"Optimizing Virtual and Distance Learning During Pandemic and Beyond - Sleep Medicine Fello wship Edition" Hira Bakhtiar (03.31.2021)

April 11, 2021

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00:00Keeping stuff that's OK and then turn it
00:02over to you got it.
00:07Poker.
00:29So I have two screens now. I don't
00:33know which ones is the one with the
00:35camera. Oh. You're you,
00:37you're in camera and. But
00:42and you're presenting,
00:43everything looks fine from our side.
00:46Yeah, it looks perfect.
00:48Alright, I think we'll get started everybody.
00:51Good afternoon.
00:51I'm Lauren Tobias and I'd like
00:53you to welcome like to welcome
00:55you Tauriel sleep Seminar.
00:57I have a few brief housekeeping
00:59announcements before I turn it over to Ian.
01:01We're to introduce our speaker today.
01:03Please feel free.
01:04Please take a moment to make sure
01:07that you're muted in order to
01:08receive CME credit for attendance,
01:10please see the chat room for instructions.
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01:15conference anytime until 3:15 and if
01:17you're not already registered with,
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01:221st, If
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01:24during the presentation,
01:25please make use of the chat room
01:27and we will invite you to unmute
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01:32questions aloud if you wish.
01:34We do have recorded versions of our
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01:45And finally, please feel free to
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01:50else who may be interested.
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01:56so I will turn it over to Ian
01:59to introduce Doctor Bhatia.
02:00Refer today great.
02:01Well, thank you very
02:03much. So I have the honor
02:05of introducing our speaker,
02:06Doctor Hero Bakhtiar.
02:07She is one of our sleep fellows
02:09and I've known here for at least
02:11four years and so it's fantastic
02:13that she's presenting this topic,
02:15which you know, just for everyone's sake.
02:17This is really could count as
02:19a faculty development lecture.
02:21So if you need that for your AC
02:23GME requirements, this is a.
02:25Really on point topic.
02:26So Doctor Hera went to the University
02:29of Texas Health Science Center 4 at
02:32Tyler for her Turtle Medicine residency
02:34and we were lucky to have her for the
02:37last four years at the North Hospital,
02:39Yale University Pulmonary Program as well as
02:42she did her critical care year at at Yale,
02:45New Haven and then I was able to
02:48convince her to stay for one final
02:50year of training at Sleep Medicine.
02:53So little interesting fact about Doctor Hira.
02:56So she also.
02:57Initially,
02:57when she was young,
02:58she wanted to be a beekeeper and this
03:01was her her dream to be a beekeeper.
03:03But when she was six years old,
03:06she was stung by a bee and
03:08how to anaphylactic reaction.
03:09An Luckily her father was quick to respond
03:12and administered epinephrine and that
03:13was the end of her beekeeping career,
03:15and we're lucky that she that she
03:17was with us today and able to be
03:20a fantastic position that she is
03:22were also very lucky to have her.
03:24She's decided to stay on at New York
03:27Hospital and should be one of our.
03:29Core faculty for pulmonary critical
03:31care and sleep at Norwalk Hospital
03:33so will be working at professional
03:35colleagues and I couldn't be
03:37any more happier,
03:38so her topic will be on optimizing
03:40virtual distance learning
03:41during pandemic and beyond.
03:43And really,
03:43this is meant to be sort of a little
03:46unique topic and that this is a medical
03:49education topic which will have
03:51interest to both faculty and fellows.
03:53So Doctor here
03:54and take it away. Thank you.
03:56Thank you so much and welcome everyone.
03:59Just a few housekeeping.
04:01Items I don't have any commercial support.
04:04I'm a fellow and I have
04:07no conflicts of interests.
04:08This is the text code and this will
04:12appear in your chat box later as well,
04:16so I am going to start talking about
04:19what I'm passionate to talk about.
04:22So GME graduate medical education has
04:24relied on face to face interactions to
04:27fulfill clinical didactic and scholarship
04:30components amid the coronavirus pandemic.
04:32And the need for social distancing.
04:35This virtual learning platform
04:37has significantly reshaped anina
04:39rated on how we teach and engage
04:42with our medical trainees.
04:44Due to the pandemic,
04:46the residencies and fellowships have
04:48implemented programs to optimize
04:50virtual and distance learning,
04:52and I'll be discussing how specific
04:55aspects of Sleep Medicine training,
04:57such as clinical care,
04:59didactic scholarships,
05:00training well being, and can be adopted.
05:03In a virtual learning environment,
05:06so my objectives for today's talk are to
05:09discuss virtual learning and didactic.
05:12Delivering a virtual clinical
05:13learning environment,
05:14strategies to optimize and maximize
05:17learning for the trainees,
05:18and how to take care of our trainees
05:21in the setting of distance learning
05:24an Lastly to review the news
05:27sleep Medicine's milestones 2.0.
05:30Before I get into a virtual clinical care,
05:33you know, talk,
05:34I just want to say that you know, we've had.
05:38I don't want to define it again because
05:41we've had many deli medicine talks,
05:43but I want to emphasize that, you know,
05:46telling medicine is the forefront
05:48of our clinical care delivery now.
05:50Sleep Medicine is very well suited
05:53for telling medicine.
05:54Given the use of cloud based technologies
05:56for Pap adherence and monitoring,
05:58you know.
05:59While the field has long advocated
06:01for telling medicines.
06:02Hello,
06:03Ship programs have not implemented
06:05them universally for the trainees,
06:08but recent adaptations to pair
06:10policies have made Tele Medicine
06:13services more accessible to patients
06:15and the AC GME also now permits
06:19study medicine to be incorporated
06:21into our clinical training programs.
06:24The rapid shift to social distancing and
06:27remote working presents the programs
06:30with the time we opportunity to explore.
06:33Expose Sleep Medicine trainees to
06:35tell him medicine an equip them with
06:38the skills that they will undoubtedly
06:40build upon during their careers.
06:42Before I discuss the case,
06:44I would like to, you know,
06:47do a pull about you know how.
