All right, everyone. So hello, and welcome to medicine grand rounds. We've got a packed agenda today. So we'll go ahead and get started right on time. 

As many of you know, there's a special grand rounds today. So we will be doing some annual year-end awards and honoring a number of-- well, it's house staff as well as other individuals important to our house staff within the health system. We have a number of house staff devoted awards that we'll give out today. And then following that, we'll be hearing from the chief residence for their year-end grand rounds. So to get the awards part started, I'll ask Dr. Tim Short to come up from the Brodie Award Committee to present the Brodie Resident Award. 

Thank you. I'm standing in for Evan Heald, who's the chairman of the Brodie Medical Education Committee. And the Brody committee was formed in honor of an Anne L Brodie, who was a patient that arrived here. Her husband started a division in the NIH, is a famous pharmacologist. 

And she arrived kind of limping into Charlottesville in need of medical care and found a physician here at UVA, who not only cared about her, but cared for her and got to know her. And she deeply trusted that physician and had nobody else in the world other than this physician to leave her by that time significant estate too. And he couldn't accept that for obvious reasons. And turned it over to UVA to promote medical education and promotion of generalists, providing that kind of care. 

That was Gene Corbett. And as part of that, we have sponsored an award for generalists in each of the primary care divisions. I'm down here. Sorry, I can't see you guys. I just realized. 

And this Anne L. Brodie resident clinician ward the purpose is to recognize residents who demonstrate clinical excellence in primary care at UVA. And they serve as models for peers and medical students for their artful compassionate patient-centered care and their willingness to take primary responsibility for the care of the whole person. And it's a great honor to recognize Sumner Abraham as this year's recipient. 

Hi. 

While you're up here, Sumner, I will read just briefly a statement so everybody can see you blush. There are so many skillful, compassionate, dedicated, thorough, and responsible residents in this class, who take amazing care of their patients, but I've never seen one who approaches patients with such joy and intentionality in seeing their personhood. Sumner Abraham never met a patient who didn't like each of his patients-- who he didn't like. And each of his patients seems to be his favorite patient 

He's worked miracles with some of our chronic pain patients managing to taper some folks off contracts and never flustered by any patient behavior. He's a role model of positive energy and has all the requisite, knowledge, and skills to be a great general internists. Many of his patients were in genuine tears at his departure due to his loving and thorough care. Congratulations. 

Thank you, Tim. So I have the honor of presenting the Resident Voted Award. So each year residents vote on a nurse from the outpatient side of their practice to honor. And this year that award goes to Nikki Price. 

So similarly, we honor an Inpatient Oriented Nurse Of The Year From The Residence. And that is from the medical ICU Kendall Barger. We honor a case manager of the year each year. And from eight west this year, Sarah Gertler. 

We honor I believe it's a Reciprocal Exchange, a colleague with whom we interact through the emergency room each year. And this year that's Dr. Aaron Blackshaw. We're getting there. All right, this year the fellow of the year voted on by the residence from cardiology, Dr. Saad Ghumman. 

Now, into the last three awards. So each year our residents vote on an Outpatient Attending Of The Year Award for their faculty at University Medical Associates. And this year that award goes to our fearless leader and medical director at UMA, who can't be here today, but for the residents, we will honor her in person with this award next week at business meeting, Dr. Ira Helenius. 

So for the second year in a row, for inpatient attending of the year, our residents have honored a first time winner of the award. And in looking through what our residents have said about this faculty member over the last year in comments and evaluations, she's been noted for her scientific approach to pulmonary and critical care, excellent procedural skills, and incorporation of evidence-based medicine into the ICU, so this year that award goes to Dr. Alex Cottle. And our last voted award by the residence is the Dunn Award. 

So the Dunn Award is given annually to a PGY3 resident. Again, this was started by a donation from a grateful family. So this award goes to a resident. 

And the judgment of his or her peers deserves particular recognition for skill in the technical aspects of medicine, the qualities of thoughtfulness patients and caring, which characterize Dr. Dunn's patient care. Dr. Dunn was described as kind, truthful, reassuring, and infinitely patient. So this year, this award certainly goes to Dr. Jack Nelson. 

All right. So now, we will transition into chief resident grand rounds. And it's my honor to introduce them for the stage and so to just kind of set the tone for what they're about to share with us. 

So each year the chief's annual grand rounds is a kind of a capstone and a look back at the past year in the life of the program, some of what's been going on, where they have been laboring, and where all of us have been laboring in our education and in our clinical environment. So there was a kind of a preview of where graduate medical education is heading, both here and sometimes on the national level. And it really begins in most years a figurative passing of the torch from them to their successors. 

This year, because of scheduling, two chief grand rounds is a little later than it sometimes is. So it's really a literal passing of the torch. This is our chief's last day in the saddle. And this is the first time I can ever remember our grand rounds from the chiefs being on their last day. 

So each year, whether by the needs of a given year or just the interest and skills of a particular group of chiefs, the year takes on its own unique direction and achievements. And I think as I think back on this year for each of the four of you, there are many notable things that I'm going to remember, but one in particular for each of you, just as I present you with your chief resident graduation certificate and just a note of thanks from me. So for, Kerry, Kerry, we'll start with you. 

And again, I'm not trying to spoil too much of your content here, but you're open [INAUDIBLE]. And that's Walid El-Nahal Walid, always excited and innovative teaching styles and engagement [INAUDIBLE]. 

