group response 

and discussion. The conference is held 

every other Wednesday from 3-4pm 

during protected educational time and is 

mandatory for any resident not on 

vacation, nights, ICU, or inpatient 

general medical wards. Multiple general 

medicine faculty and occasionally 

ambulatory clinical pharmacists or 

subspecialists are also in attendance. 

Topics are diverse, ranging from 

women’s health to obesity treatment to 

sleep disorders. Topics are chosen by 

the resident in collaboration with the 

clinic director, and emphasis is placed on 

opportunities seen for improvement in 

medical knowledge and patient care, 

such as a women’s health focus in the 

fall of 2011. Workshops on ambulatory 

procedures, practice management 

topics, and quality improvement 

supplement the resident presentations 

throughout the academic year. 

Cases Presented by Residents at ACC by Category, July 2009-February 2013 

10 10 

9 9 9 9 9 

7 

5 5 

3 

2 

Presenter 

PGY-2 resident 




IM Faculty 



Clinical Pharmacist 

OB-GYN physician 







IM Faculty 

IM/FM Faculty 





Topic 

Hypertension 

Spondyloarthropathies 

Fibromyalgia 

Secondary amenorrhea 

Vaginitis 

Breast Cancer Screening 

Graves disease 

Oral Contraceptive Pills 

Cervical Cancer Screening 

Obstructive Sleep Apnea 

Weight Loss Management 

Chronic Low Back Pain 

Atrial Fibrillation 

Hidradenitis Suppurativa 

Male Hypogonadism 

Common Errors in 

Outpatient Medicine 

Joint Injection/Skin Biopsy 

Workshop 

Rheumatoid Arthritis 

Osteoporosis 

Psoriasis 

Anticoagulation 

Management 

2010-11 ACC Schedule 

Presenter 

Topic 

PGY-3 resident Diabetes Mellitus, Type 2 


Colon Cancer Screening 

IM Faculty 

Quality Improvement 


Subclinical Hypothyroidism 


Gastroesophageal Reflux 

Disease 

PGY-3 resident and IM 

Faculty 

Clinical Pharmacists 










Opioids for Chronic Non- 

Cancer Pain 

Drug Monitoring 

Osteoporosis 

Community-Acquired 

Pneumonia 

Dizziness 

Chronic Kidney Disease 

Acute Sinusitis 

Depression 

Getting to Know Your 

NSAIDs 

COPD Treatments 

Skin Cancer 

A survey of residents in June 2011 

(sixteen respondents) indicated that on 

a 5-point Likert scale, residents agreed 

that “Ambulatory Case Conference has 

added value to my residency training” 

(4.62) and that “presenting an 

Ambulatory Case Conference during my 

residency was a valuable experience” 

(4.44). Residents agreed that “MKSAP 

questions related to the ACC topic add 

value to the Ambulatory Case 

Conference session” (4.31). 

Ambulatory Case Conference provided 

an opportunity to cover ambulatory 

topics that were not discussed during 

other didactic sessions. A review of 

topics from 2008-2011 indicated that 

72% of topics presented during 

Ambulatory Case Conference were not 

presented at our daily noon conference. 

Topics were well distributed by category, 

with Endocrinology the most frequent 

category represented (Graph 1). 

2011 ACC Survey Results 

Based on 5-point Likert Scale 

ACC has added value to my internal 

medicine residency training 

MKSAP questions related to the ACC 

topic add value to the ACC session 

Procedural workshop improved my 

confidence in performing joint injections 

Procedural workshop improved my 

confidence in performing skin biopsies 

Billing/coding workshops improved the 

accuracy of my outpatient billing 

My confidence in managing outpatients 

on chronic opioids improved during the 

course of this academic year 

Presenting an Ambulatory Case 

Conference during my residency was a 

valuable experience 

Presentations by clinical pharmacists 

were helpful in managing my outpatients 

4.62 

4.31 

4.0 

4.12 

4.38 

3.68 

4.44 

4.53 

An evidence-based, multidisciplinary 

educational conference devoted to 

case-based discussion of common 

ambulatory diseases has improved 

our program’s training in ambulatory 

general internal medicine. It has also 

provided a forum for board-style 

review with MKSAP questions related 

to the topic discussed and has 

provided a setting to incorporate 

ambulatory workshops, quality 

improvement, and practice 

management topics into the residency 

curriculum. 

References 

Spickard A III, Ryan SP, Muldowney JA 

III, Farnham L. Outpatient morning 

report: a new conference for internal 

medicine residency programs. J Gen 

Intern Med 2000;15:822-824 

Wenderoth S, Pelzman F, Demopoulos 

B. Ambulatory morning report: can it 

prepare residents for the American 

Board of Internal Medicine Examination? 

J Gen Intern Med 2002;17:207-209


Poster Title: Ambulatory Case Conference—A Novel Approach to Outpatient Education 

Authors and Affiliate Institutions: Stephen Knaus, Laurel Fick, St. Vincent Hospital and Health Care Center 


Stephen J. Knaus, MD 






Telephone: (317) 338-7619 

Email: sjknaus@stvincent.org 

Discussion of How the Problem was Identified and Explored: Evidence-based discussion of common 

ambulatory disease states is often missing in traditional internal medicine didactic conferences. Many institutions 

have successfully implemented Ambulatory Morning Report as a way to improve ambulatory education and cover 

ambulatory topics not covered in other parts of the conference curriculum. Our program developed an Ambulatory 

Case Conference to improve our resident training in common conditions encountered in ambulatory general internal 

medicine. 

Description of the Innovation: Ambulatory Case Conference is a 30-45 minute resident-led case presentation and 

evidence-based discussion of an outpatient topic of the resident’s choosing—typically based on a case encountered 

in the resident’s ambulatory experience. This is followed by faculty-led topic-related MKSAP questions with 

group response and discussion. The conference is held every other Wednesday from 3-4pm during protected 

educational time and is mandatory for any resident not on vacation, nights, ICU, or inpatient general medical wards. 

Multiple general medicine faculty and occasionally ambulatory clinical pharmacists or subspecialists are also in 

attendance. Topics are diverse, ranging from women’s health to obesity treatment to sleep disorders (complete list 

available). Workshops on ambulatory procedures, practice management topics, and quality improvement 

supplement the resident presentations throughout the academic year. 

Results to Date: A survey of residents in June 2011 (sixteen respondents) indicated that on a 5-point Likert scale, 

residents agreed that “Ambulatory Case Conference has added value to my residency training” (4.62) and that 

“presenting an Ambulatory Case Conference during my residency was a valuable experience” (4.44). Residents 

agreed that “MKSAP questions related to the ACC topic add value to the Ambulatory Case Conference session” 

(4.31). Ambulatory Case Conference provided an opportunity to cover ambulatory topics that were not discussed 

during other didactic sessions. A review of topics from 2008-2011 indicated that 72% of topics presented during 

Ambulatory Case Conference were not presented at noon conference. 

Discussion/Reflection/Lessons Learned: An evidence-based, multidisciplinary educational conference devoted to 

case-based discussion of common ambulatory diseases has improved our program’s training in ambulatory general 

internal medicine. It has also provided a forum for board-style review with MKSAP questions related to the topic 

discussed and has provided a setting to incorporate ambulatory workshops, quality improvement, and practice 

management topics into the residency curriculum. 


Morbidity and Mortality Conference Working Group – Resident Driven Change 

Tasha Kouvatsos, MD, Emily Stewart, MD and Gretchen Diemer, MD 

Thomas Jefferson University, Department of Medicine, Philadelphia, PA 

Introduction 

Results 

The Morbidity and Mortality 

Conference (MMC) has been a 

requirement for all medical training 

programs by the Accreditation 

Council for Graduate Medical 

Education (ACGME) since 1983 (1). 

Residents graduating from ACGME 

accredited residency programs must 

demonstrate competence in practice 

based learning and improvement 

The working group meets after each MMC and monthly to discuss the 

systems issues and create the plan of action. The residents divide the 

responsibilities and provide updates to the group via email in between 

meetings. All education and systems interventions are presented by the 

participating residents at the final MMC of the year and the patient safety 

officers of the hospital monitor patient outcomes from the interventions. 

For example, one MMC highlighted a series of complications from 

paracentesis. The working group identified several education and systems 

issues and then established a multi-level action plan with supervision, 

education and procedural components. 

(PBLI) and systems-based practice 

(SBP) (2). The New Accreditation 

System has a specific emphasis 

on patient safety and quality 

improvement. Consequently, the 

objective of the MMC focuses less on individual culpability and more on the 

identification of systems-based errors to develop systems improvements 

to increase patient safety and quality of care (3). 

Innovation 

To identify issues uncovered during MMC and develop an action plan 

to improve our current systems-based practice, we created a Morbidity 

and Mortality working group comprised of 10 interested residents, chief 

medical residents and multidisciplinary faculty. It is the residents who take 

ownership of steering the group with guidance from the chiefs and faculty. 

This group provides the residents exposure to systems thinking, supporting 

the ACGME core competency of systems-based practice, and encourages 

systematic review of our current practice, collaboration with hospital 

administration and patient safety officers and hands on development of 

methods for quality improvement. 

1 st Generation Trainer 

1 st Generation Certified 

2 nd Generation Trainer 

2 nd Generation Certified 

3 rd Generation Trainer 

“Train the Trainer” 

Paracentesis MMC Interventions: 

• Develop a “train the trainer” program 

• Establish a yearly ultrasound use/techniques 

workshop led by Radiology faculty including 

resident practice with a standardized patient 

• Distinguish therapeutic from diagnostic 

paracentesis for procedure certification 

• Evaluate procedure kits to optimize safety 

• Implement a validated procedure-specific 

checklist 

• Increase use of post-procedure order set 

• Create a resident simulation case featuring a 

patient with a post-paracentesis complication 

to assess and teach recognition and 

management of post-procedure complications 

Discussion 

The goal of the Morbidity and Mortality Working Group is to empower 

residents to implement systems-based changes to improve patient care. 

The participating residents become adept at identifying the systems issues 

associated with adverse patient outcomes, and understand the steps 

needed to achieve change using a multidisciplinary approach. 

References: (1) Kauffmann R, Landman M, Shelton J, et al. The Use of a Multi-disciplinary Morbidity and Mortality Conference to Incorporate ACGME General Competencies. J Surg Educ 2011; 68(4):303-308. (2) ACGME Outcomes Project. General 

competencies. http://www.acgme.org/outcome/comp/compmin.asp (3) Rabizadeh S, Gower A, Payton K, et al. Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to Serve as a Vehicle for System Changes. Clin Pediatr 

2012;51(11):1079-1086.


Poster Title: Morbidity and Mortality Conference Working Group—Resident Driven Change 

Authors and Affiliate Institutions: Tasha Kouvatsos, Emily Stewart, Gretchen Diemer, Jefferson Medical 

College of Thomas Jefferson University 


Tasha Kouvatsos, MD 



Jefferson Medical College of Thomas Jefferson University 

1011 Chestnut Street 

Apartment 502 East 

Philadelphia, PA 19107 

Telephone: (717) 968-7305 

Email: tasha.kouvatsos@gmail.com 

Discussion of How the Problem was Identified and Explored: The Morbidity and Mortality Conference (MMC) 

has been a requirement for all medical training programs by the Accreditation Council for Graduate Medical 

Education (ACGME) since 1983 (1). Residents graduating from ACGME accredited residency programs must 

demonstrate competence in practice based learning and improvement (PBLI) and systems-based practice (SBP) (2). 

The New Accreditation System has a specific emphasis on patient safety and quality improvement. Consequently, 

the objective of the MMC focuses less on individual culpability and more on the identification of systems-based 

errors to develop systems improvements to increase patient safety and quality of care (3). (1) Kauffmann R, 

Landman M, Shelton J, et al. The Use of a Multi-disciplinary Morbidity and Mortality Conference to Incorporate 

ACGME General Competencies. J Surg Educ. 2011; 68(4):303-308. (2) ACGME Outcomes Project. General 

competencies. http://www.acgme.org/outcome/comp/compmin. asp (3) Rabizadeh S, Gower A, Payton K, et al. 

Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to Serve as a Vehicle for 

System Changes. Clin Pediatr (Phila). 2012 Oct 3. [Epub ahead of print]. 

Description of the Innovation: To identify issues uncovered during MMC and develop an action plan to improve 

our current systems-based practice, we created a Morbidity and Mortality working group comprised of residents, 

chief medical residents and multidisciplinary faculty. It is the residents who take ownership of steering the group 

with guidance from the chiefs and faculty. This group provides the residents exposure to systems thinking, 

supporting the ACGME core competency of systems-based practice, and encourages systematic review of our 

current practice, collaboration with hospital administration and patient safety officers and hands on development of 

methods for quality improvement. 

Results to Date: The working group meets after each MMC and monthly to discuss the systems issues and create 

the plan of action. The residents divide the responsibilities and provide updates to the group via email in between 

meetings. All education and systems interventions are presented by the participating residents at the final MMC of 

the year and the patient safety officers of the hospital monitor patient outcomes from the interventions. For 

example, one MMC highlighted a series of complications from paracentesis. The working group identified several 

education and systems issues and then established a multi-level action plan with supervision, education and 

procedural components. Interventions included a “train the trainer” program where radiology faculty train senior 

housestaff/fellows in appropriate ultrasound technique for paracentesis who then supervise the residents performing 

this procedure. Radiology faculty will teach techniques for ultrasound-guided procedures using standardized 

patients to allow residents to practice in a controlled environment at orientation each year. The residents also 

suggested distinguishing therapeutic from diagnostic paracentesis for procedure certification. The procedural 

solutions include evaluating our procedure kits to optimize safety, implementing a validated procedure-specific 

checklist instead of the universal procedure checklist and initiating a policy that requires a post-procedure order set, 

prompting recognition of complications and initiation of rescue management earlier. 

Discussion/Reflection/Lessons Learned: The goal of the Morbidity and Mortality Working Group is to empower 

residents to implement systems-based changes to improve patient care. The participating residents become adept at 

identifying the systems issues associated with adverse patient outcomes, and understand the steps needed to achieve 

change using a multidisciplinary approach. 


The July Transition – Making It Easier 

EIP Working Group 

Baystate Medical Center / Tufts University School of Medicine 

The Problem 

• Many residents feel ill prepared for the 

transition to new responsibilities in July. 

• A unique “Fly-up” within our Learner-Manager- 

Teacher (LMT) model (Fig. 1) was designed to 

allay fears and to develop core skills. 

The Innovation 

Manager/PGY2 Fears: autonomy on nightfloat, 

CICU and wards, code situations. 

‣Fly-up focus: independence and autonomy. 

•Teacher/PGY3 Fears: knowledge, teaching, 

being “in-charge.” 

‣Fly-up focus: teaching and leadership . 

The “Fly-Up” Solution 

Structure: 

• The last two weeks of June 

(before interns arrive). 

• Alternating one-week rotations address 

challenges identified above. 

Education: 

• “New” Managers/PGY2s and 

Teachers/PGY3s rotate through two of their 

upcoming rotations with at least one peer and 

the additional support of a soon-to-be 

graduating resident. 

• Daily conferences (Fig. 2) highlight key 

transitional topics for the two groups. 

Figure 1: Baystate LMT Model 

M T W Th F 

Morning Orientation Illness Scripts Learning Model Case Small Group 

Objectives Presentation Teaching 

Report 

Manager 

ACLS Organizing your EMR Tricks and Managing Your Self-Directed 

Algorithms 

Day 

Tips 

Attending 

Precepting 

12-1PM 

Teaching Styles Rounding Tips 

Giving 

One Minute Communication 

and Tricks 

Feedback 

Preceptor 

Teacher 

1-2PM 

SIM Center: 

SIM Center: 

Code Training 

Code Training 

Figure 2: Conference Schedule 

Results 

• The majority of residents rate the rotation 

as ‘above average.’ 

• The majority of residents believe that the 

overall experience either ‘got them started’ 

or helped to ‘consolidate knowledge and 

skills.’ 