06:51Everybody in this meeting
06:53feels about telling medicine,
06:55and I I really wanna know whether you
06:58agree if Sleep Medicine training has
07:00become an important important part
07:03of practicing Sleep Medicine for you,
07:06and you know whether you were
07:09an academic setting or not.
07:15I'll just give this a few more seconds
07:17and then share my results with you guys.
07:25So that's good. Almost 70% of the
07:30people agree that it is an important
07:34part of practicing Sleep Medicine.
07:38So let me start with a clinical case.
07:41We have a typical bread and butter,
07:44Sleep Medicine case of Mr.
07:45Piper, who's a 68 year old
07:48male living in Shelton, CT.
07:50He has hypertension.
07:51He's on two medications.
07:52He reports Nonrestorative sleep
07:54to his primary care physician.
07:56In addition,
07:56he snores has gasping and choking spells
07:59at night as well as business apneas.
08:02He easily nods off in the morning
08:04and does not have morning headaches.
08:07His exam is notable for a BMI of 33.
08:10His neck circumference is 70.
08:12And a half inches and Marlon party for Herve.
08:15So the next steps would be for him to
08:18be referred to a Sleep Medicine clinic.
08:21After you know the stock Bank
08:23of eight out of eight.
08:25And now I'm just gonna dive into how this
08:28wizard would be conducted in person.
08:31So you know the patient is seen in the
08:33clinic evaluated by the Sleep Medicine.
08:36Fellow history is obtained and
08:38then you know attending in the
08:40fellow recommend a sleep study.
08:42Home versus in lab studies and the
08:45steep studies performed and scored.
08:47A results are discussed again with Mr.
08:50Piper and the next visit,
08:52and then he chooses C Pap based
08:55on the severity of OSA and DME,
08:57company meets him to start the see
09:00PAP and then he follows up again
09:03to review the download adherence
09:05and if any questions he has now
09:08if this wizard was to be conducted
09:11virtually you know.
09:12In this distance learning environment,
09:14how do we incorporate our trainee and
09:17you know how will they conduct a visit?
09:20You know, whatever platform you use,
09:22all the steps remain the same.
09:25If you see that except that they
09:27all become remote and virtual,
09:29you know he's seen in the clinic.
09:32Virtually sleep studies performed at home.
09:34The results are on cloud.
09:36It can be scored virtually as well,
09:39you know, and then DM.
09:41He can also do a virtual setup.
09:44And then the patient meets again remotely
09:47to review, download, and adherence.
09:49What it does for our Mr Piper is that it
09:53does eliminate the need for five visits,
09:55which can be cumbersome, time-consuming,
09:57and time away for work and then.
10:00Also, it brings us to a point.
10:03If our trainees are ready to do
10:06virtual clinic during their training.
10:08A former trainee perspective,
10:10you know,
10:11I have another poll question that
10:14I like to ask before I start on.
10:18You know how?
10:20We can train our fellows to do
10:23virtual medic medicine,
10:23so I'm gonna launch that pool Now.
10:26And what I really want to know is
10:27that how much daily medicine do
10:29you incorporate into your practice?
10:48I'll give it a few more seconds.
10:56Alright, I'm gonna share the results
10:59so this is kind of a divided.
11:02About 40% participants have
11:03over 50% of their, you know,
11:06practice intelli medicine, an A-40.
11:09A good half is less than 25%, you know?
11:13Now this may be something because of
11:17institution you know, or you know,
11:20not everybody has telemedicine technology.
11:22So what would a virtual visit
11:25look like for a fellow?
11:28You know, despite widespread use
11:30of outpatient telling medicine?
11:32You know there are logistical differences
11:34that exist in its implementation.
11:36As you can see in these pictures
11:39of the first one on the left,
11:41you can see we're meeting the
11:43patient virtually in the attending
11:45could potentially be present
11:47for the entire visit with them.
11:49It was a break for the fellow in attending
11:52to confer go over the assessment plan
11:54and recommendations for the patients,
11:57which does provide that ending opportunity
11:59to observe the fellows history
12:00building and communication skills.
12:02This kind of direct observation
12:04is a potential benefit for telling
12:06medicine environment,
12:07as attendings presence is not as
12:10physically obtrusive as it might be
12:12during the face to face visit and this
12:15other picture on the right that you see,
12:18you do see that the attending and the
12:20fellow are conducting the virtual wizard,
12:23going over results of in this
12:25picture CAT scan.
12:26But in our case would be a
12:29polysomnography or some other sleep test.
12:32You know and discussing the care plan
12:34with the patient and you know you can
12:37have a medical student or a resident.
12:39Also observing at the same time remotely,
12:41you know.
12:41And then the next point I want
12:44to make is that you know this.
12:47These pictures you know in the top left
12:50approach that ending is conducting
12:52the wizard with the patient and going
12:54over the results with the patient,
12:57while the fellow could be observer
12:59observing the whole entire visit.
13:01And this could be,
13:02you know,
13:03in the beginning of the fellowship
13:05and then on the right you can see
13:08the resident or the fellow is
13:10just speaking with the patient.
13:13While the attending is,
13:14you know,
13:15in another room and maybe going over a
13:18study or something and then they come back,
13:21discuss together and then go
13:23back and speak with the patient
13:25again to go over the results.
13:27So there's many,
13:28many flavors of how you know
13:31virtual visits can perform while
13:33you have a training program.
13:35Some of the things you know to
13:37conduct a video visit from attorney
13:39training perspective, you know,
13:41make sure you have a space.
13:44That is quite an valid and you know.
13:48Where you're able to do your tally
13:51examination and visit and then also
13:53make sure the patient who's there can
13:56hear and see you well and the other
13:58thing I want to emphasize is that be
14:01familiar with the platform that you
14:04have an you know some of the things
14:06where the buttons are how to navigate it,
14:09and you know if it's not working or if there
14:12are any system glitches how to reset it and
14:15then two of the things that are important.