So, Anthony Peters, don't stand yet. So again, I just wanted to thank you for [INAUDIBLE] the incredible work that I think people might assume [INAUDIBLE]. And, Amy, I want to thank you for the really the new standard of the role of the empowered and system aware resident and engagement with the health system and all the other processes of collaboration that you've really been committed and engaged to this year. Thank you. 

So as the four of you pass the torch today and move on to new adventures, we will remember the uniquely walk shaped imprint that leave behind. And we'll look forward to keeping you connected to the program as you go off on your future adventures. And thank you from the department and then from me personally for all of your labor, ideas, and friendship. So with that, I'm going to turn the podium over to Dr. Anthony Peters to kick off our chiefs grand rounds, Building The Exemplary Physician. 

All right, everyone. Welcome, and thank you. We're extremely excited to be here today. 

I've been honored to serve this year as chiefs. We're excited to talk to you guys. And we'll really I think look back fondly on the year and miss everyone here. 

But in kind of thinking about this presentation, new disclosures, we don't have any. And thinking about the presentation for this year, I think it had it us looking back at the year, thinking about our goals at the beginning of the year. I think many lofty goals, but one of whom was just to get through the year unscathed. 

And unfortunately, we were unable to do that, as seen here exhibit A, exhibit B, segue incidents, diseases you thought only happened in children, or run-ins with mandolin slicers. So did not achieve that, that logo, but I think a couple of things were did get done. 

And I think that's largely thanks to all of you guys residents and faculty alike. So that's what we'd like to cover a little bit today. And to do that, we'd like to use a framework of Building Exemplary Physicians, so in the modern era building an internist who can handle anything. 

So that's what we'd like to utilize as the theme today. And to do that, we'd like to kind of step through everything, each of these topics, in terms of background, both nationally, and here at UVA. So interventions here at UVA and then possible future directions. 

And the agenda, It's going to be a little bit wide-ranging and to try to hit these four domains and do so, because we feel like they all play a role in that exemplary internists. So it'll be a little bit past-based, a little bit-- a lot of different topics, but we think it's all linked together in that exemplary physician. And some of those specific things we're going to touch on are understanding some of the challenges in graduate medical education, specifically communication in the modern era, the use of technical skills, and ultrasound in the modern era, how to balance both autonomy, and support for trainees, and a few other things that we'll get to, but we'll step through them. 

So for the first one we're going to touch on clinical knowledge and skills and specifically these four domains. And I'll start with clinical autonomy. So for some background on that, I think we all know autonomy is a bit of a buzzword. And we all know that there's been a lot of variation both over the years and across institutions and how much autonomy there is for residents and for trainees. 

UVA's internal medicine program I think has largely been built on sort of resident-led decision-making. And we really feel pride ourselves in that. But we also pride ourselves and a culture of support here and support systems. 

So I think there's always a tension between those two things. And looking a little bit at the literature, most of this is survey-based. There's not a lot of outcome data here. But on the survey base data, I think across the board trainees think of autonomy as something that benefits their training for sure as these articles touched on. 

One pretty good review article and this is from the surgical literature, that includes a number of internal medicine studies kind of looked at this in a little bit more detail. And I think two conclusions from it. So one is, again, that trainees felt that autonomy benefited their training, whether it gave them increased confidence, help them make decisions better, helped their professional development, made them more ready for independent practice across the board. 

And this is the white bars being all of medical education. And the gray bar [INAUDIBLE] surgically. But across the board, trainees felt like autonomy helped them to be a better physician. 

But a little bit on that on the flipside, they didn't necessarily feel that autonomy necessitated removal of support. So this is a subset of the internal medicine studies that they looked at in this review article. And each of them talked about that the presence of additional support that it allows more senior staff member in most of these didn't kind of hold back their autonomy, as long as they were still able to make decisions. 

So I think that was the big takeaways for me from this article. So what have we done here? So four main changes in the past two years or so. So this first one happened I think about a year and a half ago now, but residents sort of autonomously reviewing ACS and MICU admissions own their own, kind of alongside the fellow in parallel. 

The new gen med five central structure as we reintegrated GI and gen med have made more of a two to one structure. And I think that's given interns some autonomy to make more decisions on their own, and then the holdovers changes that we made this year. So this is a-- I really threw a-- a large group of residents I just have a few up here, but about 20 residents led this charge along with Amy and restructured how we did our hold over handovers, making them more efficient and making them more resident-led. 

I think largely that's been a positive change. And the last one being the new fast-tracking process. So again, this is thinking about making things more efficient and making residents quicker to make decisions. And so this is a multidisciplinary effort with both emergency room and internal medicine. I'm sure I'm missing a few here, but I think largely, again, puts decision-making in the hands of residents. 

And that's what I want to touch on a little bit more in terms of the data there. So from fast-tracking, this is a chart that looks at of medium time from admiss requests to admit order. And starting on the left side in January 2018, this new fast-tracking process, again, led by residents along with Amy started in October. 

And you can see, it was a bit of a dip there. And overall, you could argue that there is a downtrend in time to admission. And this is for all general met medicine admissions coming through the ATC-- so going from about 120 minutes to about 90 minutes over this time period. 

So some positive changes there, we do think that this is coming from fast-tracking to some degree. So the y-axis changes here, these are all the fast track admissions starting in October. And these range from the 90 to 100 minute mark. Some peaks in there, but overall relatively flat. 

