 Next, we have our first tag team approach to QI, and we have Brandon, Tony, and Lydia talking about transformation of the Moran intern year. You guys are going to make Brandon roll up here. All right, hey everyone, it's us three again. So this is a follow-up from our project from last year. All three of us are involved in changing our current intern year. It's gone through a lot of transformations over the past two years, and we've been really excited and we're moving into phase two. Last year was going to phase one, so I'm going to start off us off with just reintroducing what we've been doing, and then my colleagues here will take it up on what the changes have been, the results, and where we're going next. So just a review on our phase one approach. This really came about when we had this mandate saying that ophthalmology needs to have an integrated first year, and three months of that first year needs to be ophthalmology. We've had this for a really long time, but this mandate has made it so that every ophthalmology program in the country needs to be on this too. And so we saw this as an opportunity for us to also make changes, one to make our program competitive and also as still a place where other applicants now want to come because all programs are now offering this, but also as a way to improve ourselves. So it was a great opportunity to look at that and see what we could do to change. So when we presented this last year, we titled it, oh, we wanted to flatten the curve. This was really during the COVID time, and it was because we were going through our PGY two year, and we really noted that there's a really high learning curve. And for many decades, this was like what happened in ophthalmology. You did an intern year and you just came in PGY two and got flattened. And that was like supposed to be the status quo. But we thought, why don't we change this now that there's this integrated year? Can we make a smoother transition and make it easier for PGY twos to assimilate and make it a safer time for everyone and a better learning experience too? So this is where most of our focus has been. So we're gonna talk about some data here that Lydia will present. Yeah, yeah, I'll talk about kind of the current data later. But this is just what we got last year when we looked at the actual time that was spent in clinic. And we noted that a large chunk of the time that we had was spent with purely administrative work or H&Ps where we did not even see the patient or examine the patient and felt like that was not an optimal learning opportunity for the intern. And this is really cool props to Lydia because she collected all of this data herself without any prompt. And this is really just in a way to capture what was happening because we felt like we needed some improvement. And so after this, we started this whole project, Dr. Petty, Dr. Simpson, many other residents to help improve things. And first, we wanted to look at developing our curriculum and thinking of what are some places that we could work on. So we looked at first the console service and the triage clinic. And so we revised our schedule, built that in so that the VA intern could come over to the Moran and work in a triage clinic and along with the consults residents. So the first six weeks in triage Tuesday and Friday and then in the last six weeks there on consults. And there was a little nuance here where every other Tuesday they would have a half day and seven full day. But regardless, this was the current schedule. And so we asked last year's interns how they felt about all this. And so this is where we went into phase two. Thanks, Dr. Mai for the comprehensive review. So moving forward to phase two. So like Dr. Mai kind of said, we want to look at everything that we did. We want to look at the data which Dr. Sauer will present here shortly and also look at feedback from the interns based off of satisfaction regarding the changes and if any other changes need to be made. So back to kind of that data that I showed earlier. And I want to focus your attention on the numbers of the data or the time spent on clinical time. So seeing patients, writing notes, attending lectures, all of that. That was about 27 to 36% for our class. The current interns, I got feedback from three interns but two of them actually wrote down the numbers in minutes, how they spend their time. And this is the data on how it has changed. So I think this is a huge success. We went from kind of in the lower 30s numbers to the upper 80s of clinical time. And this is just incredible to see how this has changed and really transformed the intern year. So we were super stoked about this, very happy. But we thought, what if we can make it even better? So that was the idea of doing the survey. And what we did is we had a couple of questions. We asked the interns after these changes, please write the following on your experience with consults versus triage. So the two main changes we made in phase one. You can see here the mean in regards to autonomy, overall learning and diversity of pathology. They were all higher with the consult experience than the consult rotation versus the triage. So we kind of scratched our head and said, okay, well, maybe we should just do all consults. And that's the next question we asked. It would be more beneficial just to do both six weeks blocks on the consult service and a whopping four out of four said yes. And then we also asked another question, how comfortable do you feel performing each of the following? And then in regards to the ones that kind of stuck out to me, these would be the lower ones. So Peds consults 2.75, inpatient consults 3.75 and treasuring telephone calls. And there's all things that we do extensively in the consult service. So we thought that we could benefit these interns with more consult time. And lastly, all roads here lead to consults, as you can see. So just kind of highlighting, we asked the general question, how can we improve your overall experience? A lot of them basically just said more time on consults. So we snapped our fingers, bang, switched it over to consults. So now we have a revised, revised schedule where the interns are spending more time on consults less than triage or still some time on triage. And we're hoping that this will do the trick. Thank you, everybody. And thank you to the awesome team. Any questions? I also have a short comment on credit. So I think it's a great improvement for the first year residents. But who's doing the administrative work now? Well, thank you. So we were able to switch around some of the processes. A lot of time was spent intentionally on the H&P visits that were scheduled into our clinic. And they were like pure H&P visits where we were just doing the H&P for the patient without even really examining them. And that entire visit got completely cleared out. So if we go to that data set, like that whole, sorry. So the whole category of H&P without an atomic exam did not happen for any of the interns this year. And then a lot of the purely administrative work that still remains is making chief packets. I think anti-corregulation consults and placing certain things is still in that category. But what we are not doing anymore is scheduling all the follow-ups for all the patients, for all the surgeries, and doing a lot of the scheduling administrative work that came with the H&Ps, which is currently done by Jay, who's our new surgical administrator. So he took a large chunk of the administrative work. And then, yeah, the H&Ps are kind of not there anymore. Judith, that's a comment. I don't know how much it's going to play out as you go along. There's a tendency when you've gone through medical school and done your internship for everything to be very heavily weighted towards inpatient care, which is not at all the real-life experience of every other practicing ophthalmologist after they've finished their residency. And I guess I would wonder, I know that the inpatient consult service is very cool and interesting, but how well does that translate to your long-term sort of career experience? And I'm not sure if the PGY4s could sort of comment on that, the skills that you learn. A relevant piece of information, which is out of the scope of what they presented, is that we will now have a resident in triage every afternoon, not interns. And it's a really great point, you may, Judith, as far as the timing of when we're teaching things and being in triage versus on consults. And if I may sneak in at what I really suspect the answer here is they start out on consults for years as lone rangers now at Teresa Support straight away as just running the whole service in pediatrics and at the university. And that's such a significant burden to shoulder that that opportunity in the intern year to prep for that really has seemed to be the thing that's driven that strong desire to make sure they're prepared for consults, where they clearly are going to become experts in the other side of undifferentiated patients coming into the clinic. And then again, during chief year, now this is new, each afternoon we'll have a resident in triage the entire year. And that's, again, a new change. The comment I wanted to make during chief year. The comment that I wanted to make is just an overall comment to every one of the speakers so far. This residency is very much a living organism that thrives on you and your ideas and making it better. The VA is the perfect example of a bureaucracy where there are so many reasons why we can't make change, because so many things are really out of our hands. And I just have to give credit to you all, to Dr. Simpson and Griffin, Teresa, Catherine, Srav, all of you come in and just ask, how can we make this possible? I'm thinking back to even how we pay for you as residents, the fact that we're having you go over to the university while you're at the VA and how that could land Dr. Simpson in jail, for instance, if she didn't do it right, where she had this now, the glaucoma chief is going over. And that's a tremendous burden, administrative burden on leadership to be able to make these things happen. And anyway, it's incredibly heartening to see how many improvements you guys are making in the residency and caring enough to make it happen. Thank you.