14:19An unique to virtual visit is that you
14:21have to make sure you're speaking to
14:24the patient you're scheduled to see,
14:26and then you also explain to them the
14:29limitations of a virtual visit, an take
14:32permission from them to go over the visit.
14:35Some of the things we can do during your
14:38tally or virtual visit for trainees
14:40that you know while the exam is limited,
14:44but there are still some things that
14:46you can observe or visualize during.
14:49You're interviewing with the patient
14:51like their general appearance.
14:53How do they look?
14:54Are they sad, happy, or angry?
14:57You know their work of breathing.
15:01Sorry, there's some.
15:07Hello.
15:09And I already went over documentations.
15:11The two unique things about a Tele visit,
15:13or that you know you do need a consent
15:16for a video visit an you know also
15:19have to verify the patient's location.
15:22Some primary care visits,
15:23you know it may not be very unique to
15:26Sleep Medicine is that if you are able,
15:29and if you're patient can you can always
15:32ask them to check their temperature.
15:34Wade polls blood pressure prior to
15:36visit and then that way you can
15:39document as well because you know
15:41there is a limitation and that
15:43when it comes to virtual visit,
15:45one thing I want to emphasize is that you
15:48know not just having a regular work routine,
15:50but having an adequate workspace.
15:53Is important as you see on the left,
15:56this is a Doctor Who was having a jury duty
16:00while in the middle of performing a surgery,
16:04and while it is possible and he
16:07probably thought it was right,
16:09but you know it,
16:10it's not the most appropriate thing to do.
16:16Some of the factors and you know,
16:19I don't have a lot of scientific evidence.
16:22There's a lot of anecdotal
16:24data and a lot of commentary,
16:27but some of the factors that can
16:30or characteristic's that can show
16:32the fellow will be able to perform
16:35the tasks independently or do well
16:37with a virtual environment include,
16:40you know, an organized fellow who
16:43can perform tasks independently.
16:45Or is able to work with minimal
16:48direct supervision,
16:48which is not synonymous with
16:51the lack of supervision.
16:52Someone who has official who's sufficient
16:55has good time management skill and
16:57communication skills is able to
16:59identify people to be communicated to,
17:02you know, is able to speak with
17:05the perceptor clearly have a plan
17:07outline and then someone you know.
17:09Because we're using technology,
17:11it's always good to be tech savvy
17:14and have a back.
17:16Backup plan for technical
17:17disturbances and then Lastly you know.
17:20Have a clear documentation of
17:22supervision and the virtual visit.
17:24Some of the challenges of the
17:26virtual learning or the virtual
17:28visit is that you know choosing who
17:31is appropriate for a virtual visit.
17:34It's not always.
17:35Not everyone can do it and then and
17:38that is not entirely up to you.
17:41Know our training because some of
17:43the front staff schedules are patient,
17:46and while patients are offered to.
17:48See us virtually some of the patients
17:51may not be able to, you know,
17:54do very well with the virtual technology so.
17:59The other thing is that it is important
18:01that we need Internet technology,
18:04so Accessibility to a stable phone or a
18:07broadband broadband connection can be a
18:09challenge in rural areas for patients
18:11and also patients with limited income.
18:14Not everybody has Internet or uses Internet,
18:16and then you know time management.
18:19What I really mean by that is there
18:21are some virtual platforms that
18:23end the visit at a certain time.
18:26So because of the limited times.
18:29Lot you know you,
18:30you may be still in a conversation.
18:33It may just abruptly an in the
18:35Lastly is there is always a physical
18:37examination limitation.
18:38An physical exam is a core component
18:42of training.
18:43And we're not there yet.
18:45In order to, you know,
18:47get our virtual formats where we're able to.
18:50You know Oscar theater longs or
18:52listen to their heart sounds,
18:54which may not be so relevant to
18:56Sleep Medicine.
18:57Or, you know, look at the airway,
19:00because it's not very easy to look
19:02at the airway if you've tried it.
19:05So how do we make our fellows
19:07trained for a virtual visit?
19:09First and foremost is that while we
19:12do practice telehealth to an extent.
19:14We don't really have a structured
19:16Anna define training like there is no
19:19virtual virtual curriculum for or or
19:21a curriculum for virtual clinical encounters,
19:25so you know something that
19:27would be helpful would be,
19:29you know, online modules,
19:31virtual lectures or simulation of,
19:33you know, simple bread and butter,
19:36Sleep Medicine cases off, you know.
19:38Oh I say,
19:40restless leg narcolepsy or insomnia.
19:42While you know you starting.
19:44To train your fellows and then technology
19:47is why don't you practice learning
19:49what is standard to your center is
19:52also important during orientation,
19:54and then if you go to several training
19:58places, learning what is unique.
20:00To those places is also important.
20:02One good thing about sleep is that you
20:05know we do have digital diagnostics.
20:08You know PSG's all sleep studies
20:10can be read and scored virtually,
20:12and you know attending and fellow can
20:15you know meet while zoom and go over
20:18the scoring while they are remotely
20:20working or not in the same place.
20:23And then Lastly something we
20:26tend to you know.
20:28Kind of assume that people know is
20:31that you know website manners thinks
20:33as simple as positioning of the camera,
20:37maintaining eye contact,
20:38you know picking up on the
20:40nonverbal cues of the patient,
20:42and you know also doing the virtual
20:45clinic in an appropriate place like
20:47not in an R or not while you're
20:50driving some patients you know.
20:53Maybe it will also for the patient,
20:56some patients may be doing
20:58something and be distracted.
21:00And then you know,
21:01if they're not distracted,
21:03it's easy to engage them.
21:06So how can we enhance the sleep
21:09education for telly sleep education?
21:12First and foremost,
21:13you know sleep education Delhi sleep
21:16education for fellows and also training
21:19the faculty into training the fellows.
21:22And you know,
21:23I already discussed this but you know
21:27having a curriculum for virtual training
21:30and then if the fellow an attending
21:34are going to have remote working.
