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Triaging Admissions: A Survey of Internal Medicine Resident Experiences and Perceptions and Recommendations on Inpatient Triage Education

  • Emily S. Wang
    Correspondence
    Requests for reprints should be addressed to Emily S. Wang, MD, Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229.
    Affiliations
    Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio

    South Texas Veterans Health Care System, Medicine Service, San Antonio
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  • Sadie Trammell Velásquez
    Affiliations
    Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio

    South Texas Veterans Health Care System, Medicine Service, San Antonio
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  • Michael Mader
    Affiliations
    Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio

    South Texas Veterans Health Care System, Medicine Service, San Antonio
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  • Joel C. Boggan
    Affiliations
    Department of Medicine, Duke University School of Medicine, Durham, NC
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  • Jeff E. Liao
    Affiliations
    Division of Hospital Medicine, Massachusetts General Hospital, Boston
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  • Luci K. Leykum
    Affiliations
    South Texas Veterans Health Care System, Medicine Service, San Antonio

    Department of Medicine, University of Texas at Austin Dell Medical School
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  • Jacqueline Pugh
    Affiliations
    Department of Medicine/Division of Hospital Medicine, University of Texas Health San Antonio

    South Texas Veterans Health Care System, Medicine Service, San Antonio
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  • Triagist Collaborative Group
    Author Footnotes
    1 TRIAGIST Collaborative Group: Maralyssa Bann MD, Andrew White MD (University of Washington), Jagriti Chadha, MD (University of Kentucky), Joel Boggan MD, MPH (Duke University), Sherwin Hsu MD (UCLA-Olive View), Jeff Liao MD (Massachusetts General Hospital), Tabatha Matthias DO (University of Nebraska Medical Center), Tresa McNeal MD (Scott and White Texas A&M), Roxana Naderi MD, Khooshbu Shah MD (University of Colorado), David Schmit MD, Sadie Trammell Velásquez MD, Emily S. Wang MD (University of Texas Health San Antonio), Manivannan Veerasamy MD (Michigan State University).
  • Author Footnotes
    1 TRIAGIST Collaborative Group: Maralyssa Bann MD, Andrew White MD (University of Washington), Jagriti Chadha, MD (University of Kentucky), Joel Boggan MD, MPH (Duke University), Sherwin Hsu MD (UCLA-Olive View), Jeff Liao MD (Massachusetts General Hospital), Tabatha Matthias DO (University of Nebraska Medical Center), Tresa McNeal MD (Scott and White Texas A&M), Roxana Naderi MD, Khooshbu Shah MD (University of Colorado), David Schmit MD, Sadie Trammell Velásquez MD, Emily S. Wang MD (University of Texas Health San Antonio), Manivannan Veerasamy MD (Michigan State University).

      Keywords

      Perspectives Viewpoints
      • Of the Internal Medicine (IM) academic medical centers surveyed, 2 had dedicated triage training and only one of these sites required triage training.
      • Most IM residents believe triaging inpatient admissions is important for future practice and believe there should be dedicated curricula for triaging, 88% and 87%, respectively.
      • Triage training should focus on Accreditation Council for Graduate Medical Education Internal Medicine Milestones 2.0, with an emphasis on systems-based knowledge and interpersonal communication aimed at conflict resolution.

      Introduction

      Transitions of care (TOCs) have been identified as critically important for patient safety. The Joint Commission Center for Transforming Healthcare, World Health Organization, and national societies have emphasized the importance of TOCs.

      The Joint Commission. Podcasts: Take 5: understanding transitions of care. Available at: https://www.jointcommission.org/resources/news-and-multimedia/podcasts/take-5-understanding-transitions-of-care/. Accessed February 10, 2022.

      ,

      World Health Organization. Technical series on safer primary care: transitions of care. December 2016. Available at:https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599-eng.pdf. Accessed February 10, 2022.