So we do think that this turning over things to two residents to a certain degree to make quicker decision about admissions has led to getting patients into the hospital quicker. And thinking about some future directions here and sort of this autonomy piece-- so one, maybe continuing to track some outcomes for this these fast track admissions. We know we're doing the efficiency data, perhaps what clinicians think of it, if possible looking at outcomes for continuing to optimize how we do hand-offs. 

And I think we can look to the literature here a little bit and look at some themes for how to make really both efficient, but also effective hand-offs. And then lastly think about new structures that can emphasize residents, making decisions without necessarily always removing support systems as the lecture shows us. All right, so stepping forward to one other topic kind of within clinical knowledge and skills, so department education. Kerry's going to touch a little bit more on sort of program specific education later, but department education kind of brings to mind for me medical grand rounds. 

So I'm going to talk just for a few minutes about that. And looking at the literature on that, it actually suggests that there is kind of nationally speaking maybe some decreasing relevance in attendance at medical grand rounds. I think modern day grand rounds is very different from the traditional format. And I think we're struggling still to find how to most effectively use kind of modern formats and grand rounds. 

So some of the literature here is a little bit dramatic and talking about this. So can we make grand rounds grand again or requiem for a grand rounds? But these touch specifically on kind of reasons that people cite for it. 

So this is a long list here. And I won't go through it all, but it's things that you would think of, so whether it's lack of an engaging presenter, lack of patient-focused, poor food, poor parking, lots of reasons for it, but it also it also looks to some guidance for how to restore medical grand rounds. And these are the points that this article on the left here makes. So advanced planning, we're looking forward to about a year and planning for it, incorporating how adults form best. And that's often in an engaging format and in a format where the learner has a role in the planning and execution of the teaching, offering CME credit for faculty, leaders within the department playing big roles, and then interactive nature of it with pertinent topics-- so what they touch on. 

So in terms of structure changes here, in the past year, Dr. Rosner and Dr. Uthlaut have led the creation of the Medical Grand Rounds Committee and have done a few of these things that the literature actually talks about. So we've kind of integrated departmental updates to highlight specific endeavors within the institution, have added MOC credit obviously, have narrowed the time that we have we want people to talk for, and tried to make it a little bit more interactive, more time for Q&A, and then thinking about the topics themselves, tried to make them as practical case base as possible and then multidisciplinary when possible. And really these are the folks that you can thank for that. 

So as I mentioned, Dr. Rosner and Dr. Uthlaut, specialty leaders from each of departments who have played a real role in that and then the staff, Tony Terry, and Terry, who helped get this done. So in thinking about future directions, lots of possibilities here. And [INAUDIBLE] of tracking it, but I think continuing to integrate innovative presentations would makes sense, thinking about kind of needs assessments. That's been touched on a lot in the literature-- The needs of a very wide-ranging audience and sourcing that, potentially through the medical grand rounds committee, and then continuing to emphasize audience participation where we can. 

So that's it for me and clinical knowledge and skills before I turn it over to Walid. And we're going to talk a little bit about technical skills. So I think procedural skills has always been a standard for internists, bedside procedural skills, but increasingly ultrasound is playing a large role in that, as ultrasounds become more prominent and smaller and smaller. 

So this is also touched on in the literature, kind of the almost as an extension of the physical exam, the ultrasound is becoming-- take this with a grain of salt. It's from the Journal of Ultrasound Medicine, but there is a lot of literature that touched on it. ACP, for instance, talks about a support statement for point of care ultrasound and then other authors talk about it as maybe even a training milestone for residents in the future. 

So here at UVA, a lot of this has been kind of resident-to-resident, fellow-to-fellow learning, sometimes we do it at the Med School Sim Center, but for the large part we've been teaching each other through the bedside, whether it's faculty fellow, a resident, or either self-to-self training, as evidence here. So I think over the three years, lots of our residents become quite skilled, but it could happen I think more efficiently and earlier. So that's what's been happening here, we made small steps this year. And a lot of that thanks you should go to the ERC Sim Center and specifically Dr. Sandy, who's led that. 

And we've worked with her to build a kind of standardized training for targeting first-years on the neck ultrasound and IJ central line placement. So again, targeting first-year residents, trying to get them trained in a standardized fashion to the SIM center and then using kind of expert teachers Dr. Sandy and some of our pulmonary fellows, like Dr. [INAUDIBLE]. 

And really I think the keys is here. It's one-on-one hands-on teaching. The equipment is as close to real life as we can get. And it's done in a standardized fashion. 

So this is an example of what the teachers will be kind of stepping through a portion of the checklist project placement. So thinking about future directions on this topic-- so I think continued training through the ERC Sim Lab and then looking at some leadership within the MICU pulmonary division and also from our residents. 

So this is a program kind of in the works that we're going to roll out next year. As for curriculum, that's really been organized through the MICU faculty you see here. And that'll include both corps lecturers, as well as some hands-on weekly training for residents and interns, who are rotating through to MICU. So I think are really excited about this and again grateful for this faculty leadership and some of the residents who are going to play a role in these endeavors. So with that, I'll turn it to over to Walid for the last bit of clinical knowledge. 

Thank you, Anthony. So to kind of round out the knowledge and skills part of our talk, I'll be talking about the last, but certainly not the least of the area where residents I think get a lot of their knowledge, which is our patients. I think certainly our patients are some of our biggest teachers in residency. The more of them we meet, the more of them we learn. 

