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TITLE: Physicians as “Patients”- Use of immersive simulated patient experiences to foster physician empathy and compassionAUTHORS: Aaron M. Lee, DO; Sean Kenmore, MD; Supraja Thota, MD; Constance Chance, MD; Anand Jagannath, MDINSTITUTION: Internal Medicine, University of California-San Diego Medical Center   BACKGROUNDThe importance of fostering physician empathy has become increasingly recognized as a critical aspect of physician training; among many things, increased physician empathy has been shown to lead to improved clinical outcomes, higher patient satisfaction, and decreased physician burnout. Despite this, there remains a paucity of interventions to effectively promote compassion and empathy in medical education. To address this void, we propose a set of novel immersive role-reversal simulation exercises which place resident physicians into patient roles to simulate the inpatient experience. We propose that increased appreciation of the patient experience through simulation can lead to improved physician empathy and compassion and thereby improved delivery of patient-centered care.   PILOT INTERVENTIONWhile the ultimate goal is to develop a formal curriculum involving numerous simulation didactics, we developed a pilot program to study the initial feasibility and effectiveness of this intervention.Aim: Use of a 1-hour noon conference to expose end-of-year interns to numerous aspects of the patient experience to increase appreciate of the inpatient experienceMethods: Several different stations were developed that each highlighted a single aspect of the patient experience. At each station, a prompt provided a simulated patient context/perspective associated with a physical item. These stations included a hospital bed, patient foods, glucometers, bedpans, common patient foods, urinals, nasal cannulas/facemasks, incentive spirometer, oral secretion device, foley and urine leg bag. Participants were given patient gowns, telemetry leads, pulse oximeter leads, to simulate common patient attire. Interns rotated through these stations and were encouraged to discuss openly with their partners their thoughts and feelings from the perspective of the patient. A debrief session was held to reflect on the experience as a group. Learners were asked to complete surveys before and after intervention, evaluating their own empathy and compassion ratings, as well as their appreciation of patient experience.Results: All 9 participants reported the activity to be useful, and all would recommend to future residents. Overall self-reported empathy and compassion ratings increased post intervention. Notably participants reported increased familiarity with the lived patient experience, increased appreciation of patients’ backgrounds and contexts, improved ability to empathize with patient complaints, and increased importance on the physician-patient interaction.   NEXT STEPS:While initial data was limited due to small number of participants, results were universally positive. Currently, this overall proposal has been accepted past phase 1 for consideration of a Seed Grant with the UCSD Center for Empathy and Compassion. We hope that this funding will allow this novel simulation intervention to be tested and expanded further, and if effective, anticipate it may provide great benefit for patients in the future.   CONCLUSIONSThe use of patient experience simulation with resident physicians can be an effective, feasible, and fun modality for promoting physician empathy and compassion. This novel teaching modality has the potential to increase high-value and patient-centered care if adopted across GME.