      The literature on TOCs has focused on inpatient to outpatient transitions, and handovers within the hospital.
      • Snow V
      • Beck D
      • Budnitz T
      • et al.
      Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine.
      Inpatient to outpatient TOCs emphasize communication at discharge and medicine reconciliation to prevent adverse events and readmissions.
      • Hesselink G
      • Schoonhoven L
      • Barach P
      • et al.
      Improving patient handovers from hospital to primary care: a systematic review.
      In contrast, the process of admitting patients from outpatient to inpatient settings has only recently begun to receive attention. Traditionally, primary care and specialty physicians admitted their own patients to the hospital. With the increasing complexity of health care systems and separation of the outpatient and inpatient settings, this transition is generally managed by an inpatient physician/hospitalist or a “triagist.”
      • Velásquez ST
      • Wang ES
      • White AA
      • et al.
      Hospitalists as triagists: description of the triagist role across academic medical centers.
      • Amick A
      • Bann M
      Characterizing the role of the "triagist": reasons for triage discordance and impact on disposition.
      • Wang ES
      • Velásquez ST
      • Smith CJ
      • et al.
      Triaging inpatient admissions: an opportunity for resident education.
      The increased complexity and siloing of clinicians is even more pronounced in medical schools and teaching hospitals,
      • Sharma G
      • Fletcher KE
      • Zhang D
      • Kuo YF
      • Freeman JL
      • Goodwin JS
      Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults.
      which typically care for the most complex patients, whose care requires diagnostic and therapeutic services not readily available throughout the community.
      • Sharma G
      • Fletcher KE
      • Zhang D
      • Kuo YF
      • Freeman JL
      • Goodwin JS
      Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults.
      The presence of learners who rotate between services also contributes to care discontinuities.
      • Vidyarthi AR
      • Arora V
      • Schnipper JL
      • Wall SD
      • Wachter RM
      Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.
      For medical patients, assessing patients for admission had traditionally been done by the on-call internal medicine resident; however, this function is now increasingly performed by faculty physicians or dedicated triagists.
      • Velásquez ST
      • Wang ES
      • White AA
      • et al.
      Hospitalists as triagists: description of the triagist role across academic medical centers.
      Several factors have influenced this shift: the growth of hospital medicine, changes to residency such as duty hour restrictions, increased attention on admission appropriateness, and efficiency of patient flow.
      With this shift in the admission process, a potential gap in internal medicine resident education has emerged. Much of the TOC education for residents has been on the inpatient to outpatient transitions.
      • Vidyarthi AR
      • Arora V
      • Schnipper JL
      • Wall SD
      • Wachter RM
      Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.
      • Carnahan JL
      • Fletcher KE
      Discharge education for residents: a study of trainee preparedness for hospital discharge.
      • Aboumatar H
      • Allison RD
      • Feldman L
      • Woods K
      • Thomas P
      • Wiener C
      Focus on transitions of care: description and evaluation of an educational intervention for internal medicine residents.
      The transition from the outpatient to the inpatient setting and the process of triaging inpatient admissions are unique educational opportunities for internal medicine resident education that could encompass clinical assessment, but also systems-knowledge specific to this TOC.
      • Wang ES
      • Velásquez ST
      • Smith CJ
      • et al.
      Triaging inpatient admissions: an opportunity for resident education.
      We sought to assess resident experiences and perceptions in the role of triaging inpatient admissions and define areas of potential curricular opportunities.

      Methods

      Ten nationally diverse medical schools were recruited from the research committee session at the 2014. Society of Hospital Medicine national meeting and the 2014 Society of General Internal Medicine southern regional meeting. Site representatives were identified and completed questionnaires about their medical schools.
      • Velásquez ST
      • Wang ES
      • White AA
      • et al.
      Hospitalists as triagists: description of the triagist role across academic medical centers.

