United States

Purpose
Supervision must be documented for every patient encounter during residency training. This is especially indicated when a bill is submitted to a payor for services performed with the involvement of a resident. The teaching physician must include an attestation documenting the level of resident involvement in the patient encounter. When submitted to CMS the GC modifier is also utilized to indicate that a resident, under the direction of a teaching physician, is involved in a patient encounter. We retrospectively reviewed our documentation of the teaching physician in a resident ophthalmology clinic. 

Methods
All patient encounters performed by ophthalmology residents over a 5-month period (January through May 2021) were retrospectively reviewed for appropriate documentation of the teaching physician. All patient encounters were supervised by teaching physicians in an outpatient ambulatory ophthalmology clinic at the Texas Diabetic Institute, San Antonio, TX. Each electronic medical record (EMR) was reviewed for appropriate documentation of the teaching attestation and GC modifier. The data was analyzed using R software. 

Results 
A total of 1,500 patient encounters were reviewed. All records (100%) documented the teaching attestation. The GC modifier was utilized in 1,388 of patient encounters (92.5%). January (95%) and May (88%) showed the highest and lowest compliance, respectively. The GC modifier was not documented in 7.5% of patient encounters.

Conclusion
All patient encounters included appropriate documentation of the teaching attestation. Residents in clinic have direct supervision by the teaching physician and the EMR sends all notes to teaching physicians to be signed and attested. In addition, all notes are reviewed internally for compliance and are amended if not documented appropriately. Compliance with the GC modifier was significantly lower. This is attributed to inadequate understanding of proper usage and that it may not be required by all payors. With recent increase emphasis on the attestation for all notes, providers are less enthusiastic to also ensure documentation of the GC modifier due to this redundancy. Good practices aim for 100% compliance in documentation. Both teaching and resident physicians should be educated on appropriate supervision and how it should be best documented in the medical record.

AMA Research Challenge 2022

Compliance with Documenting the Presence of a Teaching Physician in a Resident Ophthalmology Clinic

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#### Event Details
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Ricardo Correa, MD, EdD
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


poster

Detection and Diagnosis of Retinoblastoma: Can Mobile Devices be the Next Step Toward Early Intervention?

Abstract Title: DoubleVision Ophthalmoscope: A novel teaching fundoscope for medical student learners and beyond
Background: Learning to operate a standard fundoscope is an unintuitive process and recognizing retinal pathologies can be a subjective struggle requiring guesswork. While technologies exist to facilitate learning via screen projection from various ophthalmoscopes, a modality for the standard fundoscope, most utilized in medical student training, has not been well established. Our innovation aims to facilitate clearer instruction by physician preceptors while simultaneously lowering the barrier to entry for competent fundoscopy exams. Competent performance of a fundoscopic examination is a required skill per the American Council of Graduate Medical Education and is mandated in moderate and high-level neurologic workups per private and federal insurance agencies. 
Methods
The initial design includes a unique fundoscope based on similar mechanics of standard fundoscopes with a mini camera attachment and connection to monitor screen. The monitor screen will allow for improved visualization for the learner, image saving, and real-time annotation capabilities. 
Results
Through this innovative design we compare the current unintuitive status of fundoscopy training to a novel approach in training. We utilize various criteria in evaluating effectiveness including student/physician interviews and comparisons to other devices in the literature alongside biomedical design processes. We discuss in detail the product value proposition, market feasibility, ethical considerations, and global impact, as these concepts in relation to such device are scarce in the literature.
Conclusion
Clinical studies have emphasized the difficulty in the objectivity of the fundoscopic procedure. Simulations and training models lack fidelity due to high degree of variance between patients, as well as variance between patients and simulations. Residency and intern training of this technique have been difficult, but increased time with hands-on instructor led workshops have reduced this difficulty. There is a need for standardized training protocols across multiple centers, although some clinics may not have access to high end mentorship due to geographic constraints. The remote capabilities of our device would allow education to be performed globally. Prototypes of teaching ophthalmoscopes have been associated with improved confidence and more accuracy in objective measures of pathology identification. 