I think we also recognize that you kind of need time to wrap your head around the patients and really get that value out of them. So that kind of brings me to talk about a point that I'm going to spend a lot of time on here, which is that the census sweet spot, if you will, which is basically the belief that, although, you meet more patients, you learn more. There definitely is a point where you kind of start to get diminishing returns if you don't really have a chance to sit down and spend some time doing some learning about each of those individual patients. 

And so in a bit, I'll kind of be talking about some of the strategies that we want to incorporate to kind of manage the census and make sure that residents are getting a valuable experience. But first, I was going to just briefly review some of the literature on the perceptions about the effect of the compressed workloads that residents kind around the country are starting to deal with these days. And so this is what I'll be opening with, which is just a survey from a few years ago. 

It was around the time of incorporating the new duty hours. And they were looking at the effect of what the compression of those duty hours was going to have on residents, kind of backing up against this backdrop of the increasing censuses that places in academic centers were starting to face. And so basically they asked the duty hour changes and asked them, do you think that these are going to have a negative effect, a positive effect, or things are going to be about the same? 

And so I asked about intern and resident clinical experiences. You'll see that the largest percentage we're really concerned about worsening clinical experiences for people when you have a certain amount of work to do and you kind of go ahead and compress it into that smaller time space. And the same concern really existed around things like conference attendance or other independent learning activities when you have so many patients to see but only so little time to do it. 

And then another study kind of took a closer look at the relationship between census and educational activity specifically. So they basically would study the correlation between the number of admissions and the overall census that a team has with the amount of participation that they had an educational activities, such as going to conferences, learning independently, meaning studying on their own. And they did that by tracking those activities with a check in every few hours, while residents were on the ward and correlating that with the number of patients that they had. 

And so they would ask them, are you engaged in direct care, indirect care, educational activities, personal activities, or ancillary services? And they found that for each additional patient on the team census on non-call days, they would have a lower odds ratio for reporting that they were engaged in an actual educational activity. So point A2 odds ratio compared to doing things like indirect patient care. 

And so that census definitely had an impact on how many educational activities you getting, how much education residents were getting out of their experience. So the next question is, so where do residents kind of think that that census sweet-spot is? And a program tried to study that actually by surveying its residents on the quality of their educational experience based on the census that they had, how many patients they were taking care of at any given-- at any given point. 

And you'll see here the numbers that they actually came up with by asking residents what their educational experience was in the form of a learning score at various points throughout their ward time, varied with how many patients they were carrying. And the numbers at which those learning scores were actually highest for the interns were as low as three and for the residents were as low as six. Now, obviously that's not an exact science. 

I think many of us here would probably argue that the optimal number is definitely higher than those numbers that are portrayed here. And so that kind of brings us to UVA. So what's going on here at UVA? 

I wanted to first start by taking a look at kind of the censuses over the course of the last couple of years. I think for me and a lot of other people there's this feeling that the census has really gotten a lot busier, specifically on gen med and some of the other wards that we see. So this is a plot over the last two years of average weekly census of all the gen med third floor teams. 

This is a plot of five central, which obviously is now incorporated kind of into our gen med service. And then this is a combination of the two. So you can see that over the course of the last two years, it definitely does fluctuate a little bit up and down, kind of with seasonality to it. 

But when you really take a look at kind of where we are now at the very, very far right of the graph and then compare that to where we were the same point in the year two years ago, you'll see that there definitely is a change in terms of where we were to where we are in terms of average, average census. So the question then becomes with this increasing census, what do you do? How do you manage that? How do we approach this experience to make sure that our residents, while they're seeing a lot of patients and learning from all of them, still have enough time to really like wrap their heads around these patients? 

And so you start that by doing things like adding person power to the services so that the workload is a little bit more manageable. You think about ways to build flexibility into the system. So you can take resources from places where maybe it's not as busy on one day and put them into a place where it's a lot busier on that one given day. 

You redistribute the workload, again kind of thinking about who's doing what work at what time and are we most efficiently using our resources. And then you have to find the right balance of turnover, recognizing that census in and of itself doesn't tell the whole story. The idea of constant churn of something like holdovers, for example, really does contribute to this feeling of kind of constant being underwater and not getting a chance to read about your patients. 

So here are some of the things that we tried to incorporate this year and into next year to try and kind of address those challenges. So one thing was trialing two to one teams. And you might ask, well, how does increasing the census of residents were higher number help with the census problem? 

And you think about it a little bit more. And you see that on these two to one teams the interns each individually do have a lower census. And the resident is then kind of free from some of the nit picky detail work so that they can spend a little bit more time really learning about their patients, reading about them, being the team educator, and being the team leader. 

Other things like load sharing between a third and the fifth floor so within integration of Gen Med and Gen Med and Five Central, you have the opportunity to shift the weight, depending on if one service is a lot busier at different points in the year can you move things kind of between the two. Addition of a swing resident, which was a rotation, we added this year, as the residents note to increase the flexibility of where you can put resources. 

This is a resident that can help out kind of filling all the various gaps on the services when things get busy. And then the addition of a float resident, which is something that's going to be consistently present over the course of the next year, which is a resident to help mitigate some of that effect of the churn of holdovers that you can sometimes feel. And so that's all the pieces that I have to talk about in terms of clinical knowledge and skills. 