      Setting and Participants

      We collected data from internal medicine residents at 10 medical schools beginning in January 2018. Program size ranged from 25 to 50 residents (3 programs), 51 to 75 residents (one program), 76 to 100 residents (3 programs), to more than 100 residents (3 programs). At each site, faculty served as site representatives. A prior publication describes participating sites.
      • Velásquez ST
      • Wang ES
      • White AA
      • et al.
      Hospitalists as triagists: description of the triagist role across academic medical centers.

      Survey Development

      We used the demographic information obtained from each school and information from a pilot study at one school to develop a survey to assess resident views, attitudes, and perceptions about the triagist role. The initial survey was sent to all site representatives and modified through iterative discussion and refinement. This survey was piloted at a single site to assess for ease of use.
      The first portion of the survey requested respondent demographic information: postgraduate year (PGY), age, sex, training program and hospitals, and career plans after residency. The remainder of the survey asked about experience/exposure to triaging; attitudes toward triage work and need for triage training; interprofessional relationships; systems-based practice; and qualities of an effective and ineffective triagist. Experience questions were single answer, while qualities of effective triagists allowed open-ended answers. The questions were assessed using a 5-point Likert scale ranging from strongly agree to strongly disagree. Questions on resident exposure and experience to the triagist role include whether the experience was during medical school or residency training and during what type of rotation. Resident perceptions of triage training during residency included whether their program had a specific triage curriculum.

      Survey Administration

      We sent surveys to 1057 internal medicine residents. Contact information was provided by each site representative. Residents received the survey by e-mail (Appendix). Responses were anonymous, but non-responders were tracked by the survey system and received up to 5 reminder e-mails. The survey was administered in January 2018 and was made available for 6 weeks. Respondents who submitted incomplete surveys were sent an e-mail reminder to complete the survey. If at least 70% of the survey questions were completed by a respondent, those answers were included in the analysis.

      Data Analysis

      Quantitative

      Survey responses for Likert items were collapsed into 3 categories (agree, neutral, disagree), and the distribution of responses was calculated for each question within PGY groups. We combined the small number of PGY-4s with PGY-3s. The Chi-squared test was used to evaluate differences across year groups.

      Qualitative

      Responses to open-ended questions were analyzed using thematic analysis.
      • Braun V
      • Clarke V
      Using thematic analysis in psychology.
      Three authors read and analyzed responses; codes were developed based on response content. Codes were assessed for similarities or overlap, then grouped into themes by the reviewers. A table of the themes with supporting quotes was subsequently agreed upon by all 3 authors. Themes were organized into domains from the data and the literature. These domains were described and reviewed by site representatives to create a consensus description.
      The University of Texas Health San Antonio Institutional Review Board approved the study as exempt.

      Program Evaluation Results

      Site Resident Triage Experience and Curriculum Characteristics

      Residents performed triagist or admission point-of-contact roles at 2 hospitals, and one was a required rotation. All residents reported having triaging responsibilities during the inpatient medicine, intensive care, and night float rotations. Five programs had a formal orientation to triagist activities: 4 were verbal orientation on the first day of service and one was written. Two programs had a specific curriculum dedicated to triaging. One of these included mandatory triage training during the required hospital medicine rotation.

      Survey Results

      The survey response rate was 31% (n = 332). Three hundred thirty-two residents responded, with 306 completing all questions. Fifty percent of respondents self-identified as female and 50% as male.