• Through resident feedback, we have made 

the following changes: 

• separate noon conference tracks for to-be- 

Managers/PGY2s and Teachers/PGY3s. 

• Model morning-report session. 

• Residents: Fly-up is an invaluable rotation 

that helps to alleviate concerns and 

improve confidence. 

Lessons Learned 

• Separate tracks for to-be- 

Managers/PGY2s and Teachers/PGY3s 

allow our program to focus on classspecific 

needs. 

• Peer support and increased supervision 

during the Fly-up experience can allay 

fears that accompany the July transition 

into more autonomous and leadership 

roles. 

• The Fly-up is an integral element in our 

competency-based curriculum as it 

prepares our residents for key transitions 

and new responsibilities. 

Competency-Based 

Advancement System 

Learner 

(direct supervision) 

Manager 

(indirect supervision) 

Teacher 

(supervises) 

PGY-1 

PGY-2 

PGY-3


Poster Title: The July Transition—Making It Easier 

Authors and Affiliate Institutions: EIP Working Group, Baystate Medical Center/Tufts University School of 

Medicine 


Gina Luciano, MD 



Baystate Medical Center 

759 Chestnut Street—S2570 

Springfield, MA 01062 

Telephone: (413) 794-4143 

Email: gina.luciano@baystatehealth.org 

Discussion of How the Problem was Identified and Explored: Many residents, including ours, feel ill prepared 

for July transitions. In response to this need, we designed a unique “Fly-up” opportunity within the context of our 

Learner-Manager-Teacher (LMT) model to allay fears and to develop essential skills. 

Description of the Innovation: Our “Fly-up” period occurs during the last two weeks of June (before interns 

begin). The experience consists of alternating one-week rotations designed to address challenges identified through 

program assessment and to help to-be-Managers and to-be-Teachers gain necessary skills and confidence. 

Consistent with the goals of our LMT model, Manager Fly-up is focused on independence and autonomy whereas 

education and leadership are emphasized for Teacher Fly-up. Prior to this curricular change, Learners transitioning 

to Managers were most anxious about nightfloat, CCU and ward rotations. To alleviate this anxiety, upcoming 

Managers rotate through two of these rotations (one per week) with at least one peer and the additional support of a 

soon-to-be graduating resident. A similar schedule is arranged for upcoming Teachers who are most concerned with 

being an ICU or ward teaching resident. Our conferences spotlight key transitional topics including managerial 

skills, ACLS, and self-directed precepting for to-be-Managers and rounding tips, leadership / teaching styles, 

communication and giving feedback for to-be-Teachers. All residents attend morning report where illness scripts, 

learning objectives and small group teaching are the focus. 

Results to Date: The majority of residents rate the rotation as ‘above average’ and believe the experience either 

‘got them started’ or helped to ‘consolidate knowledge and skills.’ Through resident feedback, we have made the 

following changes: separate noon conference tracks for to-be-Managers and Teachers as described above and a 

‘model morning-report’ session were added. Anecdotally, residents often remark that the Fly-up is an invaluable 

rotation that helps to alleviate concerns and improve confidence. 

Discussion/Reflection/Lessons Learned: Separate tracks for to-be-Managers and Teachers allow our program to 

focus on class-specific needs and facilitate open and honest discussion. Peer support and increased supervision 

during the Fly-up experience can allay fears that accompany the July transition into more autonomous roles. The 

Fly-up is an integral element in our competency-based curriculum as it prepares our residents for key transitions 

and new responsibilities. 



Poster Title: A Refined Patient Safety and Quality Improvement Curriculum for Internal Medicine Residents— 

Based on a Six-Year Feedback and Review 

Authors and Affiliate Institutions: Srikrishna V Malayala, Daniel Molloy, Mushtaq Bhat, Salim H Memon, 

Abdul Samdani, Ridhwan Y Baba, Ramesh Metta, Bishnu Kattel, Tawfiq Zabaneh, Shabnam Rehman, Ammar 

Saati, Khalid J Qazi, University at Buffalo (Catholic Health System—Sisters of Charity) 


Srikrishna V. Malayala, MD 



University at Buffalo (Catholic Health System—Sisters of Charity) 

2157 Main Street 

Buffalo, NY 14227 

Telephone: (304) 951-3599 

Email: varun_msk@yahoo.com 

Discussion of How the Problem was Identified and Explored: In September 2007; ACGME Committee on 

Innovation called for identification of opportunities to enhance quality and safety in teaching institutions by 

studying the outcomes of resident involvement in organized institutional quality improvement initiatives. As of 

academic year 2012, the Internal Medicine Program of University at Buffalo/ Catholic Health System had a 4 week 

rotation titled ‘Performance Improvement’ which is designed based on the ACGME recommendations. This 

rotation was first implemented in 2006 and was scheduled in the second year of training. There were 5 learning 

activities in the curriculum: Core measure chart review, Understanding Peer Review Process, rotation with Clinical 

Documentation specialist, Clinical Patient Safety Goals and Standards & Adverse Significant Event Reporting. 

Description of the Innovation: Aim: To further refine the PSQI curriculum and enhance the resident training in 

terms of the ACGME six core competencies. Methods: Residents of the last 3 years were asked to grade the 

components of the curriculum on a scale of 1-9 (1-3: unsatisfactory; 4-6: satisfactory and 7-9: superior). Residents 

were also asked to submit a subjective evaluation of the rotation. 

Results to Date: 1) 36 residents responded to the survey. The evaluations were in the superior category for core 

measure review (7.26/9); peer review process (7/9); Adverse Event reporting (7.18/9), satisfactory category for 

Patient Safety Goals and Standards (6.94/9). Overall co-ordination of the rotation was graded as satisfactory (6.5/9). 

2) Subjectively, majority of residents felt that the rotation should be cut down to 2 weeks. Many felt that some 

components of the rotation can be moved to PGY-1 to enhance the training in an early phase. 3) Residents and 

faculty suggested a list of additional learning activities based on the available literature and current practice. 

Discussion/Reflection/Lessons Learned: Based on the feedback and recommendations, a new PSQI curriculum is 

designed which spreads over three years of training entitled Quality 101 (2 weeks in PGY-1), Quality 201 (2 weeks 

in PGY-2) and Quality 301. New components of the curriculum will be rotation with department of pharmacy, 

Infection Control and Case management. A “PSQI task force committee” comprising the current residents and 

faculty is formulated to submit a periodic feedback of the rotation. 



Poster Title: Preparing Residents for Team-Based Patient Care: The Development and Implementation of a 

Resident Leadership and Management Training Program 

Authors and Affiliate Institutions: Jared Moore, David Wininger, Maria Lucarelli, Michael Velez, Christopher 

Hanks, Neil Dunavin, Ohio State University College of Medicine, Wexner Medical Center 


Jared Moore, MD 

Assistant Program Director 


Ohio State University College of Medicine, Wexner Medical Center 

2050 Kenny Road 

Second Floor Pavilion, Suite 2400 

Columbus, OH 43221 

Telephone: (614) 685-1923 

Email: jared.moore@osumc.edu 

Discussion of How the Problem was Identified and Explored: Physicians should be the leaders of the 

multidisciplinary healthcare teams that will be required to deliver comprehensive patient care within a complex 

medical and social environment. We believe we can help our residents develop the skills needed to do that, so we 

enlisted the expertise of both medical center faculty and faculty from the university’s business college in an effort 

to create our Leadership and Management Program. 

Description of the Innovation: Our curriculum is divided into three phases: mandatory intern year training, 

voluntary second and third year training, and advanced training for select residents. The intern curriculum is 

divided into four series: awareness, communication, leadership without authority, and developing personal 

leadership styles. Individual modules focus on making the sessions applicable to interns and preparing them for 

their transition to resident. Intern modules are scheduled once per rotational block and take place during scheduled 

lecture time. Second and third year programming will focus on preparing residents to assume leadership positions 

both within and after residency training. The course will cover complex team leadership and management theory, 

conflict management, organizational and system strategic planning and leading through change. The advanced 

training program will allow residents to work with senior leadership on medical center wide projects. 

Results to Date: To date, we have delivered four intern modules with feedback in the form of post-module 

surveys. Feedback has been favorable with residents preferring modules that promote resident interaction and 

address problems that are most immediately pertinent to them. 

Discussion/Reflection/Lessons Learned: We successfully implemented the Leadership and Management Program 

because we received support from members of leadership at all levels throughout the medical center. Additionally, 

we developed internal and external validity by engaging residents and the business college faculty in the planning 

process. While a business school may not be available to all programs, institutional and community leaders could 

serve a similar purpose. Buy in for the program amongst interns has remained the greatest challenge especially at 

the beginning of the intern year. We believe that this program will be successful and sustainable if we can help 

residents recognize how a deeper understanding of the principles and skills of leadership and management can 

improve patient care. 


The Next Step in Collaborative Care: 

Medical-Legal Partnerships 

Brandon Murguia MD, APDIM Presenter 

St. Mary’s Medical Center, San Francisco 

Introduction 

In response to continued health disparities in access to healthcare and 

health insurance, rising incidence and cost of chronic illnesses, and a 

growing body of evidence demonstrating the influence of social and 

environmental factors on health and well-being 1,2 , Medical Legal 

Partnership (MLPs) are emerging as a new standard of care for lowincome, 

vulnerable patient populations across the country. Firstly 

developed at Boston Medical Center in 1993, MLPs have rapidly 

expanded over the last 10-12 years, and as of 2010, are active at 216 

health care sites across the US (in a range of specialties, settings, and 

patient populations): 

Implementation 

Since July 1, 2010 our partnership has focused on achieving the 3 core 

components of MLP practice: (1) direct assistance for patients, (2) 

training for health care staff, and (3) combined medical-legal systems 

advocacy. 

The I-HELP Legal Screening Assessment 

Legal need 

Examples of legal needs that affect health 

Income Supports 

Social Security benefits 

Disability benefits 

Insurance access and benefits 

Food stamps 

Assistance programs 

General income 

Housing and Utilities 

Sanitary housing conditions 

Foreclosure prevention / Eviction protection 

Utility access, assistance, and shutoff protection 

Access to housing subsidies 

Disabled tenant rights 

Shelter access 

Education/Employment Discrimination 

Americans with Disability Act compliance 

Family & Medical Leave Act compliance 

Worker’s compensation rights 

Fair Labor Standards Act 

Legal Status 

Personal and Family Stability 

Immigration status 

Criminal record issues 

Domestic violence 

Sexual abuse 

Elder abuse and neglect 

Divorce 

Capacity/competency 

Advance directives 

Powers of attorney 

Figure 1. Source: National Center for Medical-Legal Partnership. MLP Network 

[Internet]. Boston (MA): http://www.medical-legalpartnership.org/mlp-network. 

An MLP combines the skill sets of medical professionals and lawyers 

to treat and teach social determinants of health, 3 including income, 

nutrition, housing, energy, employment/education, and personal 

stability. In recognizing that these determinants often manifest as 

unmet basic needs with legal remedies, which largely go unmet in 

low-income communities 4 , MLPs work together to eliminate barriers 

to both good health and effective healthcare delivery. 

Initial research and evaluation of the MLP model has been promising 

in several areas. Several longitudinal studies have shown MLP 

training to improve clinical workforce skills, including increased 

resident knowledge of social disparities, community resources, and 

referral rates. 5-7 Others have demonstrated improved patient health 

and well-being, including improved medication adherence, reduced 

stress, and improved quality of life. 7-9 And finally, incorporation of 

legal services has shown to be financially sustainable (and in many 

cases revenue-generating) for participating institutions. 10-13 

In June of 2010, the Volunteer Legal Services Program (M-BARC) 

joined with St. Mary’s Medical Center in San Francisco to found a 

medical legal partnership at the Internal Medicine residents’ primary 

care clinic, the Sr. Mary Philippa Health Center (SMPHC). 

Legal Assistance 

Healthcare 

Shifting Paradigms in Healthcare and Law 

Prevailing Model 

• Service is crisis-driven 

• Individuals are responsible for 

seeking legal assistance 

• Primary pursuit is justice 

• Adverse social condi1ons affect 

pa1ent health but are difficult to 

address 

• Healthcare team refers pa1ents to 

social worker/case manager for 

limited assistance 

• Advocacy skills are valued, taught and 

deployed inconsistently 

MLP Model 

• Service is preventive, focuses on 

early identification of and 

response to legal needs 

• Healthcare team works with 

patients to identify legal needs 

and makes referrals for 

assistance 

• Aims include improved health 

and well-being 

• Adverse social condi1ons with legal 

remedies are iden1fied and 

addressed as part of care 

• Healthcare, social work and legal 

teams work together to address legal 

needs, improve health and change 

systems 

• Advocacy skills are priori1zed as part 

of the standard of care 

Figure 3. Referral Process Overview at Sister Mary Philippa Health Clinic. 

Results 

Since July 1, 2010 the MLP has provided legal assistance to over 140 

patients, addressing close to 300 separate legal issues in this time. While 

the range of assistance varies widely, the principle areas of legal need 

have proved to be housing rights, followed by income supports, family/ 

personal stability issues, and legal issues (civil, criminal, and 

immigration). Over 60% of the patients served are disabled and 35% are 

over 60 years old. Remarkably, over 50% have ≥2 unmet legal needs, 

consistent with current data on legal disparities in low-income patients 

and families. 

Legal Needs at Resident Clinic 

Housing: 30% 

Income Supports: 28% 

Family/Personal Stability: 15% 

Legal Issues: 14% 

Employment: 6% 

Other: 7% 

Figure 4. Analysis of Legal Needs by Category at Sr. Mary Philippa Clinic from July 2010 

through present. 

Concurrent efforts have focused on the development and 

implementation of a resident/faculty education module on legal 

screening advocacy, accomplished through 1-on-1 attorney-resident 

training sessions, creation of advocacy code cards, and monthly case 

report conferences analyzing medical-legal barriers, interventions, 

and outcomes across our clinic patient population. The results have 

been an increase in the total number of referrals by nurses, social 

workers, and medical assistants, as well as an increase in the 

proportion of referrals from MDs (10 to 25%). 

Figure 5. Adapted from C. Kenyon, et al., “Revisiting the Social History for Child 

Health,” Pediatrics. 120(2007): e734-738. These authors adapted the I-HELP 

assessment tool. 

Conclusions 

MLPs have emerged as a transformative tool in medicine and law, 

empowering physicians and attorneys to directly address adverse social 

conditions and work preventively towards improved health and wellbeing. 

As oncoming governmental health care reform expands access of 

vulnerable patients to medical homes and federal/state health insurance 

programs restructure reimbursement models on prevention and patient 

outcomes, MLPs may be the innovation necessary to deliver efficient, 

cost-effective, and genuinely comprehensive care to our communities. 

This year, the SMPHC MLP will undertake a research study that 

prospectively evaluates the impact of legal intervention(s) on global 

patient health; specifically, (1) objective health status (blood pressure, 

A1C, LDL), (2) healthcare utilization (preventive care visits, ER visits, 

hospitalizations), and (3) health status intermediates (perceived stress, 

subjective social status, and self-rated health). 

Bibliography 

1. WHO Commission on Social Determinants of Health. Closing the gap in a generation: health 

equity through action on the social determinants of health. Available at: http:/whqlibdoc.who.int/ 

publications/2008/ 9789241563703_eng.pdf. Accessed October 15, 2012. 

2. Braveman, P., et al. Broadening the focus: the need to address the social determinants of health. 

American Journal of Preventive Medicine. 2011;40(1S1):S4 –S18. 

3. Zuckerman B, Sandel M, Lawton E, Morton S. Medical-legal partnerships: transforming health 

care. Lancet. 2008;372:1615–1617. 

4. Services Corporation. Documenting the justice gap in America, 2005. LSC. 

http://www.lsc.gov/justicegap.pdf. Accessed October 28, 2012. 