And with that what kind of transition to the next important domain that we think is involved in building an exemplary physician as we said. And that is public health and service. And so public health I think on that topic, there's an increasing recognition that, as physicians, we have a stake in not just taking care of the health of our own personal patients, but really we have a stake in the health of the public and the system that the public exists within. 

I think we all recognize that there are a lot of external factors that go into the health of the population as a whole. And so that kind of begs the question, well, where do residents-- and really I say residents-- but I actually want to talk about where providers overall fit in? Because I think for residents to really engage in a problem, I think we have to see leadership kind from our faculty as well. 

And so I'm going to talk a little bit about where that's played out here at UVA. So first, I think we all have to recognize our role in going beyond the immediate patient. I think a lot of us came into medicine to sit down with that one patient and connect with them and have a conversation with them. 

But I think a lot of our frustration stemmed from the fact that none of our patients really exist in a vacuum. There are all these external factors that contribute to their care and to their overall health. And so I think, because of that, we kind of have a responsibility to engage with those systems that bring on those frustrations, because we're the ones most directly involved in them and with the highest stake, because we deal with the consequences of it. And more really the patients are the ones that end up dealing with the consequences of that. 

So how do we foster that? And I think the way that we foster that is by creating opportunities for our residents to allow them as providers to engage in their community, focusing specifically in areas where the need is most significant. So from that stemmed this project that really was kind of the thought child of Ross Berlin. There's a GI fellow currently. 

About a couple of years ago, he wanted to create an opportunity for residents to reach out into the community and see patients, not just here in the hospital, but out in the community, where they need it the most. And after many, many conversations with Haven, which is a homeless shelter downtown, as well as the health system here, and many, many meetings over the course of two years, we eventually came to create this opportunity, where residents on a regular basis, our hope is somewhere between one to two times a month can go downtown and see patients at the homeless shelter there and have an afternoon clinic that they kind of go and see their patients, staff them with an attending. It's a multidisciplinary team. 

So during our first session, psychiatry actually went with us. And the plan was for them to staff patients with telehealth. We've already had a couple of residents kind of volunteer for this. 

We've only had two sessions thus far. Our very, very first one was last month. I'll tell you it went very, very smoothly in the sense that we had zero patients show up for our first session, but we took that as a learning experience. 

And we had our second session just yesterday. And five of the six patients, we had scheduled showed up. So it made a lot more progress that way. And I think everyone really, really enjoyed the experience. 

And right off the bat, when I reached out to residents to let them know that this was happening, a ton reached out to me and said, hey, I want to be involved in this. And I want I want to participate in it. So more on that to come. And hopefully, it will be an experience that grows over the course of this next year. 

And it really dovetails nicely into something that one of our faculty members has been working on here. I'm sure many of you all know Drew Harris. And so he actually has been working on creating an underserved populations elective for our residents, which is something that we anticipate rolling out later in this year. 

It's already kind of built into the schedules of many of our PGY3 residents. And it's essentially an experience, where they have elements of clinical work service to patients advocacy, and policy, and education. So over the course of two weeks, you rotate at various sites that give you a little bit of exposure to kind of some patient populations that we maybe don't always get to see kind of directly when we're here in our quote unquote "ivory tower." 

And so trainees will rotate at the Charlottesville free clinic, CVCHC, the Federally Qualified Health Center, the Refugee Clinic, Ryan White Clinic, and various other kind of service and advocacy opportunities over the course of their two weeks. And so between those two experiences, we really hope to foster that drive and residents to kind of reach out and engage with a lot of these things that end up being frustrating for us on a day-to-day basis as we're working with people. And with that, I will transition over to Amy to talk about our next domain, which is communication. 

All right. So I'm going to be talking about communication and how we train our residents to be better at communicating. I'm specifically going to be kind of touching on some challenges to communication that come up in kind of this post-epic world. These are not new issues for physicians, but these are definitely things that are exacerbated by having an electronic health record. 

Specifically, we're going to be talking about documentation and resident-nursing communication-- so starting with documentation. So it's not surprising that, a lot of the time, residents end up spending more time in front of a computer than in front of a patient. So in fact, one study actually found that residents sometimes spend up as much as three times as much time with the computer. 

This is actually based on survey data of about 16,000 resident internal medicine trainees that was published back in 2010. And essentially, it found that 69% of residents report that they spent more than four hours a day on documentation, whereas only 39% of residents spend that much time with patients with direct patient care. And it's not surprising that UVA data actually reflect some of these trends. 

So this is data that's actually taken from our time and motion study that we did back when we transferred to geography. Interestingly, initially the amount of time that residents spent walking around looking for others, doing direct patient care and documentation, were all about the same. Keep in mind that the documentation, that's only documenting within Epic, not necessarily doing things like writing orders. 

So luckily, when we change geography, there was a pretty big drop in the amount of time that residents wasted walking around and looking for others. So we would hope that that time would have then gone into direct patient care. But interestingly, it seems that time got transferred to documentation. 

And with that being said, you would hope that, therefore, maybe our documentation got significantly better and with much higher quality. But there's certainly a trend that documentation with any electronic health or health record has a lot of problems and flaws and in many ways getting much worse. So along those lines, I want to talk about two issues that I'm sure many of you are familiar with. 

And those are copy-forward and note bloat. So basically, these are issues that certainly are linked to many medical issues and errors. So with copy-forward, that's specifically the use of copying and pasting of information from prior documentation into new notes. And this has been in many ways linked to the medical errors, perpetuation of false information. 