      Resident Survey Results

      Twenty-one percent of respondents planned to be a hospitalist, 54% to specialize or apply to a fellowship, 14% to go into primary care, and the remaining 11% were undecided. Among those planning to be a hospitalist, 46% reported an interest in an academic career, and 30% were undecided. Sixteen percent of respondents reported exposure to the triagist role as a medical student, and 72% reported experience triaging during residency. Among PGY-3 or PGY-4 respondents, 96% reported they had some experience with triaging during residency in the form of a ward resident, intensive care unit rotation, or on a hospital medicine rotation. Eighty-eight percent of all residents believe triaging experience is important for future practice. Most (87%) believed there should be specific resident triaging curricula, and most residents (95%) believed triaging efficiency requires experience or on-the-job training. Despite these exposures, many residents do not feel adequately trained in the skills required for triaging and report anxiety specific to the role. Residents report having different opinions about patient management, and from PGY-1 to PGY-3 or -4, a decreasing minority report positive relationships with the emergency department (Table 1).
      Table 1Resident Survey Results by Postgraduate Year (PGY)
      StatementResponsePGY-1PGY-2PGY-3 & 4P Value
      I had adequate training in triaging during residency.Agree17%27%58%< .0001
      Neutral46%25%20%
      Disagree37%48%22%`
      I enjoy triage work.Agree37%44%42%0.25
      Neutral52%38%38%
      Disagree11%18%20%
      I prefer triage work to other residency roles.Agree8%7%12%0.28
      Neutral45%33%41%
      Disagree47%60%47%
      When I am triaging, I am more nervous compared with other roles as a resident.Agree28%48%50%0.003
      Neutral47%24%23%
      Disagree25%28%27%
      When triaging, I frequently have differing opinions regarding patient management.Agree26%29%42%0.17
      Neutral50%46%38%
      Disagree24%25%20%
      A patient must meet criteria for admission to be admitted.Agree87%69%63%0.003
      Neutral7%16%15%
      Disagree7%15%22%`
      The relationship between hospitalists and emergency department providers is positive in my health care system.Agree60%47%30%< .0001
      Neutral25%36%31%
      Disagree15%17%39%
      I have a positive relationship with the emergency department providers.Agree66%68%61%0.49
      Neutral28%24%27%
      Disagree6%8%12%

      Thematic Analysis

      We received 244 responses (73%) to the question “What qualities does an effective triagist have?”. We identified themes related to effective triagist qualities, and themes were grouped into 7 domains (Table 2). Selected quotes were included. To facilitate development of a curriculum that would support the growth of effective triagist skills, we mapped Accreditation Council for Graduate Medical Education Internal Medicine Milestones 2.0 to the domains.

      Accreditation Council for Graduate Medical Education. Internal medicine milestones. Available at: https://www.acgme.org/Portals/0/PDFs/Milestones/InternalMedicineMilestones2.0.pdf?ver=2020-12-02-124816-380. Accessed February 10, 2022.

      All themes were mapped to existent subcompetencies. The level of the milestone selected is based, by the authors, on the minimum skill set necessary to practice independently as a triagist.
      Table 2Thematic Analysis of Comments from “What Qualities Does an Effective Triagist Have?”
      Domains and DefinitionsThemesRepresentative QuotesMilestones 2.0
      Accreditation Council for Graduate Medical Education Internal Medicine Milestones 2.0. Milestones Level 1 (novice) to 5 (expert).
      Communication, negotiation, interpersonal skills:

      This domain encompasses collaborative interpersonal interactions.
      Effective communicator, Collaborative, Diplomatic, Respectful, Flexible, Receptive, Available“Communication, excellent clinical knowledge, trust from the ED providers”

      “Able to be polite but firm when consultants who may be pushy or want inappropriate admissions.”

      “Ability to convince others of their thought process without being argumentative or causing others to feel defensive.”
      ICS 1: Level 3

      ICS 2: Level 5

      ICS 3: Level 4
      Organizational skills:

      This domain encompasses effective use of time.
      Efficient, Able to multi-task, Decisive, Able to prioritize, Thorough“Ability to plan strategically. Calm communication. Empathy. Knowledge of protocols and reasons for said protocols. Efficiency in mining data from the EMR.”

      “The ability to quickly glean the most important information from the chart and make a decision…”
      SBP 2: Level 4

      Prof 3: Level 3
      Systems and utilization management knowledge:

      This domain encompasses getting things done in the healthcare system.
      Different levels of care, Different floor/service capabilities, Understands local culture“Ability to take the facility/staffing constraints into appropriate consideration with triaging, but to not let those constraints dictate disposition when it is at odds with patient needs.”