21:37You know,
21:38in their training approval of that,
21:41as some programs may not allow
21:43that and then training modules
21:45geared such as you know,
21:48simulation of cases,
21:49an incorporation of those into
21:51orientation or boot camp,
21:53and then always taking feedback on how
21:56we're doing while we're doing that,
21:59Ellie sleep training an also
22:01utilizing institutional resources
22:03to adopt or Kelly sleep model.
22:05Also I.
22:06I did mention this already,
22:09but setting expectations or a framework
22:11for while you're supervising a trainee,
22:14whether it's a fellow or if a fellow
22:17is supervising a medical resident,
22:20directly or indirectly,
22:21and some of the things that you
22:24can do short term is to collaborate
22:27with your institutions.
22:29Information technology expert to
22:30understand which remote meeting platforms
22:32are available with institutional support,
22:35something that is HIPAA compliant.
22:37Because,
22:38you know,
22:38we do kiss conferences and then
22:41identifying current didactic and
22:43clinical learning opportunities
22:44within the program that are
22:47amenable to virtual delivery.
22:49Pinpoint gaps in the curriculum
22:50like we don't have a virtual sleep
22:53curriculum that may be well served with
22:57innovative distance learning methods.
22:59Establishing short communications to
23:01see the transition to distance learning,
23:04and quickly address barriers
23:06to implementation long term.
23:08You know,
23:08always checking with IT 'cause
23:10there's always better online
23:12platforms that can align with
23:14the institutional standards,
23:16and then you know.
23:17Also taking it even as far as
23:20identifying and measuring outcomes
23:22such as patient related outcomes
23:25or educational outcomes if they
23:27do improve either one of them,
23:29it's always better and then evaluation
23:32of the distance learning methods
23:34as a part of either annual program
23:38evaluation or a mid year evaluation.
23:40And things that could be, you know,
23:44monitored longitudinally that are
23:46integrated into the program and comparing
23:50it to other GME programs or comparing
23:53into programs within the specialty.
23:57I have one more and this will
23:59be my last poll question.
24:06Just give me one moment and I'm going
24:09to share this so and so I want to know
24:13what formats are you all using currently
24:16for Jelly Medicine and I may not have
24:19all of them so you can you always free.
24:23Do you know use the comment option.
24:40Alright, so let me share the results.
24:44So most of the people use my chart Doc.
24:48See an American valve. That's great.
24:51I think I'm familiar with all of them.
24:55So. Now I'm going to shift my, you know,
25:01talk to my the second portion,
25:04which is distance learning
25:06and this is learning.
25:08You know, there's a broad range of
25:11didactic activities you can see.
25:13All of the ones that I've highlighted,
25:17which are a core component of
25:19fellowship training curriculum.
25:21These includes lectures, case,
25:23conferences, great round simulations,
25:25case based teaching in Journal clubs.
25:28And you know,
25:29the large the suspension of large face
25:32to face interactions has you know forced
25:35many of us do to convert to virtual
25:39platforms and requiring to you know,
25:42requiring programs to rethink
25:44high quality education.
25:45The virtual platforms do allow
25:47programs to continue structured
25:49educational curricula while complying
25:51with physical distancing directives,
25:53and have been met with varying levels
25:57of satisfaction due to inherent.
25:59Disadvantages and advantages, you know,
26:02but there are many features that
26:05you know we can incorporate an.
26:09You know,
26:10learn and keep our trainees engaged.
26:13One of the most important concerns
26:16you know among training faculty during
26:19the pandemic was whether fellows
26:22continue to receive adequate training.
26:25Seeing a diverse and heterogeneous
26:27patient makes an R will be able to
26:31do independence practice so virtual
26:34platforms do allow you to have
26:38structured educational curricula.
26:40But before the pandemic.
26:44You know we'd use them.
26:47We use social media more as well,
26:50you know,
26:51but they don't have the outlet for
26:54medical education in depth an not
26:57the organization to reliability.
27:00Implement in curriculum some of the
27:03advantages and disadvantages of the
27:05virtual an online data tactics are,
27:08you know, they've all their flexible.
27:11There's asynchronous and synchronous
27:13learning modules.
27:14But they do require self motivation
27:16and discipline which can promote
27:19personal responsibility,
27:20creative teaching techniques.
27:21You know there's online team based
27:24learning simulation exercises,
27:26but also at the same times it limits
27:29the networking because you're
27:31not meeting in person,
27:33so it also limits you social interaction.
27:36But at the same time it can encourage
27:39members to build professional relationships,
27:42individualized learning or
27:44self directed learning.
27:45But you know the disadvantage of personal
27:49learning is that it does not allow for
27:52real time faculty fellow interaction.
27:55But you know,
27:56you can always provide online
27:58summary statements to address
28:00questions from learners.
28:02The good thing about,
28:03except it is it that it is iaccessible
28:06all members can participate.
28:08There is limited nonverbal communication,
28:10but you know that can be overcome by
28:13having a facilitator or moderator.
28:16It is convenient 'cause there's
28:17really no commuter travel required.
28:19All you really need is in need is a
28:22good Internet connection and there
28:24is a general perception that virtual
28:27education is not as effective as
28:30traditional didactic teaching.
28:31While we don't have.
28:33Any you know data that proves it but
28:38you know it is just a general perception?
28:42You know one thing is that we
28:44can have equal
28:45participation through virtual
28:46learning because you know it can limit
28:49monopoly from more vocal participants.
28:52But sometimes it may be challenging,
28:54because if you're not very tech savvy,
28:57it's hard to do that.
28:58You know, engage your audience and
29:01go through your talk at the same
29:04time it is anonymous and cost saving.
29:07Some of the good things about some
29:09of the virtual platforms is that you
29:12know they're either available as an
29:14application on your phone desktop,
29:17even as a web browser, wherever you are,
29:20you can always, or you just really need,
29:23is a smartphone an Internet,
29:25and you're able to log in and you're able to,
29:29you know, share documents and
29:31slides collaboratively.
29:31You know, and then pull feature can have
29:35some audience engagement and is able to.
29:37You know and give the results right away.
