High-Volume, High-Acuity, and High-Impact Learning: Tips and Tricks for Infectious Diseases Training Programs

Abstract The Infectious Diseases Society of America Training Program Directors Committee met in October 2022 and discussed an observed increase in clinical volume and acuity on infectious diseases (ID) services, and its impact on fellow education. Committee members sought to develop specific goals and strategies related to improving training program culture, preserving quality education on inpatient consult services and in the clinic, and negotiating change at the annual IDWeek Training Program Director meeting. This paper outlines a presentation of ideas brought forth at the meeting and is meant to serve as a reference document for infectious diseases training program directors seeking guidance in this area.

The annual IDWeek Fellowship Training Program Director meeting allows program directors to exchange ideas to tangibly improve their programs."High-Volume, High-Acuity, and High-Impact Learning: Tips and Tricks for ID" was selected as the theme in 2022.The Program Directors Committee members identified 4 subtopics via consensus: improving program culture, negotiating change, and maintaining educational priorities in outpatient and inpatient settings.Attendees heard presentations, engaged in discussion, then reported on consensus discussion points, common challenges, and specific actionable items.Summary meeting notes formed the foundation for this manuscript.While there are no perfect solutions, this article offers potential strategies for programs to consider.

WHY IS PROGRAM CULTURE IMPORTANT? WHAT CAN PROGRAMS DO TO IMPROVE CULTURE?
The Accreditation Council for Graduate Medical Education (ACGME) recognizes the link between program culture and trainee well-being and stipulates that programs are responsible for trainee wellbeing by promoting self-care and maintaining a positive culture [1].The culture within training programs encompasses values, attitudes, and behaviors that shape learning environments, with "sociable working environment" cultures preferred by trainees [2].Potentially modifiable barriers to wellness and opportunities to improve culture include a lack of control over time; inconsistent, unfriendly, or unhealthy work environments; lack of wellness initiatives; and lack of space to recharge or reflect [3].Positive work environments require investment from leadership, faculty, and trainees alike as inconsistencies between institutional messaging and practice can result in frustration [1].Gestures of mutual respect are vital to program culture and can include allowing fellow input into oncall scheduling as well as advocating for improved workspaces.Trainee involvement in developing, evaluating, and assessing interventions is crucial, and those initiatives driven by trainees may be most effective [4].Frequent feedback sessions with fellows and leadership on initiatives should be planned to guide continuous workplace improvement.Healthy workplace culture requires attention to work-life integration, and programs can implement changes to positively influence this balance, including adjusting conference times to align with workflow, attending coverage of pager calls during dedicated educational time, and rotating presentation responsibilities among fellows and faculty.Programs should solicit trainee input on desired activities and consider hosting social events not tied to Open Forum Infectious Diseases

Teaching strategies a
Develop chalk talks or mini-lectures to teach on common topics [5] One-minute preceptor model that provides a framework for efficient delivery of real-time clinical pearls and "bite sized" education while also soliciting the learner's perspective [6] Signposting  6) select a case-related issue for self-directed learning [7] Attending supplied literature postrounding to supplement clinical discussions Modify your teaching approach based upon time available [8] Attending or fellow provides one article per week for team for

WHAT STRATEGIES CAN BE USED TO MANAGE VOLUME AND INCREASE TIME FOR EDUCATION ON THE INPATIENT CONSULT SERVICES?
High patient volumes negatively impact education, and implementation of census limits or "caps" in internal medicine residency programs are associated with improved resident well-being, duty hours, and conference attendance [10,11].While uniform census caps exist for internal medicine residents, no such caps exist for ID fellows.As such, programs must determine best practices to manage inpatient consult volume with time for education.Table 1 details the methods that programs may consider to preserve the balance between volume and education.Rounding efficiency and teaching time are impacted by tasks that interrupt learning.Specifically, the impact of pages, calls, and messages warrants attention.Programs may consider utilizing nurses, advanced practice clinicians, or other staff to triage and route consults and calls.Primary teams may communicate consult requests through the electronic health record (EHR) rather than paging.System-wide procedures that address consult timing (ensuring consults are placed before a specific time) allow for more predictable workflow and teaching time during rounds.Programs may consider diverting some inquiries to pharmacists or stewardship teams.
The structure of rounds influences the balance between volume and education.Additional consult services or nonteaching teams represent one method to decrease fellow workload.These services may be fixed or may operate as an overflow service.
Strategies to incorporate regular teaching even when there are high clinical volumes include teaching in the context of specific patients rather than a set curriculum.Posting teaching points, discussing one article or guideline per day/week, incorporating board review questions or microbiology rounds, and summarizing key points after rounds are also effective strategies.Alternative learning platforms, including social media, podcasts, and virtual learning modules, can be incorporated during or outside of rounds.