5. Klein, D., et al. Training in Social Determinants of Health in Primary Care: Does it Change 

Resident Behavior? Academic Pediatrics. 2011;11:387-393 

6. Cohen et al. Medical-Legal Partnership: Collaborating with Lawyers to Identify and Address 

Health Disparities. Journal of General Internal Medicine. 2010; 25(Suppl 2):136–9. 

7. Weintraub et al. Pilot Study of Medical-Legal Partnership to Address Social and Legal Needs of 

Patients. Journal of Health Care for the Poor and Underserved. 21(2010): 157-168. 

8. Zevon MA, et al. Medically-related legal needs and quality of life in cancer care: a structural 

analysis. Cancer. 2007;109:2600–2606. 

9. Fleishman SB, et al. The attorney as the newest member of the cancer treatment team. Journal of 

Clinical Oncology. 2006; 24:2123–2126. 

10. Teufel, et al. Process and impact evaluation of a legal assistance and health care community 

partnership. Health Promotions Practice. 2009(10):378-384. 

11. Rodabaugh, et al. A medical-legal partnership as a component of a palliative care model. Journal 

of Palliative Medicine. 2010;13(1):15-18. 

12. LegalHealth. Financial impact study of LegalHealth services to New York City hospitals . 

LegalHealth. Nov 2007. Available at: http://legalhealth.org/docs/lgh_financial_impac_study.pdf. 

13. MLP for Children. Health Care Recovery Dollars: A Sustainable Strategy for Medical- 

14. Edward, Paul, et al. Medical-Legal Partnerships: addressing competency needs through lawyers. 

Journal of Graduate Medical Education. Dec 2009: 304-309. 

Figure 2. Source: National Center for Medical-Legal Partnership. MLP Network [Internet]. 

Boston (MA): http://www.medical-legalpartnership.org/mlp-model. 

www.postersession.com


Poster Title: The Next Step in Collaborative Care: Medical-Legal Partnerships 

Authors and Affiliate Institutions: Brandon Murguia, Nooshin Yashar, St. Mary’s Hospital and Medical Center 


Brandon R. Murguia, MD 



St. Mary’s Hospital and Medical Center 

2250 Hayes Street 

Fourth Floor, Medical Education 

San Francisco, CA 94117 

Telephone: (415) 750-5955 

Email: Brandon.Murguia@dignityhealth.org 

Discussion of How the Problem was Identified and Explored: In response to continued health disparities in 

access to healthcare and health insurance, rising incidence and cost of chronic illnesses, and a growing body of 

evidence demonstrating the influence of social and environmental factors on health and well-being, Medical Legal 

Partnership (MLPs) are emerging as a new standard of care for low-income, vulnerable patient populations across 

the country. An MLP is a combined delivery model that brings together medical professionals and attorneys, 

integrating legal assistance into the primary care setting to address social determinants of health (including income 

and food security, housing, energy, employment/education, and personal stability). 

Description of the Innovation: In June of 2011, the Volunteer Legal Services Program (M-BARC) joined with St. 

Mary’s Medical Center in San Francisco to found a medical legal partnership at the Internal Medicine residents’ 

primary clinic, the Sr. Mary Philippa Health Center (SMPHC). 

Results to Date: Since then, the MLP has provided legal assistance to over 200 patients, addressing over 150 legal 

issues in this time. The principle areas of legal need over this time have proved to be housing rights, disability 

income benefits, employment issues, family law, and health insurance issues. Over 60% of the patients served are 

disabled and 35% are over 60 years old. Remarkably, over 70% have ≥2 unmet legal needs, consistent with current 

data on legal disparities in low-income patients and families. Concurrent efforts have focused on the development 

and implementation of a resident/faculty education module on legal screening advocacy, accomplished through 

attorney-resident training sessions and monthly case report conferences analyzing medical-legal barriers, 

interventions, and outcomes across our patient population. The results have been an increase in total number of 

referrals by healthcare professionals, as well as an increase in the proportion of referrals from MDs (10 to 30%). 

Discussion/Reflection/Lessons Learned: MLPs have emerged as a transformative tool in medicine and law, 

empowering physicians and attorneys to directly confront adverse social conditions and work preventively towards 

improved health and well-being. This year, our MLP is undertaking a research study that prospectively evaluates 

the impact of legal intervention(s) on global patient health; specifically, (1) objective health status (blood pressure, 

A1C, LDL), (2) healthcare utilization (preventive care visits, ER visits, hospitalizations), and (3) health status 

intermediates (perceived stress, subjective social status, and self-rated health). 



Poster Title: Improving Resident Documentation: Coding and Billing Practices with a Practical Tutorial 

Authors and Affiliate Institutions: Moyna H Ng, Lenox Hill Hospital 


Moyna H. Ng, MD 


Department of General Internal Medicine 

Lenox Hill Hospital 

100 East 77th Street 

New York, NY 10075 

Telephone: (212) 434-4849 

Email: mng3@nshs.edu 

Discussion of How the Problem was Identified and Explored: While Internal Medicine residents undergo 

rigorous clinical training, they rarely participate in any structured learning in medical coding and billing. There is 

cursory exposure in the ambulatory care setting. However, in the inpatient setting, residents have minimal 

knowledge regarding proper medical coding, billing and adequate supporting documentation. Since these skills are 

essential once they become practicing attending physicians, an innovative tutorial was developed and incorporated 

into the Medical Consultation rotation targeted at the PGY-3 trainees. 

Description of the Innovation: During a two week rotation on Medical Consultation, a PGY-3 resident works 

with an academic hospitalist and they are charged with coding and billing each patient encounter on mock billing 

cards. The tutorial is divided into four phases. Phase One – the resident codes and bills each patient visit without 

any aide. Phase Two – the resident is given a reading packet consisting of two articles on documentation, coding 

and billing, a hospitalist progress note template, a hospital pocket pamphlet on coding and billing and a one page 

reference guide published by CMS. Phase Three –the resident meets with the academic hospitalist to review each 

mock billing card and the corresponding documentation (initial consultation or follow up progress note) for 

appropriate Evaluation & Management coding and level of service billing. Phase Four – the resident continues to 

code and bill patient encounters and a final review is performed at the end of the rotation. A pre- and post-rotation 

survey based on a Likert scale assessing the resident’s knowledge, confidence and ability to teach documentation, 

coding and billing is given on the first and last day of the rotation, respectively. 

Results to Date: Results to date reveal a statistically significant trend towards improvement in knowledge, 

confidence and ability to teach the fundamentals of medical coding and billing with accurate supportive 

documentation. Residents were highly satisfied with this short and effective tutorial. 

Discussion/Reflection/Lessons Learned: It also incorporates the Systems Based Practice competency to teach 

residents to work effectively in various health care delivery settings. It can be easily imbedded in a variety of two 

or four week rotations during academic training with recruitment of a few faculty members. 


Ambulatory Clinician‐Education Rotation for Primary Care Residents 

Kerri Palamara, MD; Valerie E Stone, MD, MPH 

Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 

Statement of the Problem 

Results 

Rotation Components 

 

 

 

 

ACGME requirements that 1/3 of all residents’ time be spent 

in ambulatory setting led to fewer differences in the training 

experience of MGH primary care and categorical residents. 

Primary care residents expressed a need to better develop 

their teaching skills. 

Coincidentally, the proportion of MGH’s primary care 

residents entering careers in primary care internal medicine 

was rising. 

This presented an opportunity to innovate and develop 

experiences to better prepare primary care residents for the 

careers they were entering 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

Change in Teaching Abilities 

‣Prepare and deliver ambulatory didactic curricular talks –small group, large 

group, and case‐based 

‣Select useful ambulatory teaching cases and apply them to varied teaching 

environments 

‣Participate fully in mentored precepting experiences 

‣Review Ambulatory Clinician Educator curriculum and apply knowledge to 

talk preparation 

‣Meet with rotation mentor weekly to discuss progress, plan for upcoming 

talks, navigate challenges 

Findings to Date 

Objectives of Innovation 

Expose primary care senior residents to the knowledge and 

skills necessary for competent practice as an ambulatory 

clinician educator. 

Provide an opportunity and setting for direct observation of 

teaching skills with specific feedback for development. 

Description of Innovation 

Ambulatory Training Structure at MGH: 

‣ Regular continuity clinic sessions scheduled through the 

academic year. 

‣ 3 months of ambulatory block scheduled in each trimester 

‣2 weeks Ambulatory Subspecialty Rotation, 2 weeks 

Ambulatory Care Rotation 

PC Senior Residents –4 months of ambulatory; 1 month as 

designer block, 1 month as Ambulatory Teaching Senior 

Four week rotation coordinated by APD. 

Scheduled time for preparation, teaching, continuity clinic, and 

shadowed and mentored precepting. 

Ambulatory educational activities in didactic and clinical 

settings: 

‣ Large and small group didactics 

‣ Precepting 

‣ Case‐based teaching 

0% 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Create positive 

learning 

environment 

Curriculum 

helpful 

Modify 

teaching to 

learners needs 

SGT 

exercise 

useful 

Use OMP 

Model 

LGT 

exercise 

useful 

Prepare 

focused 

presentation 

on essential 

teaching points 

Prepare AV 

materials to 

enhance 

presentation 

Use engaging 

delivery style 

Encourage 

audience 

participation 

No change Some Improvement Large Improvement 

Satisfaction with Curricular Components 

Preceptor 

shadow ing 

useful 

Agree 

Mentored 

precepting 

useful 

Running 

Ambulatory 

Intern 

Report 

useful 

Strongly Agree 

Morning 

report 

exercise 

useful 

Meeting w ith 

mentor 

useful 

Apply Feel 

facilitation comfortable 

techniques to w ith silence 

improve small w hen teaching 

group 

dynamics 

Prep time 

adequate 

OMP = One Minute Preceptor; LGT = Large group talk SGT = Small Group Talk 

Good 

addition to 

the Primary 

Care 

Program 

All 9 primary care senior residents surveyed – 100% completion. 

Varied curricular components were uniformly well received and residents 

all reported change in teaching behaviors. 

100% strongly agreed that the rotation was a good addition to primary care 

program. 

Participating supervising faculty increased from 9 to 16 in year 2. 

In Year 2, residents asking for additional shadowing and precepting 

experiences. 

Survey comments: 

“Great training for becoming an ambulatory preceptor/educator and fills 

a void in our curriculum.” 

“I appreciated trying out different teaching modalities and expanding 

skills.” 

Key Lessons Learned 

Based upon our experience, 

‣With dedicated ambulatory clinician educators and faculty supervision, 

residency programs can incorporate an Ambulatory Clinician Educator 

Rotation for residents 

‣A four week dedicated teaching rotation is academically valuable, allows 

residents to improve upon their teaching skills, and develop greater 

confidence in their teaching style.


Poster Title: Ambulatory Clinician-Educator Rotation for Primary Care Residents 

Authors and Affiliate Institutions: Kerri Palamara, Valerie Stone, Harvard Medical School Massachusetts 

General Hospital 


Kerri L. Palamara, MD 




Harvard Medical School Massachusetts General Hospital 

55 Fruit Street 

Boston, MA 02114 

Telephone: (857) 383-8172 

Email: kpalamara@partners.org 

Discussion of How the Problem was Identified and Explored: The ACGME requirement that one-third of 

residents’ time be spent in the ambulatory setting led to fewer differences in the training experiences of primary 

care residents compared to categorical residents at Massachusetts General Hospital. Additionally, the proportion 

of MGH’s primary care residents entering careers in primary care internal medicine was rising. This presented an 

opportunity to innovate and develop experiences for primary care residents to better prepare them for primary care 

internal medicine careers. Our residents expressed a need to better develop their teaching skills, and therefore, the 

Ambulatory Teaching Senior Rotation was created. 

Description of the Innovation: In this 4 week rotation, primary care senior residents participate in ambulatory 

educational activities in both the didactic and clinical settings. The goal of the rotation is to expose primary care 

senior residents to the knowledge and skills necessary for competent practice as an ambulatory clinician educator. 

Activities include large and small group observed teaching, preceptor observation, mentored precepting, career 

focused discussions with faculty mentors, observed case-based teaching, and their own continuity clinic 3-4 

sessions per week. They are expected to prepare and deliver ambulatory didactic curriculum lectures, select useful 

ambulatory teaching cases and apply them to large and small group teaching sessions, and participate fully in 

resident precepting sessions. 

Results to Date: All nine of the primary care senior residents were anonymously surveyed after they had all 

completed the rotation. 100% agreed that the Ambulatory Teaching Senior Rotation was a welcome addition to the 

program. 100% reported at least some improvement in their ability to facilitate a small group discussion, encourage 

audience participation, prepare a presentation with focused teaching points, modify their teaching to fit the learners’ 

needs, and use an engaging delivery style. 100% of residents agreed that the opportunities to deliver a small group 

talk, PowerPoint talk, be observed precepting, and meet regularly with a faculty mentor throughout the rotation 

were useful. 

Discussion/Reflection/Lessons Learned: With dedicated ambulatory clinician educators and faculty supervision, 

residency programs can incorporate an Ambulatory Clinician Educator Rotation for residents. A four week 

dedicated ambulatory teaching rotation allows residents to improve upon their teaching skills and develop greater 

confidence in their teaching style. 


14 

12 

10 

8 

6 

4 

2 

0 

16 

14 

12 

10 

8 

6 

4 

2 

0 

30 

25 

20 

15 

10 

5 

0 

Less Sinking and More Swimming: Resident Primary Care Immersion Blocks 

Kerri Palamara, MD; Alaka Ray, MD; Blair Fosburgh, MD; Valerie E Stone, MD, MPH 

Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 

 

 

 

 

Statement of the Problem 

The demand for primary care physicians is rising, but fewer trainees are 

entering the primary care workforce. 

Based on our end‐of‐year resident survey, graduating residents feel 

unprepared for careers in primary care. 

Work hour regulations have led to longer gaps between continuity clinic 

sessions and increased inpatient demands. 

Without a regular clinic experience, residents are unable to gain an indepth 

understanding of resources available to their patients and the 

rewards of a primary care career. 

Immersion Block Experiences: 

Continuity Clinic (3 sessions weekly; 6 total) 

1:1 time with preceptor (discuss feedback, high‐risk patients, billing, clinic 

procedures) 

Shadow preceptor clinic session 

1:1 time with practice RN 

Shadow clinic‐based Diabetes NP 

Panel Management session 

1:1 time with EMR specialist 

Practice Reorientation 

Begin a Practice‐Based Improvement Project 

EBM review of a clinic‐generated question 

Report back to group on chosen project and EBM review 

Objectives of Innovation 

Abillity to Use EMR 

Findings to Date 

Increase resident comfort level in care of ambulatory patients 

Reinforce principles of team‐based care 

Expose residents to positive role models in primary care 

Increase resident satisfaction with their continuity clinic 

Increase resident preparedness for careers in primary care 

Description of Innovation 

Resident population: All primary care and categorical residents graduating in 

2014 

Typical ambulatory training structure at MGH: 

Regular continuity clinic sessions scheduled through the academic year 

3 months of ambulatory block scheduled in each trimester of year –2 

weeks ambulatory subspecialty experience, 2 weeks Ambulatory Care 

Rotation 

Residents in 2 major teaching practices were assigned a Primary Care 

Immersion Block (IB) during one regularly scheduled Ambulatory Care 

Rotation. 

Experiences were focused on Practice‐based Learning & Improvement and 

Systems Based Practice competencies. 

Voluntary survey data was collected from all participating residents mid‐year 

(prior to IB) and at the end of each year of training. 

Surveys evaluated their views towards their continuity clinic, primary care, 

and the likelihood that they would enter a career in general medicine. 

Poor Fair Good Very Good Excellent 

IB res Pre IB res Post nonIB res Pre nonIB res Post 

Likelihood of Asking MA or RN Help 

Very Unlikely Unlikely Unsure Likely Very Likely 

IB res Pre IB res Post nonIB res Pre nonIB res Post 

How Effective Do You Think You Are At 

Providing Primary Care for Your Patients 

78% of residents agreed that the Primary Care Immersion Block was a useful 

educational experience. 