And in fact, 70% of residents on a survey conducted found that they recognized that this was an issue and something that can lead to medical errors. However, 80% of residents and attendings plan to continue to use it. Also, another issue is note bloat, which is intimately related to copy-forward. 

So because of the electronic health record, it's very easy to add a ton of information to our notes. So this includes things like auto populated data, like hemoglobins from 10 years ago and things like that. And it just ends up being a lot of repetitive unnecessary and often sometimes erroneous information. And that certainly is a problem. 

So now that I'm overwhelmed with all of that, the question is how do we intervene? Luckily, there was an article that was published last January called A Prescription for Note-Bloat. And this is based on a collaboration between four academic centers that essentially they created a streamlined progress note template paired with resident education with the goal to minimize copy-forward in auto populated data and focus on personal interpretation of pertinent information. 

So there were a lot of really awesome outcomes that came out of this study, but I'm just going to highlight a few. So things like 25% fewer lines, notes being done earlier in the day, and overall improved quality of notes. So we have shorter notes done earlier that are better. So certainly, that's something we wanted to aspire to here at UVA. 

So what we did is last spring I got together with a group of eight residents kind of on an initial task force to work on improving our template here at UVA. Once we kind of had our own first draft of this, we then reviewed that at the Wednesday morning ambulatory curriculum. So each resident rotates through that so therefore had the ability to kind of give their own input and their own touches to this new template. 

We then sent that off to the general medicine redesign committee in order to get approval, and we then paired that working with Dr. [INAUDIBLE] on resident education, focusing on improving note quality and proper billing practices. Just to see how we did, we did a pre and post-intervention survey of the residents, see if this actually had any effect on their practices. So this is actually data that was presented by ND at Southern SJIM back in February. Unfortunately, we were hoping that we would see that-- residents would finish their notes before conference because of these changes, but that didn't really change. 

However, we did see that residents-- were reporting using less auto-populated data within their notes, as well as having a better understanding of what the level of service of notes is. One of the reasons we really wanted to focus on that is we felt a lot of residents think that they need a lot more information in their notes than they actually do in order to get the highest level of billing. The question is what can we do with future directions here? So basically at this point, we are reviewing the notes pre and post-intervention using a validated scoring system that was actually used in the previous study to see if there's any actual improvement. 

We're going through and analyzing that data. We're going to continue to implement this into resident education and intern orientation, morning reports, and things like that, and just hope to continue to create a general cultural shift. I think it's also important that we continue to review and revise this template as needed. Interestingly, I just got word this morning from Dr. Voss that apparently the surgery residents are going to use our template as a basis to inspire their own changes to the template, so we will certainly take it as a compliment that the surgeons want to use our efficient notes to make their notes more efficient. 

All right, so moving on to the other aspect of communication that's very dear to my heart is improving our resident nursing communication. So again, this is not necessarily something that's new, but I think there's really a lot to be said that spending more time in front of the computer means that we're going to have decreased face-to-face time with our other care providers. This lack of direct contact leads to breakdowns in communication, it may lead to negative effects-- ultimately the most concerning of which could be negative issues-- with patient care. 

And it's really important that we have effective collaboration between physicians and nurses, and-- those things depend on things like mutual trust, respect, and shared decision making. And in one systematic review that looked at both physicians and nurses, we all agree that these are important pillars of making sure that we have good communication. So here at UVA, we really identified three major areas where we can improve nursing and physician communication. First is having just a general understanding and appreciation of what each other does. Improving our communication in high acuity settings where things can often break down, specifically MET calls, as well as interdisciplinary rounding. 

So for purposes of time, I'm really going to just focus on this first one. So in terms of figuring out how we can have a better idea of what each other does, and a better appreciation of each other's jobs, we wanted to implement-- or actually re-implement a previously existing nurse shadowing program. And there's actually a lot of benefit of having a resident nurse shadowing program. So this is based on a study that was published in 2017, looking at a nurse shadowing program at a pediatric residency. Basically, of the people who went through it-- 10 residents and 10 nurses had structured interviews-- and when they went through and qualitatively looked at those interviews, they found seven recurring themes. 

Not going to read through all of them, but these are all certainly very positive outcomes both the nurses and the residents reported that they were able to notice-- so things like having a better understanding of the nursing role, identifying work challenges-- so things like, why I'm most busy slash least busy at these different times of the day. And I think one of the most important things is development of interpersonal relationships. It's much harder to be rude to someone over the phone if you've never seen their face and spoken to them and actually have a relationship with them, so this is a really important part of this. 

So here at UVA, what we've done this year is we have collaborated with residents-- Matt Kerwin has taken a lot of this on-- third floor nurses as well as program leadership to really re-implement and revamp the nurse shadowing program. It allows mutual opportunities for shadowing, because we really think it's important that both we shadow them and they shadow us. So this involves during the plus one week residents rotate-- from 7:00 to 10:00 AM, and nurses have three different shifts where they can shadow us, depending on different flow of our workflow for that day. 

In terms of implementation, we officially restarted this program in January of this year, and nearly 100% of rising PGY 2s and 3s have participated since we restarted it. We plan to have this be a continued requirement for each year, for each resident, and we have also been collaborating with nursing leadership to make sure that we have nurses incentivized to continue to shadow us as well. And I've pass this on to seminar as being something that I want to make sure it continues, and we are working together to come up with a curriculum between-- for both nurses and residents as we move forward with this program. 