Title: I’ll make a “Patient” out of you: An Update to “Physicians as ‘Patients’”- Design, Implementation, and Challenges of Novel Immersive Simulated Patient Experiences to Foster Physician Empathy and Compassion Author: Aaron M. Lee, DO, MS (Internal Medicine, Chief Resident) Co-Authors and Specialty Program Affiliations:  Khanh Hoang Nicholas Le, MD (Internal Medicine, PGY-1), Preetham Suresh, MD (Anesthesia, faculty), Ricardo Wood (UCSD Simulation Center), Sean Kenmore, MD (Internal Medicine, faculty)  Issues Addressed/ BackgroundThe importance of fostering physician empathy and compassion has become increasingly recognized as a critical aspect of physician training, with the ACGME and AAMC both acknowledging empathy as a key component of professionalism, with recommendations to incorporate empathy education into core medical education goals. The challenge remains how best to teach physician empathy and compassion in medical education, and to create long term effective educational interventions. Empathy curriculum in graduate medical education remains limited, as there are few standardized methodologies for teaching empathy.  Herein lies an opportunity for growth and development of novel and new methodologies to deliver patient-centered and empathy/compassion education to physicians in training. We hypothesize that lack of appreciation or understanding of the patient experience is much to blame in the deficits in teaching physician empathy and compassion. To address this void, we propose a set of novel immersive simulation exercises to place resident physicians in the role of a patient with space for guided reflection. We propose that a standardized longitudinal curriculum based on high-fidelity immersive simulation exercises throughout medical training will improve physician empathy and compassion, and the delivery of this form of education can be effective, easily disseminated, cost effective, and enjoyable to the learner, ultimately leading to better patient-centered and high-value care.This project was previously presented at PSQI 2022 in an earlier iteration, wherein the simulations were less immersive and in smaller sample size. The updated model presented here utilizes the UCSD patient room simulation labs to create high-fidelity fully immersive role-reversal simulation experiences.  Description of project/protocol/innovationStudy design and measuring empathyThis project was funded via a generous seed grant award from the Sanford Institute for Empathy and Compassion, Center for Empathy and Compassion Training in Medical Education. This study is being performed in the UCSD Internal Medicine residency program, which consists of 143 resident physicians at varying training levels. Simulations are based off national VA patient survey data and reflect aspects of the patient experience that are painful or common. Our first simulation session, which will occur April 14, 2023, will encompass 20 residents in several high-fidelity immersive simulations at the UC San Diego simulation labs, with the help of the UCSD Simulation team. We also have plans to have a separate simulation session to include another 10-20 residents in early May 2023.This study utilizes standardized survey data (Jefferson Scale of Empathy) to evaluate the effectiveness of role-reversal simulation didactics in fostering physician empathy. Baseline survey data has been collected from the entire residency, and additional survey data will be collected after interventions have been complete. An intervention group will include those residents who are randomly assigned to the simulation group, while the remainder of the cohort will make up the control group. Statistical analysis will be performed by the Jefferson Scale of Empathy team comparing the two cohorts. All results and responses are de-identified to the primary researchers.The intervention/simulationsSeveral original simulations have been designed, each representing several aspects of the patient experience. Each resident is intended to rotate through each of the simulations in the role of the patient, which in total equals 30-40 minutes of simulation time. A debrief exercise is held afterwards for 30 minutes as well. During this debrief time, participants also will experience several forms of patient’s foods supplied by UCSD Health Dining, which will add another sensory component to the patient experience. Simulation A: a patient on the commode in a shared room is unable to reach their nurse to help them get back to bedSimulation B: ED patient boarding in a busy hallway is given bad news, physician leaves partway through without finishing the newsSimulation C: patient undergoing central line procedure, being done by a novice resident who is visibly nervous, and accosted by a circulating nurseSimulation D:  patient interacts with a physician who speaks only a foreign language, who brokenly obtains consent for a procedure  Lessons Learned/expected outcomesThese novel simulations will be performed on April 14, 2023 over a 2 hour session, and an additional session in May 2023. Preliminary results from a prior iteration of this simulation idea suggested a positive signal between role-reversal simulations leading to increased empathy and compassion. We anticipate that these higher fidelity simulations and sensory immersion are powerful tools towards fostering greater appreciation of the inpatient patient experience, and will be effective towards increasing physician empathy and compassion.We recognize several challenges with building this form of curriculum. These simulations require resources, including equipment and simulation space, actors who can play roles of physicians (which most standardized actors are not trained to do), and dedicated educational time, all of which can prove challenging to obtain.    Recommendations/ Next stepsWhile the development and implementation of these simulation activities is not without its own challenges, we believe these exercises may truly revolutionize how we approach empathy education in medical training. Current versions of standardized encounters do not take into consideration the patient experience, which we feel to be a crucial aspect of building empathy. These simulations are relatively easy to reproduce, and in a world where simulation has become more commonplace, should be easily adopted into curricula. As such, we feel that the next steps for this exercise are to build more robust simulations and disseminate this information to other academic institutions. We have produced an educational packet for these simulation exercises, which will serve as a distribution tool so that other academic institutions may adopt this novel teaching modality. Within this educational packet includes the background and evidence supporting these interventions, a toolkit which includes a supplies list, the simulations and scripts, and generally provides the overall structure to recreate these simulations.