Residents in Immersion Block practices felt more supported by their clinic staff 

than residents in non‐IB practices, demonstrated by increased likelihood of asking 

for help from MAs, RNs, and Patient Care Coordinators. 

There was a trend towards improved effectiveness at providing primary care for 

their patients in all residents, regardless of whether they were in an Immersion 

Block practice or not. 

Key Lessons Learned 

Based upon our experience, Resident Primary Care Immersion Blocks: 

‣ Expose residents to what a career in primary care would look like 

‣ Increase resident comfort level in their primary care practice 

‣ Increase resident satisfaction with their continuity clinic experience 

‣ Are generalizable to other institutions looking to improve the resident continuity 

clinic experience 

‣Additionally, the overall trend amongst all residents toward improved 

effectiveness at providing primary care for their patients suggests that regular 

continuity clinic throughout the year and focused ambulatory care rotations are 

sufficient, and Immersion Blocks can only enhance that experience. 

Ineffective 

Somewhat 

Ineffective 

Neither Somewhat Effective Effective 

Pre 

Post


Poster Title: Less Sinking and More Swimming: Resident Primary Care Immersion Blocks 

Authors and Affiliate Institutions: Kerri Palamara, Alaka Ray, Harvard Medical School Massachusetts General 

Hospital 


Kerri L. Palamara, MD 




Harvard Medical School Massachusetts General Hospital 

15 Parkman Street 

WACC 535 


Telephone: (857) 383-8172 

Email: kpalamara@partners.org 

Discussion of How the Problem was Identified and Explored: The demand for primary care physicians is rising 

yet fewer trainees are choosing primary care careers. The ACGME work hour regulations complicate this issue due 

to longer gaps between continuity clinic sessions and increased inpatient work demands. When residents are not in 

clinic regularly, they are unable to gain an in depth understanding of the resources available to them and their 

patients. 

Description of the Innovation: The objectives were to increase resident comfort level in outpatient practice, 

reinforce the principles of team-based care and expose residents to what a real career in primary care might look 

like. We designed Primary Care Immersion Blocks focused on Practice-based Learning & Improvement and 

Systems Based Practice. All residents from the intern class of 2011-12 with clinics in the 2 major teaching practices 

were assigned an Immersion Block during one of their regularly scheduled ambulatory blocks. Immersion Block 

(IB) experiences include 1:1 time and shadowing with their preceptor and the diabetes nurse practitioner, panel 

management time, 1:1 time with the EMR specialist, practice reorientation, time for a practice-based improvement 

project, and time to review data behind a clinic-generated question (EBM time). Voluntary survey data was 

collected from all residents from the intern class of 2011-12 at mid-year and the end of each year of training to 

evaluate their views towards continuity clinic, primary care, and the likelihood that they would enter a career in 

primary care. 

Results to Date: Seventy-six percent of residents surveyed agreed that Immersion Blocks were useful. Residents 

in IB practices reported feeling more supported by their clinic staff than residents in non-IB practices. There was a 

trend amongst all residents, regardless of IB participation, toward improved effectiveness at providing primary care 

for their patients. 

Discussion/Reflection/Lessons Learned: Resident Ambulatory Immersion Blocks increase resident comfort level 

in their practice and satisfaction in their continuity clinics. Immersion Blocks are generalizable to other institutions 

looking to improve the resident continuity clinic experience. 



Poster Title: Training Residents for Independent Inpatient Practice (TRIIP): Ongoing Development of a Novel 

Clinical Rotation Using PDCA and Milestones to Improve Education in Hospital Medicine 

Authors and Affiliate Institutions: David Paje, Peter Watson, Charles Coffey, Clifford Kaye, James Jeffries, 

Gregory Buran, Peter Luyeho, Errol Zimmerman, Henry Ford Hospital; Kelly Caverzagie, University of Nebraska 

Medical Center 


David Paje, MD 



Henry Ford Hospital 

2799 West Grand Boulevard, CFP-4 

Detroit, MI 48374 

Telephone: (313) 916-8144 

Email: DPAJE1@hfhs.org 

Discussion of How the Problem was Identified and Explored: Evaluation of resident performance on predefined 

competencies while delivering inpatient clinical care has historically been difficult. We developed a novel 

clinical rotation incorporating new educational and assessment strategies providing residents intense hospital 

medicine training and significant autonomy. 

Description of the Innovation: In July 2011, the Training Residents for Independent Inpatient Practice (TRIIP) 

Rotation was established to prepare PGY-2/3 residents for unsupervised hospital medicine practice and allow 

faculty to assess their demonstration of high-level integrative skills required of an independently practicing 

physician. TRIIP is intended to provide an “academic stress test” and assess progression towards unsupervised 

practice. The core of the program is an inpatient preceptor model pairing individual residents with a hospital 

medicine faculty cycling through several different roles (primary inpatient provider and medical consultant). 

During its implementation, we have utilized a continuous PDCA cycle of resident, faculty and nursing feedback to 

enhance the clinical and learning experience. 

Results to Date: Over 60 internal medicine residents have been trained. Overall resident assessment of teaching 

was 4.15/5 and curriculum 3.80/5. Resident feedback emphasized several strengths (availability of faculty, 

increased resident autonomy/independence, improved resident efficiency, and clinical decision making 

development) and opportunities for improvement (difficult block scheduling, more didactic teaching, variability in 

peer resident performance on small team). This feedback led to further stratification of the rotation into a Level I 

(PGY-2 inpatient rounder focus) and Level II (PGY-3 inpatient medical consultant focus) that is linked throughout 

the month. 

Discussion/Reflection/Lessons Learned: This new rotation met the core goals of increasing resident 

independence and performance on specific clinical activities as judged by faculty, although this experience was 

viewed differently depending on the trainee. Without interns or students, residents provide direct clinical care and 

are evaluated in a “real-world” clinical environment. The use of “micro-geography” on a geographic clinical unit 

allowed residents to work in interdisciplinary teams and for direct observation of resident teamwork skills. Faculty 

working as one-on-one clinical coaches with a resident allows for an in-depth behavioral-based evaluation of the 

integrated skills required of the unsupervised physician. Finally, focusing on clinical rotation improvement with 

the same rigor as clinical process improvement was an intense faculty development exercise. 



Poster Title: Remediating Residents in Transition: Individualizing the Learner-Manager-Teacher Model 

Authors and Affiliate Institutions: Anne Pereira, David Hilden, Sam Ives, Hennepin County Medical Center 


Anne G. Pereira, MD 

Associate Professor 

Division of Medical Education 


Hennepin County Medical Center 

G5 

701 Park Avenue 


Telephone: (612) 873-2691 

Email: anne.pereira@hcmed.org 

Discussion of How the Problem was Identified and Explored: The educational model for PGY-1 to PGY-2 

transition places high demand on the new PGY-2 in the inpatient setting: in addition to responsibility for an 

increased number of patients, PGY-2s must lead interprofessional teams and teach students and interns. Often, this 

is the new PGY-2’s first substantial professional leadership role. The majority of our trainees are able to make this 

transition with time-limited training in preparation for their new role. However, we recognized that the PGY-1s 

who struggled to obtain mastery at their level of training were substantially more challenged in this transition. 

While faculty could ensure that patients were safe with the struggling new PGY-2’s, their lack of leadership and 

peer teaching led to suboptimal experience for their interns and students. 

Description of the Innovation: Since 2006, we have modified the PGY-1 to PGY-2 transition for interns 

identified by the clinical competence committee as at risk (typically by February of the PGY-1 year) for 

unsuccessful transition. In the first two months of their PGY-2 year, they work exclusively with our academic 

hospitalists to manage patients independently, separate from housestaff teams, in a modified approach to the 

Baystate “Learner-Manager-Teacher” model. Goals of remediation are developed collaboratively with the resident, 

the program director and the director of the hospitalist division and shared with the teaching hospitalist(s). 

Biweekly meetings review progress and identify outstanding goals. Upon completion of the remediation months, if 

goals have been met, the resident is integrated into the standard PGY-2 year. 

Results to Date: Since 2006, eight of 130 (6%) residents have been required to complete our remedial pathway, 

with a range of zero to two residents per year. Five of the eight residents have graduated on time, having made a 

successful integration into the standard program. Of the graduates, 4 have been board certified (one delayed 

examination), 2 entered subspecialty training programs and 3 are in community practice. 

Discussion/Reflection/Lessons Learned: While most trainees are able to successfully transition from intern to 

supervising resident, struggling trainees are able to build skills in an individualized academic hospitalist experience. 

With this experience, they are able to successfully transition to team leadership and intern/student supervision. 



Poster Title: Training Homework: Does a Structured Reading and Testing Program Improve Performance on the 

ABIM In-Training Exam? 

Authors and Affiliate Institutions: Seth Politano, Eric Hseih, Keck School of Medicine at the University of 

Southern California 


Seth Politano, DO 


Department of Geriatric, Hospitalist, Palliative, and General Internal Medicine 

Keck School of Medicine at the University of Southern California 

1200 North State Street 

IRD 637 

Los Angeles, CA 90089 

Telephone: (323) 226-6571 

Email: politano@usc.edu 

Discussion of How the Problem was Identified and Explored: Internal Medicine residency programs use the 

American Board of Internal Medicine (ABIM) In-Training examination (ITE) to assess the performance of their 

trainees. Both Program Directors and Residents use the information from the examination to target deficient areas 

of medical knowledge. In addition, programs can gauge the results of the ITE to target residents that have a high 

likelihood of not passing the initial internal medicine certification examination (i.e. the “boards”). Our Internal 

Medicine Program has noticed that residents were not progressing in their knowledge levels after advancing each 

year as demonstrated by results on the in-training examination. Therefore, our program initiated a structured 

curriculum/reading program to target weak areas. Our goal was to see if this learning program did indeed improve 

performance on the ITE, with an eventual goal towards improvement on the boards. 

Description of the Innovation: Study modules were created by the authors in each of the content areas specified 

by the ABIM (i.e. Cardiology, Neurology, Geriatrics, etc.). The packets are based on specific content area as set 

forth by the ABIM using the Medical Knowledge Self-Assessment program (MKSAP), Medstudy, and internet 

resources as a guide. Each packet contains open-ended questions for residents to study. At the end of the month, 

the resident was required to take a written quiz based on content in the packet and required a score of at least 70% 

to pass the module. Data was collected regarding who had completed a module, and results were compiled until the 

ITE in October 2011. 

Results to Date: There was a significant increase in ITE scores in those subjects in which residents completed the 

learning module and quiz compared to those in which no module and quiz was completed. 

Discussion/Reflection/Lessons Learned: Our core curriculum reading program increases performance on the 

ABIM ITE. Perhaps by requiring residents to read monthly, and assessing the knowledge gained by administering 

a quiz, we are simply enforcing good study habits. The use of the program will hopefully increase board pass rates, 

and a similar structured learning program can be used by other training program to improve medical knowledge. 



Poster Title: “Intern Boot Camp:” Case-Based Interactive Curriculum for the New Intern 

Authors and Affiliate Institutions: Patrick A Rendon, Mark E Garcia, Marc T Montanaro, University of New 

Mexico School of Medicine 


Patrick A. Rendon, MD 



University of New Mexico School of Medicine 

2211 Lomas Boulevard, NE 

Albuquerque, NM 87120 

Telephone: (505) 264-3217 

Email: prendon@salud.unm.edu 

Discussion of How the Problem was Identified and Explored: New interns starting in July have often gone 

several months without any clinical duties or patient care, often leaving them underprepared for the rigors of their 

internship. The controversial so-called “July effect” has been extensively documented in the past and provides an 

excellent opportunity for systems improvement and education. 

Description of the Innovation: In the Department of Internal Medicine at the University of New Mexico, the 

Chief Residents have developed a curriculum for interns the first 2 months of their internship called “Intern Boot 

Camp”. This hour-long weekly curriculum focuses on the day-to-day skills necessary for a functioning intern and 

is run in small group sessions led by upper level residents and fellows with assistance from the Chief Residents. 

Cases were developed by the Chief Residents and fellows to educate interns in the following areas: Cross-cover, 

EKGs, Chest X-rays, common complications on wards, common medicine admissions, sepsis, and empiric 

antibiotics. 

Results to Date: The interns were surveyed regarding these sessions using a 1-7 Likert scale rating their abilities in 

these areas before and after the session and we found a net gain on average of 1.5 points (preliminary data) on the 

scale. The greatest level of improvement was found in the area of crosscovering (preliminary data). Although not 

formally surveyed, anecdotally the upper level residents who ran the small groups also found these sessions to be of 

high educational value. 

Discussion/Reflection/Lessons Learned: In summary, this innovative resident-led case-based small group 

curriculum for the starting intern helps improve interns’ skills in diagnosis and management of common problems 

encountered early in their internship. This may be an area for further inquiry into patient safety effects of this 

curriculum and the “July Effect.” 



Poster Title: Hospital Practice Profiles: Improving Training by Linking Patient Outcomes to Resident Practice 

Authors and Affiliate Institutions: Julius Yang, Anjala Tess, C Christopher Smith, Sarah Moravick, Eileen E 

Reynolds, Harvard Medical School Beth Israel Deaconess Medical Center 


Eileen E. Reynolds, MD 



Harvard Medical School Beth Israel Deaconess Medical Center 

330 Brookline Avenue 


Telephone: (617) 632-8264 

Email: ereynold@bidmc.harvard.edu 

Discussion of How the Problem was Identified and Explored: Study Aim: To design, implement, and assess the 

potential utility of trainee-specific “hospital practice profiles” in a structured self-assessment and improvement 

program to promote resident competency in the domains of patient care, problem-based learning improvement, and 

systems-based care. 

Description of the Innovation: Methods: Hospital practice profiles were created for each PGY-1 intern in the 

Department of Medicine, based on each intern’s authored discharge summaries. Each profile contains data 

including patient names, principal diagnosis, attending MD, discharge floor and division, PCP MD and practice, 

insurance, principal diagnosis at discharge, discharge date, discharge hour, length of stay, number of medications at 

discharge, 30-day readmission outcomes, and patient satisfaction survey results. A faculty member met with 

interns in small groups (approximately 6-8 interns) to introduce the data available in the profiles, then assigned 

three structured reviews for each intern to perform based on his/her own data: a 30-day readmission review, a 

chronic disease management review, and a patient experience review. The small group re-convened with the 

faculty member one week later to share discussion and findings based on their reviews. A post-intervention survey 

was administered at the end of the second meeting to assess educational impact. 

Results to Date: Results: 54/58 (93%) interns completed the survey. For each of the following statements, the 

proportion of respondents who either agreed or strongly agreed were as follows: “I learned something about my 

practice that I didn’t previously know/understand”: (50/54, 93%); “I generated questions about my practice that I 

didn’t previously have”: (48/54, 89%); “I learned something about the health care system that I didn’t previously 

know/understand”: (45/54, 83%); “I generated questions about the health care system that I didn’t previously 

have”: (50/54, 93%); “I anticipate that my future practice will change as a result of this experience”: (44/54, 81%); 

“I found this experience valuable, would recommend to future interns”: (53/54, 98%); “I found this experience 

valuable, would recommend I should repeat this in subsequent years of training”(50/54, 93%). 

Discussion/Reflection/Lessons Learned: Conclusions: A structured self-reflection program based on reported 

patient outcomes, including patient experience survey data, can promote self-assessed learning in the domains of 

patient care, problem-based learning improvement, and systems-based practice. 


Educational Competition to Improve Resident Experience 

Heather Sand, Varaz Bozoghlanian, Lloyd Rucker 

University of California, Irvine, Department of Medicine 

Introduction 

Internal medicine is the largest, most diverse specialty in the United States. 1 

At our acute care academic medical center, residents provide care for diverse 

patients with challenging diagnoses and management. Residents are 

expected to assume personal responsibility for the care of individual patients 

in order to develop the skills, knowledge, and attitudes necessary for 

proficiency as an internist. 2 However, great teaching cases are often not 

widely discussed across teams in the hub-bub of busy days restricted by duty 

hours and limited teaching interactions across teams. We wanted to identify 

great cases with important learning points, but residents often were 

reluctant to bring these cases forward, and morning case conferences could 

not accommodate all the cases. We sought to create an entertaining and 

thoughtful conference to incentivize residents to present their great cases: 

Best Case of the Block. 