Briefly, I'm just going to touch on two other efforts we've also been working on. So as I mentioned, there's certainly a lot of risk for there being high breakdowns of communication during high acuity settings, such as MET calls. So this has actually been a collaborative effort since last July between us, surgery, MET team, GME, et cetera, as well some floor nurses, to try to come up with a way that we can have a more systematic approach to the beginning and end of MET calls. 

So we're actually going to be starting a pilot on 5 Central in the upcoming weeks looking to see if this is coming-- or something that can be helpful. More will coming on that in the future though. Also, we have worked to improve interdisciplinary rounds-- so that includes creation of interdisciplinary rounds on 5 Central as well as 8 West just this week, and we also have an ongoing pilot on 3 Central where we're working to make interdisciplinary rounds more structured. And with that, I will pass it on to Kerrie. 

All right. I'm going to round this out-- we're talking about the last building block of making a good educator and learner, and hitting on these three points of quality improvement collaborative environment and high value care. So as we know, in many residency programs, quality improvement has become basically-- a central part of the program, and we've been able to implement that here in multiple ways, most recently during our inventory education during our outpatient week. What we've done this year too is, residents have really come up with their own projects and have had some really great ideas out of that. 

In total, we actually have currently 14 projects working that are in active work right now, with extensive faculty and admin support and also support from our data specialists. We focus on a lot of different things, just summing them up is-- patient flow through the clinic, order sets that we use on a daily basis, utilizing clinical resources in the most effective way, safe prescribing habits, and then also hitting patients where-- the critical times of patient contact are during admissions, discharges, and then unfortunately, readmissions that we do that do happen. 

So I just want to highlight two projects of these 14 that are ongoing right now, the first one being focusing on palliative care involvement for patients with metastatic solid tumors, both on general medicine and hem-onc, and looking at their readmissions and mortality, and how we can make improvements for that. So it's been a really fantastic project that the residents have really taken off with, and they've had extensive collaboration with obviously our general medicine faculty, hem-onc faculty, and the palliative care departments-- and are doing some really great work. 

So here is actually some of their data that they presented at our conference about two weeks ago for our residents, and they showed that, for both lung and colon metastatic cancer, that palliative care consultation for our group of patients here at UVA both decreases 60-day mortality and 30-day readmissions, which is really pretty impressive. However, as you can see, there are a significant amount of patients that did not receive a consult. I think the biggest area of focus for them are focusing our patients on our general medicine service to see if we can work more closely with palliative care to improve the quality of life as they near the end of their lives. 

The next project I want to highlight is actually more focused on our quality of life in the general resident everyday setting, with using a universal order set for hospital admissions. So when patients come into the hospital, they often have a multitude of different issues, and we have specific order sets for if they have neutropenic fever, if they have an [INAUDIBLE], if they have heart failure, acute leukemia, et cetera-- and oftentimes we're tracking down trying remember what the buzzword is to be able to pull up that order set. So this group of-- residents has worked to combine it all into one to make it just much easier for the workflow of everyday resident life. 

And here is actually a sample of how everything will be integrated, again both including the specific problems focus order sets that we do use in addition to changing the admission orders to things that we would actually use. So sending Miralax over Colace and milk of mag, just to give an example. So focusing on the next part, on the collaborative environment, focusing on a few ways that we've tried to make improvements to our existing structure, but also go outside the box a little bit, and go outside the traditional lecture style of morning reports that we all are used to. 

So first, focusing on our feedback-- so feedback is an extremely important player in creating a really great physician, as you can't get better without someone telling you if you're doing a good job or not. As we all know, you know we have-- there's a lot of barriers to feedback. It's uncomfortable, we don't have time, we-- the attending, sometimes we don't feel comfortable, et cetera. And another way that there is a big barrier to this is that sometimes writing out how someone is doing in the form of an evaluation is often lengthy and very time consuming. 

So through some work in our PEC groups or program evaluation committee, these four residents have really worked hard in trying to improve the written feedback that residents give to attendings, and they've focused on these aspects-- so rounding, both the style and the efficiency of rounding; resident autonomy and how they feel about that; teaching environment; professionalism. And then clinical care would really focus on how they feel the attending puts weight into cost conscious care, evidence-based medicine, and things like that. So the next thing that I've really put a lot of work into this year is focusing on the hidden curriculum. 

So the hidden curriculum, not surprisingly, is hidden in the sense that it is-- these things that do happen every day with our interactions, with each other and patients, that fall outside of our lecture style and formal medical curriculum. And unfortunately, the negative aspects of this is that residents do experience micro-aggressions, moral distress, sexism and racism during their daily clinical practice, and this was a study that described some of this, that this is unfortunately not a surprise to anybody-- that superiority, hierarchy, unprofessional behavior, emotional neutralization, is something that we do experience and wears us on a daily basis. 

So how do we work on trying to combat that and turning the hidden curriculum into a more positive one? So the thing that has the best data actually for it is the practice of reflection, both oral and written, and individual, and also in the group setting. So this study evaluated the impact of reflection on how empathetic you were, your comfort in learning very complex situations-- and this reflection actually really worked quite well in a whole different host of ways-- deep and professional values, increased empathy and increased attitudes and comfort with dealing with these difficult subjects. 