WHAT AMBULATORY EXPERIENCES AND STRATEGIES CAN BE USED TO OPTIMIZE OUTPATIENT ID TRAINING?
Outpatient experiences and education are integral components of comprehensive ID training.Various ambulatory models exist and include weekly or biweekly clinics and ambulatory blocks that vary in duration.Dedicated outpatient rotations can provide focused experience in subspecialty ID clinics (transplant, hepatology, travel/tropical medicine, orthopedics, sexually transmitted infections, and outpatient parenteral antimicrobial treatment [OPAT]).
While participating in these clinics offers experiential learning, outpatient training should complement focused education, including case-based learning and didactics.Teaching content should include the evaluation and management of patients with known or suspected infections in ambulatory settings as well as strategies to optimally use the EHR, coordinate care in interprofessional healthcare teams, and communicate with patients and families.
High clinical volumes, pressure to maintain work relative value unit outputs, and lack of adequate support limit time for teaching.Logistical barriers may exist, such as commuting to ambulatory clinical sites and sharing resources (eg, computer terminals, examination rooms, and workspaces) with other healthcare team members.Addressing outpatient messages and clinical documentation while balancing education and other requirements can be challenging as well.Strategies to optimize outpatient education are delineated in Table 1.

HOW SHOULD PROGRAM DIRECTORS APPROACH NEGOTIATING CHANGE WITH LEADERSHIP?
Negotiating support for substantive changes in ID fellowships should begin a Teaching strategies may be appropriately applied to either the inpatient or outpatient setting and are not necessarily exclusive or universally applicable.
by assessing the needs of specific stakeholders: fellows, faculty, patients, divisions, and healthcare systems (Table 2).
Programs should determine what support is needed and from whom.Such assessments require data on consult volume, workflow, and duty hours and metrics on patient safety, quality and satisfaction, and provider quality of life and burnout.Needs can be further classified as perceived, expressed, or relative to those of peer programs.
It is important to recognize that these needs may be shared nationally [12,13].Furthermore, fellows look to faculty for support; however, faculty themselves must be adequately supported [14].Therefore, addressing the needs of the fellowship requires a partnership with faculty and leadership to advocate for better resources, compensation, and promotion including outside the training program setting [14][15][16].
If resources external to the division are required, advocacy lessons can be drawn from antimicrobial stewardship and OPAT.These programs promote opportunities for increased revenue and costsavings (eg, shorter lengths of stay), while improving patient care and treatment outcomes [17][18][19].Furthermore, leveraging partnerships with clinical services with high utilization rates to negotiate salary support may be effective.To effectively advocate for resources, clinical programs must demonstrate their impact on patient quality, safety, and financial metrics [20].Aligning requests for resources with overall goals of the organization and executive leadership is essential.

CONCLUSIONS AND FUTURE DIRECTIONS
Increased volume and acuity of clinical ID services have the potential to impact fellows' education negatively.Implementing specific structural and cultural programmatic changes with support from leadership and stakeholders can mitigate these impacts, preserve an appropriate balance between clinical service and education, enhance fellow well-being, and potentially strengthen the ID workforce.

Table 2 . Needs Assessment Worksheet
Set expectations with faculty that over the lunch hour on the last day of service, attending and fellow have lunch together and provide 15 min for feedback session Educational content Minimal teaching on healthcare disparities in the core curriculum Set expectation that every faculty speaker at a didactic teaching session incorporates how their topic is influenced by, or influences health disparities Diversity and inclusion Lack of engagement from fellows in DEI efforts Develop a "fellowship arm" or representative to the DEI committee for the program Clinical experience and education Surpassing 80-h work week Develop assessment of which services lead to work hour violations and revisit structure to identify how fellow time can be better supported Fellow well-being Fellows reporting high levels of burnout Use listening sessions between fellows and program leadership to identify main stressors for fellows, and develop strategies to address these causes of burnout Potential data sources: Accreditation Council for Graduate Medical Education survey, internal survey (institution-wide or unique to program), informal regional or peer program survey, Training Program Directors' Committee, and list-serv.