Innovation 

The “Best Case of the Block” contest challenges each of our six ward teams to 

identify and present their best case of the current ward block. 

Teams 

Select 

Cases 

Teams 

Present 

Cases 

Vote 

FIGURE 1. Process of preparing and hosting Best Case of the Block. 

Prize 

In the days leading up to competition, teams select their best case (Figure 1). 

Teams prepare a 5-minute presentation, often using handouts, slides, and 

skits. The day before competition, each team must submit their slides and a 

brief form outlining information such as the diagnosis and teaching points. 

The competition is held during a thirty minute morning report at the end of 

the rotation. Students, residents, and faculty vote for the best case with 

points based equally in 3 categories: uniqueness of the case, importance of 

the learning issue, and quality and innovation of the presentation (Figure 2). 

The team’s attending must be present for a team to win in order to allow for 

additional case discussion as needed. The team with the highest overall score 

wins Best Case of the Block. The residency program pays for a team lunch for 

the team with the best overall presentation. 

Team 

Uniqueness & 

Interest of 

Diagnosis 

Importance of 

Learning Issues 

Quality & Style of 

Presentation 

Total Score 

A 12 3 4 5 12 3 4 5 12 3 4 5 

B 12 3 4 5 12 3 4 5 12 3 4 5 

C 12 3 4 5 12 3 4 5 12 3 4 5 

D 12 3 4 5 12 3 4 5 12 3 4 5 

E 12 3 4 5 12 3 4 5 12 3 4 5 

G 12 3 4 5 12 3 4 5 12 3 4 5 

FIGURE 2. Score sheet to be completed by voting medical students, residents, attending phyicians. 

Results 

To date, 16 competitions have showcased 89 cases. Cases have covered a breadth 

of medicine specialties and pathologies (Figure 3). Teaching points have also 

varied from clinically rare pathology to how to approach diagnostic data. 

Cardiology 

• HOCM 

• HACEK Endocarditis with 

septic emboli 

• Methamphetamine 

cardiomyopathy & 

withdrawal 

• Syncope 2/2 metastatic 

pericardial effusion with 

impending tamponade 

Pulmonology 

• Aspergillus necrotizing 

pneumonia 

• Bilateral PE 

• Hiccups secondary to 

lung cancer 

• Active TB 

• TACO vs. TRALI 

• Portopulmonary HTN 

Gastroenterology 

• Metastatic liver 

adenocarcinoma with 

cavernous sinus 

involvement 

• Biloma following 

cholecystectomy 

• Lynch syndrome 

• Ischemic pancreatitis 

• Autoimmune 

pancreatitis and necrotic 

mucocele presenting as 

"Rectal mass” 

Endocrinology 

• Myxedema coma 

• Hashimoto's thyroiditis & 

Pernicious anemia 

• Cushing's syndrome 

• Polyglandular autoimmune 

syndrome 

• Stage IV insulinoma & 

concomitant skin cancer 

• Nesidioblastosis (noninsulinoma 

hyperinsulinemic hypoglycemic 

syndrome) 

Nephrology 

• Nephrotic syndrome from 

minimal change disease 

• RPGN 

• Severe hyponatremia, 

ulcerated Torus palatinus 

• Severe hyponatremia, 

tea/toast diet 

• AKI from multiple myeloma vs 

septic ATN & rhabdomyolysis 

Hematology‐Oncology 

• Spur/Burr cell anemia 

• Anemia & malnourishment 

• Acquired autoimmune 

hemolytic anemia 

• DRESS 

• Immune reconstitution 

syndrome with 

thrombocytopenia 

• Hodgkin's lymphoma 

FIGURE 3. Examples of diagnoses presented at Best Case of the Block. 

Infectious Disease 

• Dengue hemorrhagic fever 

• Capnocytophagia infection 

with gangrene 

• Disseminated histoplasmosis 

• Disseminated cryptococcus 

• Disseminated gonoccus 

• AIDS with PCP pneumonia 

and candidal esophagitis 

• TB Meningitis 

Neurology 

• Paraplegia from B12 

deficiency with NO inhalation 

• Neurological changes from 

migrated PICC 

• Hemineglect from MCA CVA 

• Necrosis of craniotomy seal and 

aseptic meningitis from GBM 

vaccine 

Rheumatology 

• Polymyalgia rheumatica 

• Scleroderma with pulmonary 

adenocarcinoma 

• Pseudogout & epiploic 

appendigitis 

• Lupus flare, ischemic 

Raynaud’s crisis and arterial 

occlusion from APS 

• Pseudoporphyria cutanea tarda 

• Fitz‐Hugh‐Curtis syndrome 

Participants were surveyed to assess their perceptions of the competition. 

Survey results showed an average quality and learning score of 4 on a Likert 

Scale, suggesting that students and residents agree that the competition is an 

important learning experience and should be continued (Table I). 

Average Score 

Best Case is an important learning experience and should be continued. 4 

Best Case has increased my medical knowledge. 4 

I apply the teams’ lessons learned to the care of my patients. 3 

Thinking about my cases as the potential Best Case has increased my 

4 

focus on potential learning opportunities. 

TABLE I. Survey of medical students and residents (n=33) regarding Best Case of the Block. 

Scores are on a Likert Scale, 1-5, 1 = Strongly Disagree, 5 = Strongly Agree. 

Discussion 

The “Best Case of the Block” competition successfully engages students and 

residents, increases their exposure to educational cases, and increases their 

focus on potential learning opportunities throughout the inpatient rotation. 

As exhibited by the participant feedback, the implementation of the “Best 

Case of the Block” challenge has improved the learning experience of our 

medical students and residents. 

Since implementation, some challenges were noted. For instance, residents 

may find it difficult to identify extraordinary cases. However, participants 

are encouraged that voting is based on three categories, not only the rarity of 

the diagnosis. Voting methods have also been a concern. Voting rules are 

strict and overseen by the chief resident. Rules include that all voters must 

be present at the beginning of morning report, the attending physician must 

be present, and each participant may only cast one ballot. 

The UC Irvine Internal Medicine Residency Program intends to continue the 

competition each rotation, and to maintain a record of the cases. The authors 

are considering a “Best Case of the Year” competition for the future. 

Acknowledgements 

The authors thank the students, residents and hospitalists at UC Irvine for their creative 

participation in competitions, and APDIM for the opportunity to share this programmatic 

innovation. 

References 

1 “Facts About Departments of Internal Medicine.” Alliance for Academic Internal Medicine, 

n.d. http://www.im.org/About/FactsaboutDepartments/Pages/default.aspx. 

2. “ACGME Program Requirements for Graduate Medical Education in Internal Medicine,” 

July 1, 2009. 

http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/140_intern 

al_medicine_07012009.pdf. 

For more information, please contact Lloyd Rucker at lrucker@uci.edu.


Poster Title: Best Cases Create Best Case Scenario: Educational Competition to Improve Resident Experience 

Authors and Affiliate Institutions: Heather Sand, Varaz Bozoghlanian, Lloyd Rucker, University of California, 

Irvine, School of Medicine 


Lloyd Rucker, MD 

Vice Chair and Program Director 



University of California, Irvine, School of Medicine 

101 City Drive South 

Route One, City Tower, Suite 400 

Orange, CA 92868 

Telephone: (714) 456-5691 

Email: lrucker@uci.edu 

Discussion of How the Problem was Identified and Explored: Internal medicine residents at our acute care 

academic medical center provide care for diverse patients with challenging diagnoses and management. However, 

great teaching cases are often not widely discussed across teams in the hub-bub of busy days restricted by duty 

hours and limited teaching interactions across teams. We wanted to identify great cases with important learning 

points, but residents often were reluctant to bring these cases forward, and morning case conferences could not 

accommodate all the cases. We sought to create an entertaining and thoughtful conference to incentivize residents 

to present their great cases. 

Description of the Innovation: The “Best Case of the Block” contest challenges each of our six ward teams to 

identify and present their best case of the current ward block. Teams prepare a 5-minute presentation of their best 

case, often using handouts, slides, and skits. The competition is held during a thirty minute morning report at the 

end of the rotation. Students, residents, and faculty vote for the best case with points based equally in 3 categories: 

uniqueness of the case, importance of the learning issue, and quality and innovation of the presentation. The 

residency program pays for a team lunch for the team with the best overall presentation. 

Results to Date: To date, eight competitions have showcased 48 cases. Cases have covered a breadth of medicine 

specialties and pathologies including endocrinology with nesidioblastosis, infectious disease with dengue 

hemorrhagic fever, and dermatology with pseudo porphyria cutanea tarda. Teaching points have also varied from 

clinically rare pathology to how to approach diagnostic data. Participants were surveyed to assess their perceptions 

of the competition. Survey results showed an average quality and learning score of 4/5 on a Likert Scale, suggesting 

that students and residents agree that the competition is an important learning experience and should be continued. 

Discussion/Reflection/Lessons Learned: The “Best Case of the Block” competition successfully engages students 

and residents, increases their exposure to educational cases, and increases their focus on potential learning 

opportunities throughout the inpatient rotation. As exhibited by the participant feedback, the implementation of the 

“Best Case of the Block” challenge has improved the learning experience of our medical students and residents. 


A Longitudinal, Experiential Curriculum 

Lloyd Rucker, Bindu Swaroop, Kanwalpreet Hundal 


Introduction 

Results 

Discussion 

Cost consciousness is central to high quality, safe medical care. Cost control 

is one of the highest priorities for health care in the US, and cost awareness 

must become fundamental to medical education. Ironically, caring for 

patients in teaching hospitals has always been a very expensive proposition. 

Residents and faculty tend to practice expensive care. In recognition of the 

need to change this and to train residents in the importance of quality and 

cost, the ACP has introduced the “High Value, Cost Conscious Care 

Curriculum.” This curriculum consists of “10 interactive one hour modules 

based upon actual patients and their hospital bills” and designed to “ help 

residents develop habits of using high value care by using a 5-step 

framework.” We sought to incorporate this curriculum into a more 

comprehensive and experiential curriculum on medical economics and cost 

consciousness designed for internal medicine residents in our universitybased 

IM residency program. 

Innovation 

In the PGY1 year, our internal medicine residents engage in a seminar 

series on process improvement. This series introduces awareness of cost 

and also enhances the residents’ critical thinking on the topic of cost. In the 

PGY2 year, the longitudinal curriculum continues with faculty member-led 

small group seminars on medical economics including health care systems, 

the history of cost-control efforts in the US including the HMO movement, 

the role of the medical-industrial complex, and the potential impact of 

changes introduced by the Affordable Care Act. These seminars address the 

massive cost of medical care in the US ($2.7 trillion per year or 18% of 

GDP) and the affect of that massive expenditure on health outcomes and 

the health of the economy. 

Each resident then chooses an aspect of medical care where he or she has 

personally noted opportunities for saving resources such as test ordering, 

procedures, algorithms of care, or medication use. Using the medical 

literature, the resident then develops quality guidelines for cost-conscious 

test ordering, medications or other aspects of medical care. He or she then 

evaluates up to 50 consecutive current patients to see how ordering 

patterns meet the recommendations from the literature. The residents 

present the results of this survey, first to a small group of colleagues and 2 

or 3 faculty members and then to a large conference of residents and 

hospitalists. Before each conference, a faculty member presents one of the 

interactive seminars from the “High Value, Cost Conscious Care 

Curriculum”. The department of medicine then uses the data from the 

presentations to implement changes. At times, the data are further 

presented to relevant groups such as the ICU faculty or radiology 

department. 

32 residents have participated to date. All have completed their initial cost 

evaluation projects. 18 residents have presented to the joint residenthospitalist 

conference. The conferences have been integrated into the core 

educational conferences of the residency program. Residents have 

enthusiastically embraced the curriculum and several have gone beyond the 

basic requirements to introduce educational programs based upon their 

findings. 

PPI 

CBC 

CXR 

CT 

Additional 

Topics 

By conservative criteria, 34% of medicine ward patients were 

placed on PPIs inappropriately. An intervention based on these 

findings cut down PPI use by 75%. 

Many patients get daily CBCs. One resident developed strict 

criteria for CBCs and found that only 1/3 were indicated. 

Furthermore, of those indicated, most were ordered with a 

differential that was not indicated. 

Patients in our MICU were undergoing an average of 1.4 CXRs per 

day. One patient had 35 CXRs in a 15 day period. These findings 

were presented to our intensivist faculty and critical care fellows. 

A follow‐up project is planned to assess the impact of this 

presentation. 

Only 4 of 48 patients presenting with syncope had 

documentation of abnormal neurologic exams. All of those with 

abnormal exams had abnormal CTs. However, of the 44 with 

normal exams, only 4 (12%) had abnormal head CT scans. Of 

those 4 patients, none of the abnormal head CTs explained the 

syncope. ThisprojecthasledtoajointIM–EDtaskforcePI 

project to create diagnostic protocols for syncope. 

Iatrogenic Anemia 

Constipation Meds 

Mg and Phos Replacement 

Inpatient Lipid Screening 

Transfusion Indications 

Repeated Cardiac ECHOs 

IV Antiemetics 

Telemetry Indications & Utilization 

Admission CXRs 

Coagulation Test Ordering 

BMP Ordering 

PE Screening 

Our educational institutions are in the midst of massive change and challenge. 

The rapid pace of change is impacting graduate medical education in ways that 

we cannot entirely predict. These changes include measures introduced by the 

Affordable Care Act, concerns about Medicare and Medicaid reform (including 

quality of care measures and readmission paybacks), the recent imposition of 

the sequester, and challenges to the funding of graduate medical education 

(GME). Furthermore, we must also pile onto these changes recent reforms in 

GME including the Next Accreditation System and the duty hours regulations. 

Our hospitals and medical schools are anticipating these reforms through new 

programs and, in many cases, cutbacks. All of these challenges impact our 

residents and our training programs in ways that residents feel immediately, 

not just as some hypothetical construct that will affect their future careers. So 

that residents can understand and function in this evolving healthcare 

environment, it is imperative that GME training programs implement 

meaningful instruction in medical economics. “Parsimonious” utilization of 

scarce resources is a core element in that education. 

As part of a comprehensive curriculum in medical economics, we implemented 

a requirement that our residents perform cost awareness projects. Our 

residents choose their own projects based upon their observations in the 

context of providing care. We believe this project selection method is key to the 

learning process. The residents’ own concerns about the magnitude of 

overutilization are often significantly trumped by overutilization that is actually 

much greater than they had expected. 

All of these projects are presented to residents and faculty. Some have had 

major impact such as the 75% decrease in inappropriate PPI ordering. Others 

are in process. One resident, moved by the dramatic excess ordering of blood 

transfusions, is in the process of preparing to teach about transfusion 

indications and protocols through preparation of an online educational module 

for residents and a live presentation for hospitalist faculty. 

Residents can embrace enthusiasm for quality and safety in the context of cost 

conscious care. Residency programs can implement projects that reinforce 

theseconcerns.Intheprocess,wecanhavemeasurableimpactsthatactuallydo 

enhance the care we provide for patients through our GME programs and 

residents. 


The authors thank the residents and hospitalists at UC Irvine for their creative participation in 

in the educational sessions and cost consciousness research projects and APDIM for the 

opportunity to share this programmatic innovation. 