29:41You can stream and record conferences easily,
29:44share materials like slides,
29:45figures, an you know the one thing
29:48is that it's always just send.
29:50It's always good to send.
29:54A program announcement ahead of time.
29:58Anne, but at the same time doing.
30:00Burden with.
30:17But some of the examples that I want
30:19to use is that we used to have a seat
30:22fellowship director rounds every Friday
30:24afternoon in person before the pandemic.
30:27But as we started our fellowship,
30:29we started it.
30:29You know in July so we had converted
30:32these director rounds into a virtual format,
30:35and we've been also doing
30:36the yield sleep conferences,
30:38the fellow conferences at 4:00 PM,
30:40virtually with zoom, which I'm not
30:42sure if we were to do the year before.
30:45I think it required the fellows of travel.
30:48In two New Haven for the Norwalk Fellows,
30:51so you know, in this era the
30:54need for solutions to optimize
30:56educational endeavors has accelerated.
30:58Many programs have sought to improvise
31:01with new technologies such as Zoom,
31:04Slack, Google Rooms, Microsoft Teams.
31:08So like I said at our institution,
31:11a combination of zoom has
31:14facilitated fellowship,
31:15educational activities and then the
31:17format has been a popular format.
31:20It it kind of.
31:24Fosters a sense of community among the
31:27fellows despite rotations at multiple
31:29places in being in multiple programs,
31:31and it's an easy interface.
31:33Accessible outlets an it's a
31:36collaborative platform an it's very
31:38well integrated an you know we have
31:41secure cloud systems used by our health
31:44care systems where we store our common.
31:48Now things like articles
31:50that we want people to read.
31:53And then so All in all,
31:55it is kind of one stop shop
31:58for all our educational needs.
32:01Where in one single application we
32:03share articles stored in our fellowship
32:05Cloud Work Laboratory on the same document,
32:08like you know,
32:10we've been writing a book chapter,
32:12and we've been collaborating
32:14through Google Docs and conduct
32:16an engaging virtual conference.
32:18Uhm?
32:19The last thing I want to talk about,
32:23you know, uh, in terms of virtual learning,
32:26is that it's always good to plan before.
32:29So make a plan for your topic and
32:31how you will use the technology.
32:34It's always good to come in early,
32:36so you can,
32:38you know,
32:38troubleshoot all the problems you
32:40may have with the technology,
32:42and then it's always good to use the
32:45full feature to engage the audience,
32:47specially during a PowerPoint
32:49presentations and then.
32:51When you share the topic,
32:53or if you're doing any educational
32:55or teaching talk,
32:56there's always whiteboard features
32:58that you can use,
32:59and then while you're starting the session,
33:02when you start early,
33:03it's always good to set expectations
33:06that you're gonna use this
33:08much time for your talk and the
33:10rest for questions or comments,
33:12and then you know how you plan to
33:15use the chat function, how you,
33:18you know you can always assign.
33:20Full presenter you know,
33:22or a facilitator to monitor the
33:25chat box while you're speaking,
33:28and then during the talk you
33:31know going back to your agenda,
33:34sticking to it with your plan,
33:38and then also being intentional with
33:41the with facilitating the conversation
33:43and then paying attention to the group.
33:47Dynamics is important an you know.
33:50Ask for reflections or.
33:52Touch from participants who may be
33:55less verbal. Ask questions.
33:57Try to actively listen and respond actively.
34:01Incorporate thinking or reflecting
34:03time when your participants are
34:05learning new information an after
34:07you're done with the session.
34:09It's always good to send an email with
34:13important teaching points and dates
34:15of future sessions and recap of take
34:18home points or pertinent articles for
34:21additional reading, which we've been.
34:23Doing the whole year.
34:26The next thing I want to discuss
34:28is that you know.
34:29How to generate scholarship while distance
34:32learning trainings an faculty they
34:35can continue to generate a scholarship
34:37within a distance learning framework.
34:40Virtual collaboration platforms
34:41such as Google Drive,
34:43Slack Towel, and Basecamp.
34:45These are just some of the
34:48examples that I came through.
34:50You know they facilitate
34:52asynchronous work on group projects.
34:55In fact, incorporation of distance
34:57learning strategies for training research.
35:00Opens new possibilities for
35:02cross institutional mentorship
35:03and project collaboration.
35:05And now more than ever,
35:08programs within the same specialty can
35:11pool resources to broaden training,
35:14engagement and research and
35:16quality improvement endeavors.
35:18And this partnership can help trainees
35:21forge meaningful relationships with their
35:24peers and mentors across the institution.
35:28And the establishment of virtual
35:30training resources Xherdan sustained
35:32by faculty at multiple institutions
35:35may help the development of a more
35:38clinical researchers who in turn can
35:40propel sleep and circadian science
35:42and advanced the patient care.
35:44While it is equally important to you,
35:47know, have good training,
35:49how do we give feedback to fellows
35:52as well as faculty?
35:54You know some good things about virtual
35:57format is because the attending can.
36:00Directly observe you while you
36:02conducting an interview and also
36:04making your assessment.
36:06And sometimes you know patient may
36:08want to talk directly to a trainee
36:11and this also permits a cleaner,
36:14cleaner assessment of the fellows
36:16performance and some of the strategies
36:19that the fellows are using to optimize
36:22their virtual care can be assessed and
36:25reviewed with the fellow later on.
36:27And you know the opportunity to
36:29take assess history gathering and
36:31communication skills via telehealth.
36:33Line very well with fundamental components
36:36of competency based medical education,
36:38which I'm going to be
36:41talking about in the end.
36:43You know,
36:44and also you know if you're
36:46using the virtual platform,
36:48some institution can allow session recording
36:51and the attending can provide feedback,
36:54while post hoc review of fellow delivered
36:57care as an alternative to a medical,
37:00clinical,
37:00mini clinical exam,
37:02or mini CX.
37:03And then the fellow may also gain
37:06inside to their care delivery
37:08by viewing a video of themselves
37:11engaged in our real world.
