New York Presbyterian Hospital
New York, NY
Rachel Miller, MD
We propose that our training program be considered for the ATS “Best Practice recognition Program” due to its outstanding academic growth and achievement, and provision of educational experiences that go beyond clinical training required to practice Allergy/Immunology. We would like to showcase our outstanding trend of commendation by the ACGME, as well as our record of scholarship that is uncharacteristic for a program of our size. We also would like to highlight our program’s strengths in training fellows as critical thinkers with respect to training program systems improvement, and as educators in their own right.
In the last decade this program has completely transformed itself from one on probation issued by the ACGME in 1999. Extensive programmatic improvements led to full accreditation in March 2003. Sustained efforts by dedicated faculty and fellows led to full 5 year accreditation with ZERO citations in the last review in February 2009. Among the achievements in programmatic improvement realized during this period was the funding of a second fellowship trainee position. The new structure, with one senior and one junior fellow, introduced the critical opportunity for each trainee to be a teacher/mentor of his/her peer. As cited by the residency review Committee, “The program director is commended for the marked improvement in the program and the PIF preparation. In addition, securing funds for an additional resident is noteworthy at this time.”
The physician faculty to fellow ratio is 7:1. Forty percent of the last 10 graduates have academic appointments at major university medical schools. We argue that benchmarks of scholarly success for small programs like ours that grew from 1 fellow every two years to one fellow annually in 2008 should be assessed on a “per fellow” basis over time. This program (last 10 fellows) averaged 3.7 publications, and 1.2 manuscripts (excluding abstracts), per fellow during fellowship. one fellowship manuscript by Dr. Kathleen Donohue (Donohue et. al., Anti-cockroach, mouse IgE is associated with early wheeze and atopy in an inner-city birth cohort, J of Allergy and Clin Immunol, 2008) has been cited by 24 articles to date, including the following year’s J of Allergy and Clin Immunol “latest Advances” editions (Szefler, et al. Advances in pediatric asthma in 2008; Bush and Peden. Advances in environmental and occupational disorders in 2008). The last 10 fellows have been the principal recipients of one educational research Trust (i.e. ART) Faculty Development Award, Flight Attendants Medical research institute Award, Clinical innovator Award, 4 research fellowship awards, AAAI Clinical Fellowship Award, and one NIH K08 award during or within one year of completing fellowship.
The program has introduced recently formalized curriculum in Program Improvement in which the trainee is asked to examine the systems operations of one aspect of the program that they believe could be improved. They gather data to document the baseline level of function, propose and, with approval, implement a systems-based change in operation, and finally, gather data to assess the impact of this systems change. As an example, one fellow conducted an attending supervised project directed at improving patient waiting time in the adult allergy clinic. In the established system, all patients had been instructed to arrive at the same time and patients complained they would wait 1-3 hours to see a physician. Additional problems were that patients were not scheduled for a visit with a specific fellow, impeding continuity of care. The fellow hypothesized that she could reduce patient wait time and improve continuity of patient care and physician-patient relationship by 1) monitoring, and if needed, modifying the clinic schedule prior to the clinic date to avoid overbooking, and 2) writing the appropriate physician’s name on the patient’s chart to decrease door to room time and permit each physician to anticipate better the needs of a given patient. She developed methods that included reviewing the schedule one week in advance, verifying and enforcing appropriate scheduling with guidelines on the number of new patients per fellow per clinic, and writing the physician’s name on the chart. The mean waiting time decreased by approximately 50%, yet time spent with the physician remained an average of 30 minutes. New templates for scheduling patients were developed and implemented.
In addition, each fellow is directly involved in teaching the medical and dental student ‘introduction to immunology’ course every year. The Allergy/immunology fellows serve as preceptors in small group sessions, each paired with an experienced member of the teaching faculty. The curriculum introduces the students to case-based discussions, and the fellows teach fundamental principles of immunology. The reviews from fellows and students uniformly have been positive. This different take on “back to the classroom” motivates fellows to review important concepts in basic immunology, make sense of these concepts in order to teach them, and offers them a great sense of accomplishment. As a result of these practices, Columbia fellows graduate from the Allergy and immunology program with a better understanding of the importance of integrating self-assessment and education into their careers no matter what venue they ultimately choose.