Reference 

www.acponline.org/curriculum.html 



Poster Title: Cost Awareness Curriculum for Residents 

Authors and Affiliate Institutions: Lloyd Rucker, Kanwalpreet Hundal, University of California, Irvine, School 

of Medicine; Bindu Swaroop, Long Beach Veterans Administration Hospital 


Lloyd Rucker, MD 

Vice Chair and Program Director 




101 City Drive South 

Route One, City Tower, Suite 400 

Orange, CA 92868 

Telephone: (714) 456-5691 

Email: lrucker@uci.edu 

Discussion of How the Problem was Identified and Explored: Cost-consciousness is central to high quality, safe 

medical care. Cost control is one of the highest priorities for health care in the US. Cost awareness must become 

fundamental to medical education. In recognition, the AAIM-ACP has introduced the “High Value, Cost Conscious 

Care Curriculum”. We sought to incorporate this curriculum into a more comprehensive and experiential 

curriculum on medical economics and cost consciousness. 

Description of the Innovation: The longitudinal curriculum begins with faculty-led small group seminars on 

medical economics including the Patient Protection Affordable Care Act. Each resident then chooses an aspect of 

care such as PPI prophylaxis or a test such as head CT for syncope. The resident develops quality guidelines for 

cost-conscious test or medication ordering. He or she then evaluates the care of 50 current patients. The resident 

presents the results of this survey, first to colleagues in a small group setting and then to a conference of residents 

and hospitalists. Before each conference, a faculty member presents elements of the “High Value, Cost Conscious 

Care Curriculum”. The department then sets priorities for emphasizing areas of cost-saving potential and advertises 

these to faculty and residents. 

Results to Date: Twenty-two PGY2 residents have participated to date. All have completed their initial cost 

evaluation projects. Residents have presented 3 projects to the hospitalist-resident conference; the rest are 

scheduled throughout the year. An initial intervention project led to a 50% decrease in inappropriate PPI 

prophylaxis. Another has led to creation of a task force on syncope guidelines. Others have discovered dramatic 

excesses in ordering of constipation prophylaxis, lipid testing, chest x-rays, urinalyses, head CT, PT/PTT/INR, CT 

Angiography, echo cardiograms, CBCs, and telemetry. Residents have rated this experience very highly and 

uniformly support its continuation. Faculty members and hospital administrators have noted residents’ enthusiasm 

for and ownership of these projects. 

Discussion/Reflection/Lessons Learned: Residents have taken enthusiastic ownership of their projects and 

become advocates for change. The curriculum incorporates many formal interactions over a 12-month period of 

time. Early results show that an integrated, longitudinal curriculum which includes educational seminars, residentled 

projects, faculty involvement, and discussion of the “High Value, Cost Conscious Care Curriculum” can be 

agents for positive, cost-conscious change. 


Creation of Mini‐Lectures to Improve Resident Teaching 

Bindu Swaroop, Lloyd Rucker, Kanwalpreet Hundal 


Introduction 

Internal medicine is a vast and complex field. Residents often feel 

overwhelmed with the amount of material they are expected to learn and 

eventually teach to others. Busy residents who want to teach often do 

not have time to prepare topics. To meet this need, residents in our 

program created a learner-centered, centralized database of core, highvalue 

and evidence-based inpatient topic mini lectures. 

Skill Mark “x” if accomplished Comments 

Choose an appropriate and relevant topic 

Appropriately concise and relevant to the topic 

Practical 

Limited and appropriate number of key points 

Where appropriate, specialists review lectures and ensure they 

correspond to the guidelines and practices of the medical center. Of the 

41 lectures, seven have been revised to meet current guidelines. 

Innovation 

Each of our residents in their 1 st year of training are taught to create 

mini-lectures during a doctoring skills rotation. They then put those 

lessons into place in their 2 nd year when they create their official minilecture. 

Visual aids and handouts memorable 

FIGURE 2. Evaluation form filled out by committee members. 

Results 

Over a six week time period, lectures have been viewed 264 times 

representing an average of 44 views per week. 

Mini‐Lecture Topic 

# of views 

Intern Pearls/Orientation 19 

ECG for Interns 15 

Electrolyte Replacement 12 

To date, residents have developed and revised forty one mini-lectures. 

Lecture topics range from IV fluid management to acute 

decompensated heart failure, and also include core measures such as 

VTE prophylaxis. 

Community Acquired Pneumonia 8 

TABLE 2. Most viewed mini-lecture topics. 

To ensure durability and accuracy, residents update the lectures 

annually during a required teaching rotation. 

Discussion 

FIGURE 1. Process for creating a mini-lecture. 

Resident leaders and faculty mentors provide a set of guidelines to 

follow including a ten minute time limit, inclusion of clinical vignettes, 

and use of an objectives and summary slide. Residents use the “notes” 

section of each slide to provide information on how to deliver the talk. 

Each resident then presents his or her lecture to 2-3 attending 

physicians and 2 senior residents. Additional feedback is provided and 

the final version of the lecture is added to a website created specifically 

to host the lectures. 

Figure 3. Screenshot of the mini-lecture website. 

Both residents and attendings have demonstrated enthusiasm and 

support for the core curriculum website. The mini-lectures have 

provided a tangible evidence-based format to efficiently and effectively 

present key inpatient medicine topics during inpatient rounds. The 

residents themselves have driven the curriculum and have chosen the 

topics they feel are most relevant and useful to their colleagues. They 

are revised annually to ensure they follow the most recent and 

evidenced based guidelines. The result has been the creation of a great 

educational resource that is managed, updated, owned, and 

disseminated by the residents themselves. 


The authors thank the residents and hospitalists at UC Irvine and VA Long 

Beach for their participation in creation and revision of the mini-lectures. 



Poster Title: A Resident-Driven Mini-Lecture Curriculum for Inpatient Internal Medicine 

Authors and Affiliate Institutions: Bindu Swaroop, Long Beach VA Medical Center; Kanwalpreet Hundal, 

Lloyd Rucker, University of California, Irvine, School of Medicine 


Bindu K. Swaroop, MD 

Assistant Clinical Professor 



5901 East Seventh Street 

Mail Code 111 

Long Beach, CA 90822 

Telephone: (714) 655-8494 

Email: bkswaroop@yahoo.com 

Discussion of How the Problem was Identified and Explored: Internal medicine is a vast and complex field. 

Residents often feel overwhelmed with the amount of material they are expected to learn and eventually teach to 

others. Busy residents who want to teach often do not have time to prepare topics. To meet this need, residents in 

our program created a learner-centered, centralized database of core, high-value and evidence based inpatient topic 

mini-lectures. 

Description of the Innovation: Each of our residents in their second year of training chooses a core medicine 

topic relevant to the inpatient medicine service and creates a PowerPoint “mini-lecture” as part of a core teaching 

skills rotation. Resident leaders and faculty mentors provide a set of guidelines to follow including a ten minute 

duration, inclusion of clinical vignettes, and use of an objectives and summary slide. Residents use the “notes” 

section of each slide to provide information on how to deliver the talk. Each resident then presents his or her lecture 

to 2-3 attending physicians and 2 senior residents. Additional feedback is provided and the final version of the 

lecture is added to a website created to host the lectures. 

Results to Date: Residents have developed thirty-five mini-lectures. Topics range from IV fluid management to 

acute decompensated heart failure and also include core measures such as VTE prophylaxis. Learners and teachers 

often and widely use the lectures to teach. Where appropriate, specialists review lectures and ensure they 

correspond to the guidelines and practices of the medical center. To ensure durability and accuracy, residents 

update the lectures annually during a required teaching rotation. 

Discussion/Reflection/Lessons Learned: Both residents and attendings have demonstrated enthusiasm and 

support for the core curriculum website. The mini-lectures have provided a tangible evidence-based format to 

efficiently and effectively present key inpatient medicine topics during inpatient rounds. The residents themselves 

have driven the curriculum and have chosen the topics they feel are most relevant and useful to their colleagues. 

The result has been the creation of a great educational resource that is managed, updated, owned and disseminated 

by the residents themselves. 



Poster Title: The Last Lecture? Uniting Resident Preferences and Principles of Adult Learning to Improve the 

Noon Conference Lecture Series 

Authors and Affiliate Institutions: Adam Sawatsky, Katie Berlacher, Rosanne Granieri, University of Pittsburgh 



Adam Sawatsky, MD 

Instructor 



University of Pittsburgh School of Medicine 

Montefiore Hospital, Suite W933 

200 Lothrop Street 

Pittsburgh, PA 15213 

Telephone: (507) 993-5198 

Email: sawatskyap@upmc.edu 

Discussion of How the Problem was Identified and Explored: The lecture remains a central means for 

delivering the knowledge content of the residency core curriculum to internal medicine residents, fulfilling the 

Accreditation Council for Graduate Medical Education requirement for “regularly scheduled didactic sessions.” 

However, there is little evidence in the literature regarding the effectiveness of lectures at improving long-term 

knowledge of residents. 

Description of the Innovation: We conducted a targeted needs assessment using focus groups of residents and 

faculty, exploring motivations for attending or not attending noon conferences, learning preferences within the 

noon conference, improvements that could be made to the noon conference, and feelings about increasing active 

participation in noon conference. Using that information, we designed an active learning format that could be 

easily applied to the noon conference. The format focused on 3-5 main learning points, centered on cases and 

clinical questions, with opportunity for small group discussion and commitment to answers. We piloted the format 

using two general medicine faculty to study feasibility and measure initial satisfaction to ensure we were meeting 

residents’ needs. We have begun to implement it on a larger scale with subspecialists. 

Results to Date: Our needs assessment revealed important themes regarding resident preferences on motivations, 

content, delivery and engagement within noon conference, along with faculty opinions about barriers to change. 

Our pilot survey revealed 87.1% of the 202 attendees at 8 separate lectures felt the new format improved overall 

learning as compared to lecture, with similar results for satisfaction, clarity, relevance, usefulness and engagement. 

There was no perceived increase in stressfulness or decrement in residents’ ability to eat lunch and take a break in 

their day. 

Discussion/Reflection/Lessons Learned: The lecture is the cornerstone of resident education, yet it is not 

congruent with principles of adult learning or the educational goal of developing residents who can interact and 

apply the knowledge to patient care. The data from our focus groups can guide attempts to design new innovations 

on teaching in noon conference. We demonstrate one way this has been accomplished at our institution that can 

serve as a model. 



Poster Title: It’s All in the Execution: Description of a Duty Hours Monitoring Process 

Authors and Affiliate Institutions: Michael P Stevens, Stephanie Call, Virginia Commonwealth University 

Medical College of Virginia 


Michael P. Stevens, MD 




1300 East Marshall Street 

PO Box 980019 


Telephone: (804) 828-2121 

Email: mstevens@mcvh-vcu.edu 

Discussion of How the Problem was Identified and Explored: The ACGME has mandated a number of duty 

hours (DH) related rules. At our large, urban program with 111 residents we have traditionally struggled with 

monitoring DH in real time. 

Description of the Innovation: One Associate Program Director (APD) was tasked with both monitoring and 

addressing DH issues. Utilizing the New Innovations software platform, we rolled out a new DH logging 

compliance mandate, wherein residents who have not logged their DH within a 7 day period of time receive a 

professionalism letter in their permanent program file. Thereafter, a new DH violation assessment process was 

deployed wherein twice weekly the APD charged with DH monitoring reviewed summary violation data as well as 

logging compliance and then worked with the medicine chief residents to address issues in real time. Data on DH 

logging compliance as well as overall compliance with each DH rule were tracked throughout a 12 month period. 

Violation rates were calculated by dividing the total number of violations for a given rule by the total number of 

opportunities to violate. 

Results to Date: Over the 12 month period from 7/2011 to 6/2012, our compliance with DH logging was 95.4%. 

Our violation rates per DH rule were 1) 8 hour rule: 0.5% (203/39,677); 2) 16 hour rule: 0.6% (117/18,227); 3) 24 

hour rule: 0.01% (3/21,450); 4) 80 hour rule: 0.1% (23/39,677). 

Discussion/Reflection/Lessons Learned: Our DH monitoring and intervention process led to sustained, low 

violation rates across all DH violation types, despite our status as a busy urban program with 111 housestaff. We 

believe our process would benefit other medicine residency programs. 


Standardizing Resident Handoffs in Times of ACGME Duty-Hour Regulations 

Vishnu Laalitha Surapaneni, M.B.B.S.,MPH 

University Hospitals Case Medical Center 

INTRODUCTION 

METHODOLOGY 

RESULTS 

DISCUSSION 

•Patient handoffs refer to the transfer of patient information and 

responsibility from one care provider to the next. (Abraham 

2011) 

•In 2003, ACGME approved new resident duty-hour regulations 

that limited resident workweeks to 80 hours or fewer and limited 

continuous duty to 24hours. This caused transfers of care for a 

hypothetical patient to increase by a mean of 11% during a 

Monday-Friday hospitalization. A member of the primary team 

was present in the hospital for only 47% of a patient's hospital 

stay. (Horowitz 2006) The ACGME work-hour regulations 

effective July 2011, limiting continuous duty to 16hours for PGY- 

1s, have further decreased the time spent by residents at the 

hospital. Although these regulations are implemented to decrease 

fatigue related errors, they also make handoffs a more frequent 

and critical part of patient care. 

•However, handoffs are inherently error-prone processes. 

In 2010, the Joint Commission sentinel event data analysis 

showed that 80% of the 4800 sentinel events were due to 

improper communication. In a study by Petersen (1994), patients 

who suffered preventable errors were 3.5 times more likely to be 

cared for by a covering physician. Handoffs have also been 

implicated in 20% to 24% of malpractice claims in various 

health-care settings. (Kachalia 2007) 

•Despite these well-identified threats to patient safety, there are 

several deficiencies to the way handoffs are practiced currently. 

Sign-out skills are not routinely taught in medical schools or 

residency programs. (Horowitz 2006) Residents are expected to 

learn these skills “on the job”. Residents involved in giving and 

receiving patient handoffs often lack training, experience or 

supervision. 

•To minimize handoff failures, the Joint Commission has 

mandated that all US hospitals standardize information transfer 

practices. However, there are currently no universally adopted 

standards for handoff communication, either written or verbal. 

The templates used for handoffs are unique to each institution, 

with up to 19 different templates published in scientific journals. 

(Cohen 2009) 

•The handoff template in the electronic medical record at our 

institution is titled HOT and has 6 text boxes that allow for freetexting 

information. There are no guidelines on what patient 

information should be included in each of these 6 sections. 

OBJECTIVES 

Objective 1: Refine the existing handoff template in the 

electronic medical record to develop a standardized handoff 

template for our institution. 

Objective 2: To pilot and evaluate the efficacy of the new 

standardized handoff template. 

Study Design: 

This is a multi-method qualitative and quantitative, crosssectional 

study conducted to improve the existing template for 

patient handoffs. 

Study Subjects: 

The subjects were first year residents of the Internal Medicine 

residency program at our academic teaching hospital. 

Data Collection: 

To design a standardized handoff template, several data 

sources were used. 

•Firstly, evidence-based recommendations for ideal handoff 

templates were reviewed through extensive literature search in 

MEDLINE database using search terms such as “sign-out”, 

“handoff”, “patient safety” and “resident”. The patient 

information categories identified as essential in these studies, 

that are currently absent in the electronic handoff template 

were isolated. 

•Secondly, a focus group of Internal Medicine residents was 

held to discuss their level of satisfaction with the current 

handoff template. This focus group guided the development of 

an online survey that was disseminated electronically via 

email Through this survey, residents identified the essential 

categories in the existing template and made recommendations 

for new patient information categories. 

•Lastly, additional categories were also identified through 

direct observation of nursing shift reports and 

interdepartmental handoffs between anesthesia and surgery. 

These were compared with directly observed handoffs between 

Internal Medicine residents. 

The categories thus identified from various sources were 

incorporated to create a standardized handoff template. 

Evaluation: 

A crucial step in creating the new standardized template was to 

first determine the efficacy of the current handoff template by 

measuring handoff errors. Two sources were used to collect 

data on adverse events caused by handoffs. 

•First, data was collected from night-floats each night, in order 

to identify essential patient information that was not 

communicated by the primary team during handoff. 

•Second, data was also collected from the primary team each 

morning on how many errors had occurred overnight due 

to handoffs. Errors included all categories from near-misses 

and adverse events to sentinel events. 