37:13Virtual patient care.
37:16So and then the next and very very
37:20important topic is all about well
37:23being as we innovate to address
37:26fellow educational needs.
37:29We also must acknowledge that
37:31effective learning is hindered by
37:34high levels of stress or, you know,
37:38a burnout which is unhealthy stress.
37:41In medicine it is defined as a
37:44combination of emotional exhaustion,
37:47depersonalization.
37:47And low personal accomplishment.
37:50Uh,
37:51caused by chronic stress of medical practice.
37:54You know, burnout affects many physicians,
37:57and trainees are more effective.
38:00You know, recent studies also show
38:03their residents and fellows were
38:05more statistically burned out,
38:08about 60% and depressed with lower quality
38:11of life markers and higher levels of fatigue
38:15compared with earlier care physicians.
38:18And Furthermore, burnout is.
38:20Well known to negatively
38:22affect quality of patient care,
38:25increase health care costs,
38:27and worsening physical health.
38:29And while we do seek efforts to
38:33address this crisis by prior teising,
38:36mental well being and freedom from stress,
38:40how do we do that in a virtual you know
38:44or social distancing format you know?
38:48Ever since the 2000s,
38:50there have been many, many.
38:53Velma's there has been almost an
38:56explosion of Wellness resources and
38:58literature in the last two decades.
39:01To you know, even creation of the
39:04national academic of Medicine Action,
39:07collaboration on Clinician Val
39:09being an resilience.
39:10Few years ago an also by AC GME and
39:15this is just some of the AC gme,
39:19well being resources.
39:20That address training, burnout and Wellness.
39:24What we can do in these?
39:26You know,
39:27distance learning times is that
39:29you know we should continue to
39:32have frequent conversations and
39:35checkins too with the fellows.
39:37Or the residents about their well
39:40being during the times of remote
39:43learning and social distancing.
39:45Incorporation of virtual town halls.
39:47Happy hour's game nights, you know,
39:50or whatever the trainees like and other
39:53social interactions that can help trainees,
39:55faculty and staff feel connected even
39:59when you're physically distanced.
40:01And also you know the one good thing is
40:04as the as more people get vaccinated.
40:07You know,
40:07maybe you know we don't need to
40:09be as socially distanced,
40:11but you know, we'll find out.
40:13And also you know it is also a
40:16responsibility of a program to
40:17ensure that trainees understand
40:19how to access local Wellness and
40:21mental health resources as needed,
40:23per particularly during the time
40:25of this increase or uncertainty
40:27and anxiety and physical distance
40:29from the usual support systems.
40:31And you know,
40:32there are many evidence based interventions.
40:35Some of the ones that I've mentioned as well,
40:38you know.
40:39But it is also important to really,
40:42you know,
40:43prioritize something that's basic you know,
40:45such as you know,
40:47making sure they have food you know,
40:50or they're getting enough sleep.
40:52They do have protected time off, you know.
40:56And then from there to higher
40:58order interventions,
40:59how a program can implement Wellness.
41:02Interactive interventions during
41:03you know this year of the pandemic.
41:06Like I said, starting from the basics,
41:10making sure you know your trainees
41:13have either healthy snacks,
41:15even vitamins,
41:16water access in their common
41:18working here yeah,
41:20or you know position rooms.
41:24Then also making sure and casually
41:26checking in on them and doing burnout survey.
41:30Or,
41:30you know,
41:31making sure they have access
41:33to a mental health resources,
41:36distributing Contacts for campus
41:38mental health support as well the
41:41insuring you know it does not really
41:43apply to Sleep Medicine by ensuring
41:46there's a place to sleep and also
41:49protecting from unnecessary
41:50hours or an on call pages.
41:53And then do an intermediate level
41:57like a buddy system for peer support,
42:01virtual Department,
42:03Happy Hour or nonclinical Hangout an.
42:07Even at a leadership level,
42:10recurring meetings to check in on
42:13the fellows debriefing sessions
42:15in a safe space also help.
42:17And then making sure that you know
42:20you're involving the fellows while
42:23you're doing the decision-making on
42:26policies or collaborating on research
42:28and then taking it to a higher level.
42:31Like, you know giving.
42:33I'm not sure how to do that,
42:36but emotional intelligence training.
42:39Resilience training or you know how
42:42to plan for the next wave an how do
42:45we better next time sticking to what's
42:48better and making it even better?
42:51Incorporating equity,
42:52an anti racism teachings into our
42:55training curriculum on education
42:57of health care disparity and you
43:00know making space for what it
43:02means to return to normal.
43:04You know,
43:05some some institutions even have a HIPAA
43:08compliant and a socially distance tick tock.
43:12You don't,
43:13or an Instagram.
43:14And to express and they show
43:17pictures to express appreciation or
43:19gratitude for their team members,
43:21which can be a follower of faculty.
43:24You know an also other resources
43:27that your institutional have
43:29the institution had that may be
43:32free to available like you know,
43:34group, exercise, meditation.
43:36Or other gratitude gifts.
43:39And also always good to ask for and
43:42give feedback that will be relevant.
43:45And then Lastly you know,
43:47take advantage of Wellness initiatives
43:50that are in the community.
43:52Last last thing about you know,
43:54fellowship that I want to discuss this.
43:58You know,
43:58while in the time of distance learning,
44:02we've also moved to virtual interviewing,
44:04you know,
44:05and Sleep Medicine actually had a
44:07very successful successful fellowship match.
44:10And almost the interview season
44:12was fully virtual.
44:14It had it has a lot of advantages.
44:18It had the benefit of limiting
44:20COVID-19 exposures and also it
44:23lessens the number of last minute
44:26cancellations and saves costs for
44:28candidates for travel and for programs.
44:31And then some of the things that you know.
44:36Need to be done to make the virtual
44:39interviews more successful would
44:40be you know application review and
44:43interviewing scheduling workflows
44:45that are adaptable and flexible to
44:48adjust the upcoming recruitment
44:49season and also in preparation
44:51for the new terrain.