Category: Quality/Systems Improvement | QI/ResearchTitle: Getting Mammograms Shouldn’t Be So Bumpy- Improving Mammogram Workflow in VA Community CarePrimary Author: Aaron M. Lee, DO, MS (Internal Medicine, Chief Resident) Co-Authors and Specialty Program Affiliations: Jack Temple, MD (Internal Medicine), Susan Macdonald, RN (VA Community Care), Shayne Ovalles, RN (VA Community Care)  BackgroundThe interplay between Community Care (CC) and VA-based care has long been important for continuity of patient care, though transitioning care between the two is often fraught with problems. Mammograms ordered at VA San Diego (VASD) are often deferred to community care; while this process should be smooth and seamless, the process is instead convoluted and ripe for errors. The lack of standardization, disconnect between the interface between VASD and CC, and splintered tracking systems has led to delays in care, delays in results, and at worst, patient harm and delays in diagnosis. VA mammograms completed in the community have inconsistent rates of completion, with errors ranging from unscheduled appointments, delayed provider notification, and loss to follow up leading to late diagnoses of breast cancer. To reduce patient harm and increase fluidity of VA mammograms in the community, we applied extensive QI methodology towards overhauling the VA Community Care Mammogram workflow. MethodsWe evaluated the process of CC mammograms at VA San Diego. An A3 was used to process map the VA CC Mammogram process, beginning with VA provider entering a mammogram order to the community and ending with mammogram result release to the patient. A virtual Gemba walk was performed, during which the author evaluated how the CC team processed consults and results. Using Lean Six Sigma process improvement strategies, we identified several problematic areas within the CC Mammogram workflow that are prone to errors and can lead to patient safety issues. Weekly meetings and interviews were set up to identify pain points with the primary users, with continuous evaluation of new systems implemented.We standardized workflow by developing a Standard Operating Procedure (SOP) that would allow standardization of tracking and intake of consults, as well as release of results. We also created redundancies that would allow for backup systems and medical assistants to reach out to patients so that appointments were made and results obtained in a timely manner. We incorporated the use of the Coordinated Care Tracking System (CCTS), a new tool that being incorporated in some departments for tracking patients and creating reminders for follow up, while storing all patient data in a unified place. We also redesigned the ordering menu within CPRS for mammograms, which was a pain point for ordering providers. ResultsProcess mapping of the VA CC mammogram process revealed significant amounts of waste and several failure modes. Notably among these was the splintered tracking systems used within the CC team and lack of automated follow up or reminders; prior to our intervention, patient tracking was done on individual Excel sheets across multiple users. We implemented a standardized practice whereby the CC team would enter every patient into the CCTS system and create task reminders within CCTS to remind when follow up was required, which helped reduce follow up errors. We also redesigned the CPRS mammogram ordering menu to remove misleading information and to streamline CC mammogram ordering. Implementation of the standardized process and transitioning patient tracking into CCTS increased monthly rates of timely mammogram reporting from a median of 60% to 100% in all BIRADS groups (Figure 1). Subjective reports by the CC primary users was overall positive within this new workflow; while we did have challenges getting buy in and training to use the software, once trained, users found CCTS to be accessible and reminders helpful. CCTS also facilitated unification of all patient data, rather than individual spreadsheets. ConclusionsStandardization of workflow and incorporation of Coordinated Care Tracking System software into the Community Care Mammogram process has led to an improvement in rates of CC mammogram scheduling and results notifications. Improved tracking of community care patients has the potential to prevent loss of patients to follow up, and more importantly prevent unnecessary patient harm. It is worth considering whether CCTS and a similar standardized process should be incorporated into other community care programs, as the issue of inconsistent patient tracking is not one that is isolated only to mammograms. There remain many challenges with the CC system, especially with transitioning records and imaging from outside facilities to and from the VA; we are working on incorporating cloud-based software to further facilitate communication between the VA and the community.

Additional file 1. Additional reference ranges. Tables reporting additional normal reference ranges of mitral and tricuspid annular dimensions and tethering indices.

Supplemental Digital Content is available in the text., Background: Exposure to ambient air pollution is strongly associated with increased cardiovascular morbidity and mortality. Little is known about the influence of air pollutants on cardiac structure and function. We aim to investigate the relationship between chronic past exposure to traffic-related pollutants and the cardiac chamber volume, ejection fraction, and left ventricular remodeling patterns after accounting for potential confounders. Methods: Exposure to ambient air pollutants including particulate matter and nitrogen dioxide was estimated from the Land Use Regression models for the years between 2005 and 2010. Cardiac parameters were measured from cardiovascular magnetic resonance imaging studies of 3920 individuals free from pre-existing cardiovascular disease in the UK Biobank population study. The median (interquartile range) duration between the year of exposure estimate and the imaging visit was 5.2 (0.6) years. We fitted multivariable linear regression models to investigate the relationship between cardiac parameters and traffic-related pollutants after adjusting for various confounders. Results: The studied cohort was 62±7 years old, and 46% were men. In fully adjusted models, particulate matter with an aerodynamic diameter

Background Handgrip strength, a measure of muscular fitness, is associated with cardiovascular (CV) events and CV mortality but its association with cardiac structure and function is unknown. The goal of this study was to determine if handgrip strength is associated with changes in cardiac structure and function in UK adults. Methods and results Left ventricular (LV) ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), mass (M), and mass-to-volume ratio (MVR) were measured in a sample of 4,654 participants of the UK Biobank Study 6.3 ± 1 years after baseline using cardiovascular magnetic resonance (CMR). Handgrip strength was measured at baseline and at the imaging follow-up examination. We determined the association between handgrip strength at baseline as well as its change over time and each of the cardiac outcome parameters. After adjustment, higher level of handgrip strength at baseline was associated with higher LVEDV (difference per SD increase in handgrip strength: 1.3ml, 95% CI 0.1±2.4; p = 0.034), higher LVSV (1.0ml, 0.3±1.8; p = 0.006), lower LVM (-1.0g, -1.8 ±-0.3; p = 0.007), and lower LVMVR (-0.013g/ml, -0.018 ±-0.007; p Conclusions Better handgrip strength was associated with cardiac structure and function in a pattern indicative of less cardiac hypertrophy and remodeling. These characteristics are known to be associated with a lower risk of cardiovascular events.