Data Collection: 

Literature Review: 

362 references were identified via literature review from 

MEDLINE database. Using pre-defined inclusion and 

exclusion criteria, 91 references were studied. Categories such 

as “severity of patient illness”, “events over past 24 hours”, 

“current clinical condition” and “read-back” were incorporated 

into the new handoff template. 

Online Survey: 

Of the 46 residents surveyed, 65% found administrative data 

an essential part of the current template, and 80% voted for a 

well constructed diagnostic one-liner. Residents wanted to 

incorporate the following into the new standardized template; 

“Events over the past 24hours”, “Abnormal baseline physical 

exam findings” and “Events to anticipate overnight”. 

Nursing and Interdepartmental Sign-out: 

Additional categories that were identified were “New 

symptoms that developed during the day”, “Unstable vitals 

during the day” and “Read-back time”. 

Using data from the above sources, the following standardized 

version of the handoff template was designed. 

Evaluation: 

Night-Floats: 

On average, night-float interns covered 68 patients, and 

received an average of 47 pages per night. The most common 

reasons for the pages were pain (85%), unstable vitals (78%), 

patient developing new symptoms (70%) and critical lab 

values (60%). 15% of the time, night-float residents felt that 

they did not have enough information from the primary team 

to manage ituations overnight. 

Primary Team: 

Survey of the primary team interns revealed that night-float 

interns made 3 hand-off errors for 134 patient days. 

Results of this study indicated that each intern handed off an 

average of 5 patients per night. 60% of all patients admitted to 

the General Medicine services were handed off more than once 

each night. Night-float residents often felt that the primary 

team did not handoff adequate and pertinent patient 

information in order to deliver optimal patient care overnight. 

The standardized handoff template was designed to ensure 

transfer of updated and pertinent patient data. The new 

template allows for less free-texting and standardizes the 

format of the “diagnostic one-liner” thereby decreasing the 

chances of patient data omission. The section “Events since 

7AM today” uses the patient safety technique of forcing 

functions. This forces residents to think through all new 

outstanding clinical events for the day resulting in a more 

updated sign-out. 

Before implementing the standardized template, however, we 

quantified the efficacy of the current template by analyzing 

handoff errors. In our resident focus group, we had identified 

dissatisfaction with and safety concerns about the template. 

Thus, we hypothesized that the use of the current template 

results in several handoff errors per night. 

The data showed that despite the confusion expressed by nightfloats 

about the plan for the night, only 3 handoff errors 

occurred for 134 patient days. Thus, the second phase of the 

project, which was to implement the new handoff template, 

was temporarily held. 

Our results could be explained in the following ways. Since the 

data was collected at the end of the academic year, interns may 

have become better trained to deal with unexpected events 

overnight. There could have been a bias of underreporting as 

this data was collected by self-reporting. Participants might not 

have recorded handoff errors if they did not result in adverse 

patient outcomes. 

The next step is to repeat the study in the beginning of the next 

academic year to eliminate the factor of resident training. The 

study will also collect data by directly-observing handoffs, so 

as to eliminate the factor of underreporting. We hypothesize 

that several handoff errors will occur with the current template 

and implementing the standardized template will result in less 

handoff errors and more resident satisfaction. 

ACKNOWLEDGEMENTS 

Dr.A.Krikorian, M.D. 

Dr.K.Armitage, M.D. 

Chief residents- Dr R.Mehta, Dr.P.Oppelt,Dr.G.Prithviraj and 

Dr.J.Weingart 

Intern class 2011-12 

All residents of the Internal Medicine program at UHCMC


Poster Title: Optimizing Resident Handoffs 

Authors and Affiliate Institutions: Vishnu Laalitha Surapaneni, Armand Krikorian, Keith Armitage, University 

Hospitals Case Medical Center 


Vishnu Laalitha Surapaneni, MD 

Faculty 


Case Western Reserve University School of Medicine 

11100 Euclid Avenue 

Cleveland, OH 44106 

Telephone: (216) 844-3833 

Email: VishnuLaalitha.Surapaneni@UHhospitals.org 

Discussion of How the Problem was Identified and Explored: To minimize handoff failures, the Joint 

Commission has mandated that all US hospitals standardize information transfer practices. However, there are 

currently no universally adopted standards for handoff communication, either written or verbal. The templates used 

for handoffs are unique to each institution, with up to 19 different templates published. (Cohen 2009) The 

handoff template in the EMR at our institution has 6 text boxes that allow for free-texting information. There are no 

guidelines on what patient information should be included in each of these 6 sections. We reviewed evidencebased 

recommendations for ideal handoff templates through literature search in MEDLINE. Then a focus group of 

IM residents was held to discuss their level of satisfaction with the current handoff template. Based upon their 

feedback a survey tool for all residents was created. Additional categories were identified through direct 

observation of nursing shift reports and interdepartmental handoffs between anesthesia and surgery. These were 

compared with directly observed handoffs between IM residents. 

Description of the Innovation: Data was collected from night-floats each night, in order to identify essential 

patient information that was not communicated by the primary team during handoff. Data was also collected from 

the primary team each morning on how many errors had occurred overnight due to handoffs. Errors included all 

categories from near misses and adverse events to sentinel events. 

Results to Date: On average, night-float interns covered 68 patients, and received an average of 47 pages per 

night. The most common reasons for the pages were pain (85%), unstable vitals (78%), patient developing new 

symptoms (70%) and critical lab values (60%). 15% of the time, night-float residents felt that they did not have 

enough information from the primary team to manage situations overnight. 

Discussion/Reflection/Lessons Learned: Results of this study indicated that each intern handed off an average of 

5 patients per night. 60% of all patients admitted to the IM services were handed off > once each night. Night-float 

residents often felt that the primary team did not handoff adequate patient information in order to deliver optimal 

patient care overnight. A standardized handoff template was designed to ensure transfer of updated and pertinent 

patient data. The new template allows for less free-texting and standardizes the format of the “diagnostic one-liner” 

thereby decreasing the chances of patient data omission. 



Poster Title: Raising Resident Awareness of Their Role in Quality and Safety Through Patient Safety Discussions 

Authors and Affiliate Institutions: Tabassum Salam, Jessica A White, Christiana Care Health System 


Tabassum Salam, MD 

Associate Residency Program Director 


Christiana Care Health System 

4755 Ogletown-Stanton Road 

Suite 2E70, Ammon Building 

Newark, DE 19718 

Telephone: (302) 733-6384 

Email: tsalam@christianacare.org 

Discussion of How the Problem was Identified and Explored: It is generally recognized that physicians need 

enhanced awareness and exposure to topics in Quality and Safety. Yet, training in Quality and Safety within 

residency and fellowship programs is generally insufficient. A baseline study of knowledge, skills and attitudes of 

resident physicians, medical students and faculty [N=24] in our community-hospital based Internal Medicine 

residency program was undertaken. It revealed that the majority of respondents [62%] had an interest in Quality 

and Safety. 54% felt that knowledge about Quality and Safety would impact their current roles. The majority [62%] 

felt disquieted about being involved in care that harms or potentially harms. 81% of respondents preferred the 

integration of interactive learning into their daily educational structure. 

Description of the Innovation: A Patient Safety Discussion was instituted every day at Residents’ Morning 

Report. Quality, safety and systems issues were identified by the residents and medical students, and teaching 

faculty would catalog these cases. Once a month, an Administrative Fellow in Quality and Patient Safety would 

present focused follow-up and Safety Pearls on these cases at Morning Report in order to ‘close the loop’ for the 

residents. 

Results to Date: A survey was administered to residents 4 months after the introduction of the Patient Safety 

Discussion [PSD]. Of the respondents [N=9], 78% felt that the Patient Safety Discussion increased their awareness 

of systems-thinking, and that the PSD promoted a non-punitive environment to regularly discuss errors. Two-thirds 

of the responding residents felt that the PSD integrated Quality and Safety concepts into daily practice, and that the 

presentation of the Safety Pearls was an effective learning experience. 89% of the respondents wanted the PSD to 

continue. 

Discussion/Reflection/Lessons Learned: A relatively succinct educational experience like the Patient Safety 

Discussion positively impacted residents’ perception and learning of Quality and Safety. A key to its success was 

the integration of this teaching tool into a daily pre-existing forum such as Residents’ Morning Report. 



Poster Title: Resident-Led Decision Support Huddles to Improve Risk Factors for Patients with Diabetes 

Authors and Affiliate Institutions: David Sweet, Lynn Clough, Summa Health System/NEOUCOM; Tho Luong, 

Summa Akron City Hospital 


David B. Sweet, MD 

Professor 

Division of Clinical Sciences 


Summa Health System/NEOUCOM 

55 Arch Street 

Suite 1A 

Akron, OH 44304 

Telephone: (330) 375-3741 

Email: sweetd@summahealth.org 

Discussion of How the Problem was Identified and Explored: Our residency clinic has conducted an ongoing 

quality improvement project to improve risk factor control for patients with Diabetes Mellitus (DM). Decision 

support has included prospective EHR entries by staff including recent A1c, LDL and blood pressure (BP) results 

and prompts to encourage treatment intensification. 

Description of the Innovation: Decision support was expanded during the fourth quarter of 2011 with residents 

conducting pre-clinic huddles lasting

Hands‐on Quality Improvement: A Curriculum for Team‐based Resident‐Led Projects 

Training Residents in Quality Improvement Using Small Groups and Resident‐Initiated Projects 

Hailey Vincent, MD 1,2 , Lindsey Tricinella, DO 1,2 , Michael McNeal, MD 1,2 , Curtis Mirkes, DO 1,2 , 

Colleen Colbert, PhD 1,2 , Sunita Varghees, MD, PhD 1,2, Tresa McNeal, MD 1,2 

Scott & White Healthcare 1 and Texas A&M Health Science Center College of Medicine 2 , Temple, Texas 

Background: Quality improvement is an important 

part of healthcare that allows identification of 

problems, self‐evaluation, planned intervention, 

and implementation of solutions. The ACGME 

requires that all residency programs include quality 

improvement methods within their curriculum. The 

Internal Medicine Residency Program at Scott and 

White Healthcare/ Texas A&M Health Science 

Center College of Medicine has pioneered a unique 

curriculum that allows residents to evaluate their 

work environment and use quality improvement 

methods to solve “real world” problems. While a 

quality improvement curriculum is required, it can 

be difficult to implement a standardized curriculum 

that provides opportunities for all residents to have 

hands‐on experience. It can be more challenging to 

promote actual implementation of solutions within 

a healthcare system. 

Innovation: Working in groups of 6‐8 residents, 

with representation from each post‐graduate year, 

residents identify a problem they have 

encountered, be it direct patient care or a systembased 

issue. A program director, associate program 

director, or a chief resident facilitates a guided 

discussion and introduces quality improvement 

terminology and concepts. 

Each group performs a root cause analysis 

and value stream map of the current and 

future process for their chosen project. 

Residents are responsible for meeting with 

stakeholders, implementing improvement 

measures, and evaluating outcomes. At the 

completion of the project, small groups 

present their projects to a panel of senior 

leadership in quality improvement. All 

residents attend the presentation, gaining 

additional insight into other methods and 

areas of quality improvement. The top 

scoring team receives a monetary reward. 

Results: Six projects were completed in 2011‐ 

2012, the first year of this curriculum. Two of 

these projects are being continued and one of 

the projects has spurred further inquiry. In 

addition, residents have the opportunity to 

submit and present these projects at national 

meetings. 

Discussion: By working with “real‐world” 

problems, identified by the residents 

themselves, residents gain knowledge and 

experience in quality improvement methods. 

The small group setting allows each resident 

to play a role in a focused project. All 

residents participate in critically evaluating 

other projects, developing leadership skills in 

quality improvement. Working with the Scott 

& White Healthcare system, the residentbased 

projects often initiate a change that 

improves the patient care in our system. 

Annual QI Curriculum Timeline 

Aug ‐ Didactic curriculum is presented 

Sept –Oct – Groups brainstorm project ideas 

and choose a project 

Nov – Groups perform root cause analysis 

involving stakeholders 

Dec –Apr ‐ Groups implement change 

involving stakeholders and determine 

effectiveness of the solution. Groups may try 

several different solutions. 

May – Groups present projects in a dedicated 

noon conference event


Poster Title: Hands-On Quality Improvement: A Curriculum for Team-Based, Resident-Led Projects Training 

Residents in Quality Improvement Using Small Groups and Resident-Initiated Projects 

Authors and Affiliate Institutions: Hailey Vincent, Lindsey Tricinella, Micheal McNeal, Tresa McNeal, Curtis 

Mirkes, Texas A&M University College of Medicine 


Hailey Vincent, MD 

Resident 



2401 South 31st Street 

Temple, TX 76508 

Telephone: (254) 724-2111 

Email: hvincent@sw.org 

Discussion of How the Problem was Identified and Explored: Quality Improvement is an important part of 

healthcare that allows identification of problems, self-evaluation, planned intervention, and implementation of 

solutions. The ACGME requires that all residency programs include quality improvement methods into their 

curriculum. The Internal Medicine Residency Program at Scott and White Healthcare/ Texas A&M Health Science 

Center College of Medicine has pioneered a unique curriculum that allows residents to evaluate their work 

environment and use quality improvement methods to solve “real world” problems. While a quality improvement 

curriculum is required, it can be difficult to implement a standardized curriculum that provides opportunities for all 

residents to have hands-on experience. It can be more challenging to promote actual implementation of solutions 

within a healthcare system. 

Description of the Innovation: Working in groups of 6-8 residents, with representation from each post-graduate 

year, residents identify a problem they have encountered, be it direct patient care or a system-based issue. A 

program director, associate program director, or a chief resident facilitates a guided discussion and introduces 

quality improvement terminology and concepts. The group performs a root cause analysis and value stream map of 

the current and future process for their chosen project. Residents are responsible for meeting with stakeholders, 

implementing improvement measures, and evaluating outcomes. At the completion of the project, small groups 

present their projects to a panel of senior leadership in quality improvement. All residents attend the presentation 

gaining additional insight into other methods and areas of quality improvement. The top scoring team receives a 

monetary reward. 

Results to Date: Six projects were completed in 2011-2012, the first year of this curriculum. Two of these 

projects are being perpetuated and one of the projects has spurred further inquiry. In addition, residents have the 

opportunity to submit and present these projects as scholarly activity at national meetings. 

Discussion/Reflection/Lessons Learned: Results: By working with “real-world” problems, identified by the 

residents themselves, residents gain knowledge and experience in quality improvement methods. The small group 

setting allows each resident to play a role in a focused project. All residents participate in critically evaluating other 

projects, developing leadership skills in quality improvement. Working with the Scott & White Healthcare system, 

the resident-based projects often initiate a change that improves the patient care in our system. 



Poster Title: Outcomes from a Three-Year QI Residency Education Program 

Authors and Affiliate Institutions: David Meyers, Robert Holland, Mary Thompson, Michelle Kipp, Chris 

Hildebrand, Amy Smith, Bennett Vogelman, University of Wisconsin School of Medicine and Public Health 


Bennett S. Vogelman, MD 

Vice Chair for Education; Director, Internal Medicine Residency Program 


University of Wisconsin School of Medicine and Public Health 

1685 Highland Avenue 

Room 5116 MFCB 

Madison, WI 53705-2281 

Telephone: (608) 263-7352 

Email: bsv@medicine.wisc.edu 

Discussion of How the Problem was Identified and Explored: We saw the infusion of QI curricula into medical 

education as an opportunity to teach QI skills alongside resident-led self-assessment and performance improvement 

exercises. 

