NEW IDEAS TABLE

Comparison of Flagged PubMed ID Submissions Before and After Annual Update Scholarly Activity Monitoring Deployment 2013–2014 (Before) Faculty Resident Total

2014–2015 (After)

Out-of-Range, No. (%)

Total

Out-of-Range, No. (%)

Total

P Value

87 (17.6)

495

14 (3.2)

434

, .0001

31 (18.6)

167

8 (7.2)

111

118 (17.8)

662

22 (4.0)

545

.007 , .0001

significantly improve the efficiency of annual ADS updates at a national level. Gregory Hermann, MD, MPH Resident Physician, Transitional Year Residency Program, Department of Emergency Medicine and Department of Internal Medicine, Henry Ford Health System Amanda S. Xi, MD, MSE Resident Physician, Transitional Year Residency Program, Department of Emergency Medicine and Department of Internal Medicine, Henry Ford Health System Bret Stevens, BS Medical Education Accreditation Coordinator, Department of Graduate Medical Education, Henry Ford Hospital

Multidisciplinary Thyroid Biopsy Clinic at the University of Vermont—A Comprehensive Educational Experience Setting and Problem

Thyroid nodules are the most common endocrine tumor, with population-based studies identifying palpable nodules in approximately 5% of adults. Nikhil Goyal, MD Ultrasound and autopsy studies have demonstrated Program Director, Transitional Year Residency and that more than 50% of women and more than 20% of Director of Emergency Medicine Informatics, Department of Emergency Medicine and Department men over the age of 50 have a thyroid nodule. It also is estimated that more than 450 000 thyroid biopsies are of Internal Medicine, Henry Ford Health System performed each year in the United States. Given the expanded availability and subsequent use of imaging Corresponding author: Gregory Hermann, MD, technologies to identify thyroid nodules, the frequency MPH, Henry Ford Hospital, CFP 142, 2799 West Grand Boulevard, Detroit, MI 48202, 313.916.2889, of thyroid biopsies is a patient care issue, and the cost associated with them is a significant health care [email protected] expenditure. An efficient, cost-effective strategy for the evaluation of thyroid nodules is an important quality of care goal. Because ultrasound-guided fine needle aspiration (FNA) remains the procedure of choice in the evaluation of thyroid nodules, there is an important need to provide a comprehensive educational experience to endocrinology and cytopathology fellows that ultimately leads to a reduction in repeat FNA and unnecessary surgery.

Intervention The University of Vermont College of Medicine’s Division of Endocrinology and Diabetes and DepartDOI: http://dx.doi.org/10.4300/JGME-D-15-00597.1

448

Journal of Graduate Medical Education, July 1, 2016

NEW IDEAS

ment of Pathology and Laboratory Medicine collaborated to design a novel Multidisciplinary Thyroid Biopsy Clinic (MTBC). This clinic improves the educational experience of endocrinology and cytopathology fellows by providing immediate feedback through rapid on-site evaluation (ROSE) of FNA specimens. Prior to implementation of the MTBC, ultrasound-guided FNA of thyroid nodules was performed during endocrine fellows’ continuity clinics, and specimens were sent to the pathology department for review. A key component of the MTBC was the formation of a separate thyroid biopsy clinic. Each MTBC is staffed by an endocrine fellow, an attending endocrinologist, a cytopathology fellow, and an attending cytopathologist, all of whom see multiple patients. The MTBC format provides an endocrine and cytopathology fellow the opportunity to perform multiple biopsies—a maximum of 3 initial passes for each patient—that are evaluated on-site immediately and assessed for quality of technique and adequacy of the specimens.

pathology fellows (and vice versa), with each discipline providing a unique perspective to patient care, specimen preparation, and triage. The MTBC model could be adopted in other multidisciplinary clinic settings or procedures, such as central line placement by critical care, surgery, and medicine residents, and in biopsy procedures involving interventional radiologists and pathologists. Expanding multidisciplinary education, as evidenced by the MTBC, enhances trainee education and improves patient care. Matthew P. Gilbert, DO, MPH Associate Professor of Medicine and Program Director, Endocrine Fellowship Program, Division of Endocrinology and Diabetes, University of Vermont College of Medicine Madiha M. Alvi, MD Assistant Clinical Professor of Medicine, Bassett Medical Center

Joel J. Schnure, MD Professor of Medicine and Division Chief, Division of Outcomes to Date Endocrinology and Diabetes, University of Vermont We performed retrospective chart reviews 2 years College of Medicine before and 2 years after instituting the MTBC. Secondary analyses of surgical rates and cost were also Muriel H. Nathan, MS, MD, PhD completed. After implementation of the MTBC and Professor of Medicine, Division of Endocrinology and ROSE, the rate of nondiagnostic thyroid FNA biopsies Diabetes, University of Vermont College of Medicine in endocrinology fell from 24% prior to MTBC to 5% after (P , .001), resulting in more definitive cytopa- Michael J. DeSarno, MS thology reports and reduced repeat aspirations. There Research Biostatistician, Department of Medical was a concordant increase in the diagnosis of benign Biostatistics, University of Vermont nodules, from 48% to 78% (P , .001). The size of nodules biopsied in the MTBC was smaller when Scott R. Anderson, MD compared to the nodules biopsied at the endocrine Associate Professor and Program Director, Pathology clinic prior to the MTBC (mean size, 19.94 mm Residency Program, Department of Pathology and compared to 23.63 mm; P , .001), and there was a Laboratory Medicine, University of Vermont College decrease in surgical referrals after nondiagnostic of Medicine cytopathology (from n ¼ 20 [21%] to n ¼ 0). Development of the MTBC was primarily driven by Corresponding author: Matthew P. Gilbert, DO, the desire to better educate both endocrine and MPH, University of Vermont College of Medicine, cytopathology fellows in the technique of ultra- 62 Tilley Drive, South Burlington, VT 05403, sound-guided FNA, adequate preparation of FNA 802.847.4576, fax 802.847.2226, samples, and management of thyroid nodules. It has [email protected] achieved that goal, as demonstrated by the decrease in nondiagnostic FNA biopsies and the increase in the fellows’ ability to successfully biopsy smaller nodules. In addition, the MTBC has also resulted in a significant improvement in patient care and lower health care costs due to reduction in repeat FNA biopsies and surgical referrals. While it is often not typical to train across specialties, we have seen tremendous educational and quality benefits in having endocrinologists train Journal of Graduate Medical Education, July 1, 2016

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Multidisciplinary Thyroid Biopsy Clinic at the University of Vermont-A Comprehensive Educational Experience.

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