      “Correctly identifying if a patient needs a higher level of care".
      PC 4: Level 4

      SBP 2: Level 4

      SBP 3: Level 2
      Attitudes (Personal qualities/attributes):

      This domain encompasses patient-centeredness.
      Advocacy, Patient-Centered, Problem solver, Empathic, Functions well under stress“Able to advocate effectively for the patient in a collegial manner with physician colleagues to ensure patient is appropriately placed.”

      “Always thinking about patient first and what would be best for them.”

      “They should be diplomatic and build connections between services.”

      “Able to be a good ambassador to patients—the triagist is the first representative from the inpatient services that the patient will meet; if they alienate the patient, it makes it harder for the admitting team to establish a good relationship.”
      PBLI 1: Level 4

      Prof 4: Level 4

      ICS 1: Level 3
      Medical skills:

      This domain encompasses medical and clinical judgement.
      Synthesizes data well, Recognizes acuity, Anticipates illness trajectory/course, Clinically astute, Assesses patient independently“Being willing to see the patient if there are any disagreements.”

      “Able to think of the big picture plan."
      PC 1: Level 4

      PC 3: Level 4

      PC 4: Level 3

      PC 2: Level 2

      MK 1: Level 4

      MK 2: Level 3

      MK 3: Level 3
      Experience:

      This domain encompasses time and repeated observation in an activity.
      Does not anchor, recognizes acuity, Anticipates illness course, Asks appropriate questions, Understands when safe to discharge, Facilitates appropriate workup prior to admission“Being able to keep an open mind and run with multiple possible diagnoses, particularly ruling out the most dangerous and time sensitive ones first.”

      “Being able to see the trajectory of the patient.”

      “Understands the limitations of both the ED and the medicine ward, and so is able to anticipate what needs to get done prior to transfer to the floor vs what can wait.”
      PC 1: Level 4

      PC 3: Level 4

      PC 4: Level 2

      PC 5: Level 4

      MK 1: Level 4

      MK 2: Level 3

      MK 3: Level 3

      PBLI 1: Level 3

      ICS 3: Level 4
      Professionalism:

      This domain encompasses personal qualities and traits
      Approachability/ Friendliness, Calmness, Patience, Professional, Fair, Confident, Polite“Compassion for the consulting team”

      “Respectful of other providers, isn't pushy, but takes into consideration differing opinions.”
      Prof 1: Level 4

      Prof 3: Level 3
      ICS = Interpersonal and Communication Skills; MK = Medical Knowledge; PBLI = Practice-Based Learning and Improvement; PC = Patient Care; Prof = Professionalism; SBP = Systems-Based Practice.
      low asterisk Accreditation Council for Graduate Medical Education Internal Medicine Milestones 2.0. Milestones Level 1 (novice) to 5 (expert).