44:53Programs should have been updated on
44:56most recent you know data on their
44:58website to provide a candidate with
45:01current relevant information as
45:03programs commit to online interviews
45:05and virtual visits for all candidates.
45:08They should also anticipate a gradient.
45:11Prof. Applicants next year and then.
45:16How do they you know,
45:18solid solid fire the workflow
45:19during the recruitment season?
45:21You know how they will have a
45:23strategy to review applications
45:24and communicating with candidates
45:26in a timely manner. You know?
45:28So these are some of the things
45:30that can do an I want to share the
45:33results of the fellowship match
45:35trends for Sleep Medicine.
45:37As you can see in the last few years.
45:422021 had the highest number of
45:46matched or filled programs.
45:50Over total programs,
45:51and then if you go and look at
45:54the positions that were offered,
45:56the number of programs that
45:58filled has been the highest it
46:01has been in the last five years.
46:03Now this may be because you
46:05know people were interviewing
46:07virtually and canceling glass.
46:08Or maybe there is there has been
46:11just a general increase in Sleep
46:13Medicine fellowship because,
46:15you know, as we've started to
46:17implement more telling medicine,
46:19some people can just.
46:21Kind of work from home, you know?
46:25And the last topic of my talk today
46:27is the Sleep Medicine milestones,
46:30which is a little bit different
46:32from what I've been talking about.
46:34But you know,
46:35I just want to go over it because
46:38this is something new and very
46:40relevant to our specialty in
46:42medical education an you know,
46:45as we all know that a CGM ME published
46:48the first steep medicine file stones in 2015,
46:51but these milestones were the
46:53same among all internal medicine.
46:55Fellowship programs they were
46:58not specific to the specialty,
47:00so based on the stakeholder feedback
47:03the AC GME called for creation of
47:07specialty specific milestones and
47:10I'll be outlining those milestone
47:13reporting system and how they were
47:16created and what it means by harmonized.
47:21Milestones,
47:22so the six AC GME core competencies
47:25are patient care medical education.
47:28You know system space practice,
47:31practice based learning and improvement,
47:34an interpersonal communications
47:36and skills communication skills.
47:38However,
47:38the assessment of the competencies
47:41was complicated by differing
47:43interpretations to specific competencies
47:45and heterogeneity of implementation,
47:48so you know they were not generalize.
47:52Very general an not a specialty specific,
47:55so the ultimate decision was made
47:58to write generic sub competencies
48:00to be used by all specialties.
48:03But the disadvantage was that all
48:06sub competencies did not apply
48:08to all subspecialties.
48:10So as you can see Doctor Weir is one
48:13of those people in the working group.
48:17So in an effort to bridge the
48:20initial AC GME reporting milestones.
48:23And Sleep Medicine fellowship
48:26training ASM Fellowship Director's
48:29Council Steering Committee created
48:32the Sleep Medicine specific
48:34curriculum milestones map to generic
48:37milestones that are I just discussed.
48:41An these are the milestones 2.0
48:45or the harmonized milestones.
48:48So there are 18.
48:50Milestones in those six core competencies,
48:54and they continue to draw from them,
48:57but they are used by each programs
49:01Clinical Competency Committee,
49:02an by faculty, as well as the trainees.
49:07To assess, you know for assessment.
49:11Faculty use them to guide development
49:14as educators and fellows use them to
49:18create individualized learning plans
49:20that facilitate self reflection and
49:23measurement of individual progress.
49:26Compared with national trends.
49:28So the harmonized milestones encompassed
49:31skills related to patient care,
49:34patient centered care delivery,
49:36diversity and inclusion.
49:38Working within a team structure
49:41and navigating.
49:42Large,
49:43complex health systems and the working group.
49:46You know that Doctor Weir is also
49:49a member of focused on progressive
49:52stages of learner growth.
49:54Defining points along the
49:56trajectory from a novice learner to
49:59an innovator. A leader in
50:01the field of Sleep Medicine.
50:03And you know, these milestones remain
50:06applicable as new technologies are
50:08incorporated into Sleep Medicine
50:10practice and especially the
50:12milestones related to diagnosis
50:14and management of sleep disorders.
50:16They do not specify on procedures
50:19or treatment guidelines because
50:21there are so many things that are
50:23changing as we move forward the the
50:262.0 milestones used the Dreifus and
50:29Rafa's five stage of development
50:31model of mental activities for skill.
50:34Acquisition during the fellowship
50:36year so you know,
50:38level one is now a nervous instead of.
50:44Critical deficiency two and Level
50:472 is an advanced beginner and a
50:50Level 3 is a competent fellow an
50:53for proficient and then to an expert
50:57fellow or ready for independent
51:00training and then like I said,
51:03this is a notable difference from a
51:05first set of subspecialty recording
51:08milestones,
51:09which ranged from critical
51:11deficiencies to ready for unsupervised.
51:14Practice an aspirational.
51:16This paradigm allows fellows in all
51:19accredited programs to achieve defined
51:22competencies in the management of
51:24adult and pediatric sleep disorders
51:27within the broader context of health
51:30care systems and also the changes kind
51:33of highlight a conscious decision to
51:36remove negative language such as you know,
51:40critical deficiency and implications
51:42about fitness for graduation such as.
51:45And already for supervised
51:47unsupervised practice,
51:48in addition,
51:49milestones 2.0 include a relative
51:52leftward shift of the associated
51:54anchors for each sub competency.
51:57So like I said, Level 3 is now
52:01considered proficient versus Level 4,
52:03which is considered ready for
52:06unsupervised practice.
52:07And as always,
52:08this is just a guideline.
52:11The determination about a fellow's
52:13readiness for graduation lies
52:15within the program director.
52:18With advisement from the
52:20Clinical Evaluation Committee.
52:22And then this just kind of
52:25brings me to the end of my talk.
52:29You know,
52:30I wanna say innovation stem from necessity,
52:34exploring deli sleep services
52:36among academics, Sleep Medicine,
52:38fellowship programs.