DoubleVision Ophthalmoscope: A novel teaching fundoscope for medical student learners and beyond

Purpose: To validate the clinical utility of Vision.app in measuring best corrected visual acuity (BCVA) in a pediatric cohort. 
Methods: OD/OS BCVA of pediatric patients was obtained by a) Landolt ring (VAApp) and b) Snellen chart (VAClinic). VAApp was measured by the phone application, Vision.app, from smartphones which used a 4-force choice procedure with a dark blue Landolt C optotype on a black background displayed at 100cm. VAClinic was the smallest line where optotypes were correctly identified with patient sitting 20 ft from an illuminated screen. The two methods were compared using Pearson correlation coefficient and Cronbach α. Vision.app sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to detect significant VA changes (≥0.3) logMAR from in-clinic baseline. A Bland-Altman plot was constructed to visualize the difference between the two methods. 
Results: A total of 49 participants completed the study with data on 98 eyes collected. Mean (SD) age of 10.22 ± 3.28 years with a 26:23 male:female ratio. Mean VA difference was -0.14 (95% CI, -0.193 to -0.087) logMAR or <1 line of difference with upper and lower limits of 0.23 and -0.51 logMAR. The Pearson correlation coefficient was 0.54 [p < 0.001, (95% CI: 0.38, 0.66)]and Cronbach α is 0.68 [p < 0.001, (95% CI: 0.52, 0.78)]. Vision.app had an 80% sensitivity, 73.5% specificity, 35.3% PPV, 95.3% NPV. 
Conclusion: In our study, Vision.app is a valid method of measuring visual acuity in children.

Smartphone app visual acuity screening in a pediatric population

Background
Orthopaedic surgery has been an increasingly popular field for medical students. Many schools offer elective time to explore areas of interest through clinical rotations and research; however, most are reserved for senior medical students. The purpose of this study was to evaluate the impact of a dedicated orthopaedic surgery symposium to increase awareness about the field, and to assess students’ interest and knowledge of orthopaedic surgery before and after the symposium.
Methods
A one-day free, virtual medical student orthopaedic surgery symposium was organized. Abstracts were reviewed and selected from nine different orthopaedic subspecialty categories. Survey assessments were sent to medical students to complete before and after the symposium. The survey included questions related to participant demographics, as well as interest and knowledge about the field of orthopaedic surgery. Statistical analyses were completed to compare the participants’ responses before and after the symposium.
Results
In total, 962 medical students registered for the four-hour symposium. Of these, 58.5% completed the pre-symposium survey, and 48.0% completed the post-symposium survey. 13.3% of the respondents reported being “very knowledgeable” about the various orthopaedic surgery subspecialties before the symposium, which increased to 18.4% after the symposium (p=0.137). 46.9% of the participants stated that they were “knowledgeable” about the daily life of an orthopaedic surgery resident before the symposium, which increased to 67.3%, post-symposium (p<0.001). Similarly, the percentage of respondents who reported that they were “very knowledgeable” about the residency match process increased from 12.2% pre-symposium to 22.4% post-symposium (p<0.001). 61.7% and 80.5% of participants reported being “very satisfied” with the breakout room sessions and the educational panels respectively, with 84% of participants reporting they would recommend the symposium to others.
Conclusions 
As the interest in a career in orthopaedic surgery increases, medical students desire access to information, mentorship, and opportunities to present their research in preparation for residency applications. Our study demonstrated that a large-scale national orthopaedic surgery symposium provided a platform to augment medical students’ knowledge of the field, present their research, and interact with faculty members.

The Impact of a Virtual Orthopedic Surgery Symposium on MedicalStudents: Increasing Interest and Knowledge of the Field

Abstract Title: An Evaluation of United States Undergraduate Medical Education in Otolaryngology

Background
With an expanding knowledge base, medical schools struggle to incorporate surgical subspecialty education, such as otolaryngology (OTO), into undergraduate medical curricula. OTO complaints comprise 25% of primary care visits, yet graduating physicians report being inadequately prepared to work-up common OTO disorders. Additionally, school factors, such as OTO student resources and an OTO residency program, can impact the competitiveness of student residency applications. Therefore, this study aimed to evaluate the extent of OTO curricula and resources at U.S. medical schools.

Methods
A 48-question survey evaluated the extent of OTO teaching and resources at U.S. medical schools. The survey was distributed by email to all 155 LCME accredited U.S. allopathic medical schools in 2020 and 2021.

Results
68 unique responses were received, representing 43.9% of U.S. medical schools. Evaluation of OTO teaching practices found 36.8% (n=25) of schools reported having formal expectations of OTO knowledge in their curricula. Only 1 school (1.5%) reported having a required OTO rotation. Evaluation of OTO resources found 89.6% (n=60) of schools reported having an OIG and 91% (n=61) provide opportunities for research with OTO faculty. Schools with residency programs were more likely to have otolaryngologists teach basic science lectures and the Head & Neck exam (OR = 13.7, 95% CI [1.86, 153.9] and OR = +infinity, 95% CI [3.35, +infinity], respectively), have formal expectations of rotating students (OR = 5.67, 95% CI [1.15, 27.71]), provide students with opportunities for OTO research (OR = +infinity, 95% CI [17.06, +infinity]), offer an optional third year rotation (OR = 4.27, 95% CI [1.07, 16.99]), have an OIG (OR = 27.5, 95% CI [3.66, 148.9]), and were more likely to have an OMSED (OR = 43.56, 95% CI [6.16, 488.9]) compared to schools without residency programs. 