So how have we integrated this into our curriculum? So we've started this social morning report about once every two months focusing on a couple of different topics. So really, you know, there is an objective, obviously, for the morning report-- but it's really meant to be an open discussion. So bring up a topic, have a clinical example where something has happened to somebody, and really just open up the floor to talk about it a little bit more. So these are the things that we talked about this year, so approaching difficult goals of care discussions, difficult codes, micro-aggressions experienced by residents from staff and from patients, and then moral distress and futile care, especially in the ICU setting. 

And we have been fortunate to have some amazing attendings to be able to be present with us and really give us their insight and guidance on how they have dealt with these throughout their careers, and what we can do to deal with these better, unfortunately knowing that they are going to happen. So another thing, another area of focus, is actually on the outpatient side. So during our Wednesday morning weekly sessions, we focus on the ambulatory curriculum. And in the first hour we have basically high yield topics that we talk about, anything from IBS to migraines, things like that that you would focus more on at UMA versus the inpatient side. 

And this is the first-- or this upcoming year will be the first year that we've really had resident input to what is actually most helpful. What do you actually see on an everyday basis, and what can I learn? What topics we need to learn about most? And these residents have done a lot of work in creating that curriculum for this upcoming year. So some other outside the box styles for our morning reports that we have done this year. We've had a lot of resident-taught morning reports, which has been fantastic to be able to see them get up in front of this exact podium and teach everybody. 

So there's a couple of different formats that we've done that. So through the clinical educator track and elective, all of these people have done fantastic morning reports, and taught us a lot. We've also had people who have gone away on global health electives, dawn morning reports, or if your heart just really desires, and you need it crossed off your bucket list, that person did one too. Some other really fun ways that we've tried to change learning up a little bit is with group-based morning reports. So not surprisingly, we're a competitive group, and any time there are winners and losers involved, people will sign up and be there. 

So in-- we've done a couple of different game formats, traditionally Jeopardy, but we've also done medical Taboo, and Family Feud, which has always been really fun. But two other ways we've actually done is take two cases that have this unifying diagnosis, but actually have different clinical presentations, where you actually-- each group works and then find out at the end that they actually have the same diagnosis, and just to emphasize how different things can present. So the last thing I want to talk about is the importance of high value care for medical education. 

So this is, again, not super surprising that this is becoming a huge part of things. It's something that we need to focus on, but most people don't really feel comfortable in it. So in this one study of the pediatric literature, only about 50% of faculty alone felt comfortable in doing so, and those who did actually did receive a formal curriculum in doing so. So how can we best address this? It interestingly turns out-- direct feedback on what things cost is the best way to approach cost-conscious care and reduce your costs. 

So this was a study out of Mayo Clinic where they took residents and surveyed them on what they thought, for an example, a chest radiograph would cost-- and then the intervention that they had was to give real time data on, if you order this X-ray, it cost this much. If you choose to order a CT, it costs this much-- real time for actual patients that they did have, and showed in a lot of different areas that their accuracy of what their estimations of things in the patient setting cost got a lot more accurate after this intervention. 

So most importantly, though, it really got them thinking about-- hey, this thing really costs a lot. Maybe I should rethink it, and really think about if there is a better way I can do this, what the utility of this is. Interestingly too, it actually had more effect on PGY 1s, suggesting we should really start as soon as they come into our residency program to teach them about what things cost. So we've integrated this into our morning report-- so this is an actual screenshot of-- we have a 600-page long UVA costs. In case you were wondering, you can Google it. 

But we've done it in the setting of a team-based morning report-- again, all competition-based. So you can ask for a history and physical, which is free-- yes it is still free. But beyond that, every charge-- that you ask for is, or every test you ask for is charged after that, and basically, the team that comes to the diagnosis in the least amount of cost wins. So it's a really good way to get direct feedback on what things cost, and how to hone that down in the unfortunate rise of health care costs these days. So to wrap this up here, I just want to reiterate the fourth aspects that we capped on here. 

So first, clinical knowledge and skills-- where we focus on allowing autonomy in the residents setting, and also having a formal curriculum both around medical grand rounds and improving that, and also in ultrasound and procedural training. We then talked about public health and service, and how we need to understand and start tackling-- excuse me-- some of the social determinants of health, and how we tried to do that. Third, talking about communication both in the written documentation and with nursing and other staff. And then finally, focus on education and learning in the resident setting, specifically for QI and high value care in this upcoming setting. 

So before we end, just a few takeaways that we have learned throughout the year that we wanted to share with you all, in that clearly, there are a ton of aspects in creating an exemplary physician, and it really does take a village. It is not one person-- you don't do this alone, and you have to look around and accept help from everybody to be able to do this. Constantly, there's a balance between autonomy and support, quality and quantity of number of patients, and a case mix index-- and lastly, education and patient care, and how do you balance all that stuff? 

Very tough, to say the least, but we're super fortunate here at UVA. I know I can speak easily for the four of us, and all of our residents too, in that we have the best people around. So we have the best faculty, both outpatient and inpatient, who we look up to and learn from every single day-- administrative support, specifically in the department of medicine. The four of us know, without a doubt-- residents maybe a little bit less-- without the admin staff, this program would melt to the ground immediately. 

And then also, we are surrounded by so many other care providers-- RNs, PAs, CNAs, RTs, et cetera, et cetera, et cetera, that are there-- both we see, and then also behind the scenes really helping us grow and become a better physician. And then finally-- we are the chiefs, and we always have our residents in the front of our minds. So we by far and away have the best residents, and we are very fortunate to be had-- sitting in this job for the past year, and get to hang out with you all just a little bit more. So with that, we'll say thank you.