52:39It is an important and timely topic,
52:42especially as the field tries to
52:45understand how telehealth can best be
52:48utilized to enhance and expand patient care.
52:52An also.
52:52You know,
52:53with the net dude in a national recent
52:56survey of Sleep Medicine program,
52:59directores,
53:00while the program Directores agreed
53:02that Sleep Medicine training is
53:04important and should be incorporated
53:06into fellowship curriculum,
53:08there is a dearth of specific guidance.
53:11An concrete steps are vague
53:13and not actively pursued.
53:15So you know this is something you
53:18know the inconsistency is discerning
53:20and you know difficult to explain.
53:22So the solution is.
53:24And you know it leaves us to do things.
53:28And how do we improve?
53:30Embrace Sleep Medicine and
53:32effectively educate?
53:32Are the next generation of physicians
53:35you know are very hardworking
53:37fellows and trainees to be prepared
53:40for the needs of the community.
53:43And these are my references
53:45and I think I finished on time.
53:53Hi. Can everybody hear me?
54:00Yes, we can hear you OK. Alright.
54:05Happy to take any comments
54:07or questions anybody has.
54:12Thank you hear that was such a wonderful
54:15overview for all of us medical educators.
54:18Just really fantastic. Thank you.
54:23We can open it up to questions
54:26we have about 5 minutes.
54:28If anyone would like to
54:30know sure, sure this this is Brian,
54:33so I have a comment.
54:35I think a question so here, thanks for.
54:39For the overview and you know I just wanted
54:43to make a comment from my perspective, yeah,
54:46and sort of encouraged this idea of really
54:48adapting to this technological innovation,
54:51so I also see patients in a geriatric
54:54clinic and I think that is a place
54:57where the virtual visit has been very
55:00problematic for a lot of reasons.
55:02I mean, you know, even if people can
55:05sort of get the necessary technology
55:07even communicating with them by video.
55:10Can be challenging.
55:13Whereas you know my experience
55:14in the Sleep clinic is wow,
55:16this seems like the perfect
55:18place to do these visits.
55:19You know, it seems like a very sort of.
55:24You know it's just a perfect place to
55:26adapt this technology, so I wonder,
55:28you know you kind of mentioned what
55:30are some things that we can sort of
55:32take advantage with a video visit?
55:33You sort of said,
55:34you know, we can do vitals.
55:36We can sort of find ways to
55:38look in people's Airways.
55:39You know we can adapt that way.
55:41One of the things I think about
55:43in geriatrics is, you know,
55:44I can actually at you know it may
55:46not have the patient in front of me,
55:49but I can look at their living
55:51in the environment.
55:51And that's a big advantage.
55:53So I'm wondering what you
55:54think people should.
55:55Take advantage of that.
55:56They can otherwise get when the
55:58when the people are sort of,
56:00you know in the clinic with us and
56:02I'm wondering from your perspective
56:04or maybe some of the other trainings
56:07like what you know what is going to?
56:09What do you guys need from your
56:11training from us?
56:12What?
56:12What are some of the things we can do
56:15to make this experience better for you?
56:19You know? I'm I'm by no means an expert.
56:23I'm gonna try my best
56:25to answer that question.
56:26But you know, I I.
56:28I think if someone is good with technology,
56:31you know it could be a young patient,
56:33an old patient in, you know.
56:35And one thing I really enjoyed about
56:37virtual learning was, you know,
56:39when I would share the screen with patients
56:42and go over this sleep study results.
56:44You know, I saw how engaged they were.
56:47You know, I can never really kind of,
56:49you know, reproduce that effect when
56:51they're in person for some reason.
56:53Even when I'm showing them so,
56:56I I thought they seemed more engaged.
56:58You know more comfortable to ask
57:00questions about certain things because
57:02you know they would sometimes look up
57:05stuff while they're speaking with us.
57:07I wonder if that was the thing, and you know.
57:10Also, we have some patients you know
57:13who can't drive, you know, like I,
57:15I used to see a patient who is legally blind,
57:19but I could see them virtually because,
57:21you know, it would essentially eliminate.
57:24Their need for, you know,
57:25getting a bus or a cab to come see me.
57:28All they needed was an iPad to speak with me.
57:31So I think those were those are some of
57:34the things that I really find you know
57:36about virtual visits really helpful.
57:56Set an alarm. I had a quick question so so
58:01Doctor here are you sort of had a lot of
58:04your training in pre covid environment,
58:07pulmonary and critical care fellow.
58:08And now you know is asleep fellow.
58:11You know you're dealing more with
58:13the virtual environment in terms of
58:15learning so you know what things.
58:16Let's just assume that this
58:18is going to happen.
58:19Let's say essentially Kobid goes away.
58:21Let's all wish for the best.
58:23What things do you think
58:25will stick with things?
58:26Do you think or do better in there?
58:29Virtual format or what things do
58:31better in the in person format
58:33in terms of medical education.
58:35From your perspective,
58:36I think what certainly does
58:37better is that you know this cross
58:40institutional collaboration.
58:41We've had way more opportunities this
58:43year than any of the years before.
58:45I think combined some things that
58:47do really poorly is the Wellness.
58:49I think virtual Wellness.
58:51I'm not sure if that really works out.
58:53You can always have a you know
58:56team building activity virtually,
58:57but it's not the same.
59:00So I think you know virtual
59:02learning is there to stay.
59:03You know, if you have a way
59:06to engage audience,
59:07you know if this is a very advanced
59:10educator and they can get the audience to,
59:13you know, stay interactive and engage.
59:15That's a really really good thing.
59:17And you know.
59:18But I think Val being is one
59:20thing where I think we can do
59:23really well socially distanced.
59:28Great, well thank you. Thanks
59:30again and next week we're going to
59:33continue our string of these
59:34fantastic fellow talks.
59:35One of our yell sleep photos,
59:38Yvonne Chu is going to be speaking
59:40about the link between PCOS an OSA.
59:43So please join us for that,
59:45then have a great
59:47week everybody. Thank you.