Conclusion
This study found U.S. medical schools associated with residency programs, larger class sizes, and who employ their faculty through an OTO or surgery department have more robust OTO curricula and resources. Despite the ubiquity of OTO presentations, incorporation of OTO knowledge and resources into U.S. undergraduate medical curricula remains variable, and at times limited.



Abbreviations: 
OTO = otolaryngology
OMSED = Otolaryngology Medical Student Education Director 
OIG = Otolaryngology Interest Group

A Cross-Sectional Survey Study Evaluating Otolaryngology Education at United States Medical Schools

Authors & Affiliations: Erik Feldtmann, BSN1, Valerie Nemov, BS1, Presley G. Busch, BS2, Vinita Kiluk, MD3, Andrew Galligan, MD, MS3, Amy Weiss, MD, MPH3, Scott Coon, PharmD, BCACP2, Aimon C. Miranda, PharmD, BCPS2, Dawn Schocken, MPH4, Erini S. Serag-Bolos, PharmD2

1USF Health Morsani College of Medicine, Tampa, FL. 2USF Taneja College of Pharmacy, Tampa, FL. 3Department of Pediatrics, USF Health, Tampa, FL.4Department of Medical Education, USF Health, Tampa, FL.

Abstract Title: Analysis of Student Outcomes from an Interprofessional Education Transitions of Care Simulation

Background: Interprofessional education (IPE) improves students’ understanding of other professions, promotes communication skills, and facilitates a high functioning healthcare team. The primary objective of this study was to evaluate changes in students’ behavior and knowledge as they worked through virtual transitions of care simulations with their interprofessional teams. The secondary objective was to evaluate whether student knowledge of pediatric asthma exacerbation treatment improved through an interprofessional simulation. 

Methods: Third year medical (n= 164) and pharmacy (n= 139) students at the University of South Florida participated in an IPE simulation via Microsoft Teams in 2021 and 2022. Students were presented with a pediatric (age 12) asthma exacerbation patient and progressed through four, 15-minute stations. Each station required clinical management in the following scenarios: emergency department, pediatric critical care, pediatric floor, and discharge planning. Pre- and post-simulation surveys included nine identical questions and were analyzed using the Wilcoxon signed-rank test, Wilcoxon-Mann-Whitney test, and the MEANS Procedure.

Results: Students showed statistically significant improvement in each domain, including understanding their roles and abilities to work in an interdisciplinary environment and clinical knowledge. There was no significant difference found between cohorts, indicating that students from each year benefited from participation similarly. When analyzing differences based on professional program, it was found that interdisciplinary and clinical knowledge improved for both medical and pharmacy students, although they did not always benefit equally. 

Conclusion: This simulation improved both medical and pharmacy students’ perceptions of interdisciplinary healthcare teams and their ability to manage a pediatric asthma exacerbation patient. 


Analysis of Student Outcomes from an Interprofessional Education Transitions of Care Simulation

Background
Cerebral palsy is the most common motor disability in childhood. This condition can be found in up to 1 in 345 live births and is comprised of a plethora of symptoms—including spastic, dyskinetic, and ataxic. While this condition is extremely prevalent and is cared for by a myriad of medical professionals, we hypothesized that there is a lack of emphasis on cerebral palsy in board review materials. In this study, we explored cerebral palsy content in common board study resources.

Methods
Multiple platforms of preparatory materials for medical school licensing exams, including First Aid, Pathoma, Boards and Beyond, and other commonly utilized resources, were assessed for number of mentions of cerebral palsy. Focus was placed on USMLE Step 1 and Step 2 and COMLEX Level 1 and Level 2 due to the universality of these exams.

Results
Within board exam prep material, we found that the First Aid for USMLE Step 1: 2021 edition only mentioned cerebral palsy one time. Similarly, cerebral palsy was only directly covered in two questions within the entirety of the UWorld Step 1 question bank, updated in 2022. Other materials analyzed had zero mentions of cerebral palsy in any capacity within their scope.