Description of the Innovation: To explore this synergy, we developed a three-year process during which residents 

learn the principles of QI and how to integrate them into their practice. This curriculum results in two end points: 

patient care outcomes and resident QI project implementation. The graduating classes of 2010 (n=22) and 2011 

(n=21) audited over 400 charts annually (2547 records) for 20-22 preventive and disease-specific core measures in 

their continuity clinics. After comparing their results to peers and national standards, each resident committed to 

change in weak areas. During a one-month rotation as PG3s, residents apply KSABs acquired in prior M&M and 

a two-week QI experience to develop their own QI proposals. They are coached in skills related to problem 

identification, formal process assessment, intervention design, overcoming barriers, securing stakeholder buy-in 

and implementation. We emphasize the importance of a thorough process analysis using interprofessional 

collaboration. During presentations to multidisciplinary audiences, residents discuss proposed interventions and 

elicit feedback. Resident projects are integrated into existing hospital QI committees or coached by designated 

faculty to facilitate implementation. 

Results to Date: Both classes showed improvement from PG1 to PG3 year in their average compliance with the 

core measures (paired t test: class of 2010, p=0.001; 2011, p=0.006). Immunization rates; cancer, lipid, ETOH, 

tobacco and DM screening; HTN control; and diabetes measures improved in one or both classes. Compliance 

rates were lowest (10-80%) for tobacco cessation, ACE/ARB for microalbuminuria, HbgA1C90%), DM foot and 

eye care (>85%) and screening for cancer, HTN, DM, ETOH, tobacco and lipids (>94%). These longitudinal data 

show similar results to residency-wide cross-sectional data from 2003-2007. Residents completed 71 projects in 

five years and 58% were implemented. 

Discussion/Reflection/Lessons Learned: The chart review, reflection, and commitment-to-change process is an 

effective tool for self-assessment, learning and improving patient care in continuity clinics. By graduation, residents 

have demonstrated the ability to complete key steps in a QI project and many have seen their actions meaningfully 

impact patient care. 


Background 

“If you listen carefully to the patient, they will tell you the diagnosis.” 

‐Sir William Osler 

Ekaterina Vypritskaya, MD, FACP, Saba A Hasan, MD, FACP 

Capital Health Regional Medical Center, Trenton, NJ 

Description of the Innovation 

Results to Date 

In the era of endemic over‐testing, when billions of 

care dollars are spent on unnecessary or 

inefficiently delivered services, it is our 

responsibility to prepare the next generation of 

physicians to change their habits of practicing 

medicine. 

1. Implement the Awareness of High Value, Cost‐Conscious Initiative by ACP 

‐Curriculum of 6 lectures by core faculty was incorporated in our noon 

conference schedule. 

‐ Analyze cases of overuse/misuse of resources in real time; analysis leads to 

didactic sessions with emphasis on evidence‐based medicine principles and 

current guidelines. 

‐ Incorporate analysis of clinical reasoning during teaching rounds (discussing 

pretest probability, thinking ahead whether results of test would change 

management) 

2. Challenge the common replacement of careful history and physical exam 

with imaging and laboratory tests 

‐ Include didactic sessions on Physical Exam into noon conference schedule 

‐Perform bedside workshops on physical exam for small groups of residents 

(5‐6 people) run by subspecialists (complete neurological exam performed by 

neurologist; JVD assessment, heart auscultation by cardiologist) 

3. Respond to patient demands to overuse medications or perform 

unnecessary tests 

‐Conduct simulation sessions with role play format. (For example: Patient with 

sore throat and Centor Score 1 requests antibiotics. Residents practice 

educating patient about the nature of viral disease and harm of antibiotics.) 

4. Avoid “One size fits all” approach 

‐ Conduct didactic sessions with Social Service and Case Management regarding 

the basics of health insurance and coverage. 

‐Employ multidisciplinary rounds to customize care and craft safe discharge 

plans for uninsured and underinsured patients. 

5. Emphasize preventive care as effective tool for assuring good public health 

and for saving money on medical costs 

‐ Conduct didactic sessions on updates in immunization and screening 

‐ Address importance of discontinuation of screening for patients with limited 

life expectancies. 

‐ Include patient’s values into clinical decision making. 

‐ Implement curriculum in “Cultural awareness” 

‐ Conduct simulation sessions on difficult cultural and bio‐ethical cases 

Residents have understood principle of High 

Value Cost‐Conscious Care. Now they bring for 

discussions cases where physical exam was 

underused or/and over‐testing took place. 

They seem to be excited to apply these 

principles to patient care. 

Significance 

Incorporation of these curriculum elements in 

many aspects of training will promote the 

habit of practicing evidence‐based, 

comprehensive, patient‐centered medicine. 

References 

Cynthia D. Smith, MD; and on behalf of the 

Alliance for Academic Internal Medicine– 

American College of Physicians High Value, 

Cost‐Conscious Care Curriculum Development 

Committee; “Teaching High‐Value, Cost‐ 

Conscious Care to Residents: The Alliance for 

Academic Internal Medicine–American College 

of Physicians Curriculum.” Annals of Internal 

Medicine. 21 August 2012, Vol 157, No 4.


Poster Title: “If You Listen Carefully to the Patient, They Will Tell You the Diagnosis.” -Sir William Osler 

Authors and Affiliate Institutions: Ekaterina A Vypritskaya, Saba A Hasan, Capital Health Regional Medical 

Center 


Ekaterina A. Vypritskaya, MD 

Faculty 


Capital Health Regional Medical Center 

750 Brunswick Avenue 

Trenton, NJ 08648 

Telephone: (609) 394-6031 

Email: evypritskaya@capitalhealth.org 

Discussion of How the Problem was Identified and Explored: In the era of endemic over-testing, when billions 

of care dollars are spent on unnecessary or inefficiently delivered services, it is our responsibility to prepare the 

new generation of physicians to change habits of practicing medicine. 

Description of the Innovation: 1. Implement the Awareness of High Value, Cost-Conscious Initiative by ACP. 

Curriculum of 6 lectures by core faculty was incorporated in our noon conference schedule. - Analyze cases of 

overuse/misuse of resources in real time; analysis leads to didactic sessions with emphasis on evidence-based 

medicine principles and current guidelines. - Incorporate analysis of clinical reasoning during teaching rounds 

(discussing pretest probability, thinking ahead whether results of test would change management) 2. Challenge the 

common replacement of careful history and physical exam with imaging and laboratory tests. - Include didactic 

sessions on Physical Exam into noon conference schedule - Perform bedside workshops on physical exam for 

small groups of residents (5-6 people) run by subspecialists (complete neurological exam performed by neurologist; 

JVD assessment, heart auscultation by cardiologist). 3. Respond to patient demands to overuse medications or 

perform unnecessary tests. - Conduct simulation sessions with role play format. (For example: Patient with sore 

throat and Centor Score 1 requests antibiotics. Residents practice educating patient about the nature of viral disease 

and harm of antibiotics.) 4. Avoid “One size fits all” approach. - Conduct didactic sessions with Social Service 

and Case Management regarding the basics of health insurance and coverage. - Employ multidisciplinary rounds 

to customize care and craft safe discharge plans for uninsured and underinsured patients. 5. Emphasize preventive 

care as effective tool for assuring good public health and for saving money on medical costs. - Conduct didactic 

sessions on updates in immunization and screening - Address importance of discontinuation of screening for 

patients with limited life expectancies. 6.Include patient’s values into clinical decision making. - Implement 

curriculum in “Cultural awareness” - Conduct simulation sessions on difficult cultural and bio-ethical cases. 

Results to Date: Residents have understood principle of High Value Cost-Conscious Care. Now they bring for 

discussions cases where physical exam was underused or/and over-testing took place. They seem to be exited to 

apply these principles to daily patient care. 

Discussion/Reflection/Lessons Learned: Incorporation of these curriculum elements in many aspects of training 

will promote habit of practicing evidence-based, comprehensive, patient-centered medicine. 


A Novel Assessment System Created by Mapping Milestones to Entrustable Professional Activities 

Eric J. Warm MD, Bradley R. Mathis MD, Carl Fichtenbaum MD, Caroline Mueller MD, Savita Pai MD, Jonathan Tolentino MD, Tiffiny Diers MD, Lauren Ashbrook MD, Justin Held MD, Cheryl Lee MD, David Lee MD, Sharice Wood MD 

ABSTRACT 

Tracking 

Formative 

Summative 

Background: The ACGME’s Next Accreditation System 

Curricular Milestones 

Entrustable Professional Activities 

Sub-Competency 

NAS Reporting Milestones 

(NAS) requires measurement and reporting of outcomes 

through educational milestones. 

Aim: Describe a mapping process between curricular and 

NAS milestones and Entrustable Professional Activities 

Different educational milestones in each 

rotation. Examples: 

(EPAs) 

Different directly observed skills for every 

rotation. Examples: 

(EPAs) to assess trainee progression towards competence. 

PC F2: With minimal supervision, manage patients 

Titrate cardiac medications 

with common and complex clinical disorders. 

Setting: Internal medicine residency in an urban tertiary 

Titrate insulin based on glucose readings 

referral medical center. 

PC B4: Routinely identify subtle or unusual physical 

Manage pancreatitis 

Participants: Internal medicine residents and faculty. 

findings that may influence clinical decision making. 

Adjust short and long acting narcotics for sickle cell 

Program Description: Curricular milestones were mapped 

PC E1: Make appropriate clinical decisions based 

patients 

to more than 350 EPAs that constitute the University of 

upon the results of common diagnostic testing. 

Manage parathyroid abnormalities in the renal patient 

Cincinnati residency curriculum. Assessments based on 

PC F10: Customize care in the context of the patient’s 

Deliver appropriate goal-directed therapy for severe 

a 5-point entrustment scale assigned by evaluators for a 

preferences and overall health. 

sepsis 

given set of EPAs are also directly assigned to mapped 

curricular milestones. Curricular milestone mapping 

decisions were based on the following question: would 

the likely intent of the evaluator in assessing a trainee on 

a given EPA also be to assess the mapped milestones? 

EPAs were then aggregated based on subject matter 

and mapped to the appropriate sub-competencies. The 

aggregate entrustment score for those EPAs determines the 

NAS reporting milestones achievement level. 

Program Evaluation: Assessing EPAs and associated 

mapped curricular milestones creates the ability to track 

curricular milestone progression across rotations and 

over time. By combining these data sets, the competency 

committee can attest to specific clinical skills (end-ofrotation 

formative assessment of specific EPAs), monitor 

progression of curricular milestone attainment (figure 1), 

and develop summative assessments relative to peers and 

the entrustment scale (figure 2, NAS map). 

• Curricular milestones are mapped to EPAs by asking the question: would the likely intent of the 

evaluator in assessing a trainee on a given EPA also be to assess the mapped milestones? 

• Data from the mapping generates the figures below that the resident and program director can 

track over time 

• In this example, multiple EPAs that demonstrate development of management plans are aggregated and mapped to the patient care 

subcompetency ‘Develops and achieves comprehensive management plan for each patient’ (PC2) 

• To determine the NAS reporting level, the aggregate 5 point entrustment score is multiplied by 9/5, and then rounded down to the 

nearest 0.5, which corresponds to the 9 check boxes under the 5 columns of the NAS reporting tool 

Figure 1a. Curricular Milestone Interpersonal 

Figure 1b. Curricular Milestone Patient Care C1: 

Figure 1c. Curricular Milestone Patient Care A4: 

Discussion: Curricular milestones can be mapped 

and Communication Skills A1: Provide timely and 

Synthesize all available data, including interview, 

Demonstrate sufficient knowledge to diagnose and 

to EPAs to create a formative assessment system for 

residents . EPAs can be aggregated and mapped to the 

subcompetencies and the NAS reporting milestones for 

comprehensive verbal and written communication 

to patients/advocates. 

physical examination, and preliminary laboratory 

data, to define each patient’s central clinical 

problem. 

treat undifferentited and emergent conditions. 

Figure 2a. Communication Skills Radar Plot 

Figure 2b. Patient Care Radar Plot 

Figure 2c. Systems Based Practice Radar Plot 

summative reporting. Further study is needed to determine 

if this system predicts progression towards competence. 

This represents 25 assessments from 18 evaluators in 

the first three quarters of the year for a single PGY-1. 





This represents 202 assessments from 12 evaluators 

after eight months of the PGY-3 year. 





Entrustment Scale: 

1. Resident cannot perform this skill even with assistance. 

2. Resident should perform this skill under direct supervision. 

3. Resident can perform this skill under indirect supervision. 

4. Resident can perform this skill independently. 

5. Resident can act as instructor or supervisor for this skill (aspirational). 

• These graphs show progression over time for residents (blue lines with circles) compared to the peer average (grey lines with 

diamonds) and an idealized reference (yellow lines). 

• The PGY-1 in Figure 1a improved after feedback; the PGY-1 in Figure 1b is on track; and the PGY-3 in Figure 1c has achieved 

an entrustment level of “resident can perform this skill independently.” 

• Graphs like these can be obtained for all 142 curricular milestones. 

• Figures were derived using MedHub’s data system (MedHub, Inc., PO Box 4148, Ann Arbor, Michigan 48106). 

• These figures are snapshots of a single PGY-3 resident’s curricular milestone data (blue lines) compared to his/her peers (green 

shaded area). 

• Each of the letter designations around the circles represents a single milestone within that core competency. Levels 1–5 

represent the five levels of the entrustment scale. 

• The residency competency committee uses this information to quickly determine who is on track and who needs closer scrutiny. 

• Figures like these can be obtained for all 142 curricular milestones. 

• Figures were derived using MedHub’s data system (MedHub, Inc., PO Box 4148, Ann Arbor, Michigan 48106).


Poster Title: A Novel Assessment System Created by Mapping Milestones to Entrustable Professional Activities 

Authors and Affiliate Institutions: Eric J Warm, Bradley R Mathis, Carl Fichtenbaum, Caroline Mueller, Savita 

Pai, Jonathan Tolentino, Tiffiny Diers, Lauren Ashbrook, Justin D Held, Cheryl Lee, David Lee, Sharice Wood, 

University of Cincinnati College of Medicine 


Eric J. Warm, MD 




University of Cincinnati College of Medicine 

231 Albert Sabin Way 

Mail Location 0557 

Cincinnati, OH 45267-0557 

Telephone: (513) 558-2590 

Email: warmej@ucmail.uc.edu 

Discussion of How the Problem was Identified and Explored: The ACGME has mandated programs in the Next 

Accreditation System (NAS) to submit composite milestone data on residents every 6 months. Program directors 

have found milestones difficult to use for formative resident assessment and have turned to the Entrustable 

Professional Activity (EPA -- a professional activity the public expects physicians are capable of doing) as a more 

practical tool to measure performance. Our aim was to create an assessment system for reporting high value 

milestone-based information for each resident. 

Description of the Innovation: We rewrote our entire curriculum using the EPA as the basic element. For each 

rotation, we created both content and process EPAs. Content EPAs describe observable skills that differ for each 

rotation depending on the specific skills learned (for example, titrate insulin, manage a ventilator). Process EPAs 

describe observable skills conserved across rotations (for example, demonstrate shared decision making). Faculty, 

peers and staff assess resident performance on these EPAs using a 5 point entrustment score (1: cannot do EPA, 2: 

can do EPA with ongoing proactive supervision, 3: can do EPA with distance supervision, 4: can do EPA 

independently, 5: can teach EPA). We mapped each EPA to the 142 curricular milestones asking the question: 

Would the likely intent of the evaluator in assessing a trainee on a given EPA also assess the milestone in question? 

We then created an information system to collect, sort and report this data over time. 

Results to Date: Our curriculum and assessment system now consists of approximately 350 EPAs mapped to the 

142 curricular milestones. Faculty and residents have responded favorably to using EPAs as formative feedback. 

Milestone data derived from setting entrustment scores for each mapped EPA provide a summative assessment of 

performance over time, thereby tracking resident progress towards independent practice (entrustment score of 4). 

After mapping the entire residency curriculum we discovered important gaps and developed specific experiences to 

fill them. 

Discussion/Reflection/Lessons Learned: An assessment system consisting of EPAs mapped to curricular 

milestones can be used in formative assessment as well as summative reporting. These maps could be easily 

extended to the newer NAS milestones for ACGME reporting.

2013 APDIM Spring Meeting Poster Reception - Alliance for ...

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