Conclusion
In conclusion, there is a severe lack of coverage of cerebral palsy within the medical school board preparation materials. Given cerebral palsy is the most common childhood motor disability and requires a multitude of medical specialties to properly manage these patients, it must be increased within the curriculum and within board exam relevance. Board review content guides the studying of most medical students throughout their time in medical school, therefore, an increase in cerebral palsy education within board preparatory material would innately increase the emphasis on cerebral palsy education within medical school curricula across the country. According to a study published in 2005, an increase in curriculum may also result in a promotion of positive attitudes towards people with cerebral palsy and other disabilities. The medical student curricula should increase its overall coverage of cerebral palsy to promote the knowledge, understanding, and lessen the stigma within the medical community.

Low Prevalence of Cerebral Palsy Coverage Within Medical School Board Preparation Materials: Implications for Education and Attitudes

Background: Approximately 750,000 adolescents and young adults (AYA’s) with chronic conditions require transition from the pediatric model of care to adult care annually. The lack of a planned process known as healthcare transition (HCT) is associated with increased hospitalizations, care discontinuity, and increased morbidity. Multiple studies have reported the lack of HCT training and competency in graduate medical education (GME) trainees. However, little is known about the factors contributing to the development of HCT knowledge and practice. The present study employs a multi-center cross-sectional survey to better understand differences in HCT knowledge as well as barriers to providing HCT care and acquiring HCT training among medical trainees.

Methods: In March-June of 2022, participating residency and fellowship programs from 11 institutions were surveyed using a 74-item questionnaire. Differences in HCT knowledge and barriers to HCT care and education were analyzed between trainee type, presence or absence of Medicine-Pediatrics program or HCT champion (defined as any faculty or staff who is a mentor or leader in HCT) at residency or fellowship, and specialty type.

Results: Out of the 1,346 trainees receiving survey invitations, 154 responded (response rate: 11.4%). Mean HCT knowledge scores were higher in trainees who had a prominent HCT figure at their institution (p<0.005), attended at least one HCT lecture (p<0.001), and performed at least one transition care readiness assessment (p<0.005) or transition care consult for patient or caregiver (p<0.05). Trainees from institutions without a prominent HCT figure were more likely to cite “lack of transition coordinator” as a barrier to providing HCT care (OR 2.76; p<0.05). Residents, compared to fellows, more frequently cited “lack of skills to convey concept” as a barrier to HCT education (OR 3.52; p <0.05).

Conclusions: Results from this study highlight the importance of skills-based practice and an institutional prominent HCT figure in increasing HCT proficiency and the ability to provide HCT care. GME programs and accreditation bodies should consider these factors when developing curricula to provide effective HCT for transitioning AYA.

The Impact of Institutional HCT Champions and Med-Peds Programs on HCT Knowledge, Practices, and Attitudes: A Multicenter US Survey Study

An Altmetric Analysis of Medical School Research by Plastic Surgery Residents

Background: Cannabis is the most commonly used illicit drug worldwide. In addition to potential adverse effects, an estimated 9% consistent cannabis users are likely to become dependent and may develop a cannabis use disorder (CUD). 

Methods: This cross-sectional study developed a search strategy using Ovid, MEDLINE, and Ovid Embase for systematic reviews and meta-analyses focused on CUD treatment in June 2020. These reviews were evaluated for conflicts of interest (COIs) per previously developed classification scheme. Our primary objectives were to (1) evaluate the presence of disclosed or undisclosed COI of systematic review authors, regarding treatment of CUD; and (2) determine whether overall summary effect estimates, narrative results and conclusions were influenced by the presence of disclosed or undisclosed COIs among systematic review authors. 

Results: Our systematic search returned 560 articles which 9 systematic reviews were eligible for data extraction. We found 77.8% (7/9) contained at least one author with a COI. From the 51 authors included, 29.4% (15/51) were found to have a COI. Forty-four percent (4/9) were funded, 22.2% (2/9) were not funded, and 33.3% (3/9) had no funding statements. Out of the 7 systematic reviews with one or more authors containing COI, 14.2% (1/7) included results favoring the treatment group and 28.6% (2/7) included conclusions favoring the treatment group. Our results showed no significance between funding source and results (p = 0.429) or conclusions. Additionally, we found no significance between the presence of COIs with the favorability of results (p = 0.56) or conclusions. 

Conclusion: Multiple studies favored the treatment of cannabis-containing products, even though COIs were found in the majority of the systematic reviews. COIs have the ability to sway results of a study, which can affect clinical decision-making. Stricter guidelines should be enforced among authors displaying COIs in systematic reviews studying CUD treatment.

Evaluating the relationship between industry sponsorship and conflicts of interest among systematic review authors on treatments for cannabis use disorder

Next from AMA Research Challenge 2022

Detection and Diagnosis of Retinoblastoma: Can Mobile Devices be the Next Step Toward Early Intervention?

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