      Discussion

      We assessed resident perceptions of the triagist role at 10 medical schools. Approximately 90% of residents believe that triaging is an important area of training, regardless of future career plans. Despite being perceived by residents as a necessary skill set, only one program had a dedicated triagist rotation; 7 programs had some triaging on other rotations, and 2 reported little to no exposure. Residents did not feel that outpatient practice contributed to the knowledge needed for the triaging role. This finding was a surprise because we had hypothesized that skills to assess appropriateness for admission could be developed in the outpatient setting. The importance residents place on the triagist skill set, coupled with the lack of formal experiences or curricula, lead us to conclude that more attention should be paid to how this skill set is taught during internal medicine residency, either through dedicated rotations or more explicit incorporation of these experiences into existent rotations. Mastering these skills is increasingly important, as the triage physician role has become increasingly common.
      • Velásquez ST
      • Wang ES
      • White AA
      • et al.
      Hospitalists as triagists: description of the triagist role across academic medical centers.
      ,
      • Amick A
      • Bann M
      Characterizing the role of the "triagist": reasons for triage discordance and impact on disposition.
      ,
      • Panahpour Eslami N
      • Nguyen J
      • Navarro L
      • Douglas M
      • Bann M
      Factors associated with low-acuity hospital admissions in a public safety-net setting: a cross-sectional study.
      While the majority of PGY-3s and PGY-4s reported feeling adequately trained for triaging activities, they also felt increasing anxiety about the role, which suggests gaps in their educational experience. We hypothesize that these gaps are in 2 areas. First, systems-based knowledge is critical to the role of the triagist. Systems knowledge is often implicit, and learning it is grounded in spending time in specific clinical settings. While residents integrate some systems-based knowledge during their rotations, they may not have sufficient implicit systems-based knowledge to navigate movement of patients across multiple settings. In many internal medicine rotations, the residents are “siloed” to a specific team or service, such as caring for patients already admitted to the hospital. In contrast, triaging skills require operating at the intersection of multiple clinical services and understanding capabilities/limitations of each local system as well as practices around admissions.
      • Velásquez ST
      • Wang ES
      • White AA
      • et al.
      Hospitalists as triagists: description of the triagist role across academic medical centers.
      This implicit knowledge could inform a triagist-specific curriculum, and could be mapped to System-Based Practice 3: Physicians Role in the Health Care System–Level 2: “Describe how components of a complex health care system are interrelated, and how this impacts patient care.”

      Accreditation Council for Graduate Medical Education. Internal medicine milestones. Available at: https://www.acgme.org/Portals/0/PDFs/Milestones/InternalMedicineMilestones2.0.pdf?ver=2020-12-02-124816-380. Accessed February 10, 2022.

      The second potential gap encompasses collaborative conflict management and negotiation skills, specifically, the subcompetency of “Interpersonal and Communication Skills 2: Interprofessional and Team Communication.”

      Accreditation Council for Graduate Medical Education. Internal medicine milestones. Available at: https://www.acgme.org/Portals/0/PDFs/Milestones/InternalMedicineMilestones2.0.pdf?ver=2020-12-02-124816-380. Accessed February 10, 2022.

      The decision to admit from the emergency department can be complex and a source of conflict/disagreement. A better understanding of different priorities between emergency medicine and internal medicine physicians, such as stabilization and disposition vs making a diagnosis, may decrease potential conflict. Leaders in both disciplines have called for interprofessional collaboration, but the data suggest that relationships across specialties have continued room for growth.
      • Beach C
      • Cheung DS
      • Apker J
      • et al.
      Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach.
      ,
      • Pollack Jr, CV
      • Amin A
      • Talan DA
      Emergency medicine and hospital medicine: a call for collaboration.
      A recent study by Amick and Bann
      • Amick A
      • Bann M
      Characterizing the role of the "triagist": reasons for triage discordance and impact on disposition.
      found that triage admission discordance is “prevalent,” and most pronounced with non-medicine services. Based on qualitative analysis, our residents identify effective triagists as “approachable, flexible, collaborative, diplomatic, fair”; therefore, the subcompetency of Interpersonal and Communication Skills 2, “facilitate conflict resolution between and amongst consultants when disagreement exists,” should not be designated an aspirational milestone Level 5 in this core competency.

      Accreditation Council for Graduate Medical Education. Internal medicine milestones. Available at: https://www.acgme.org/Portals/0/PDFs/Milestones/InternalMedicineMilestones2.0.pdf?ver=2020-12-02-124816-380. Accessed February 10, 2022.

      Rather, the goal should be to educate residents to expect disagreement, seeing it as an opportunity for growth in collaboration and shared decision-making. Faculty physicians in the triagist role need to model effective interactions for residents. In addition, there are opportunities to create training tools and assessments targeted to the subcompetencies.
      This study has limitations. Our participating schools were not randomly chosen and may not be reflective of all medical schools. However, they represent a broad array of facility types, group sizes, and geographic regions.
      • Velásquez ST
      • Wang ES
      • White AA
      • et al.
      Hospitalists as triagists: description of the triagist role across academic medical centers.
      Although our resident response rate was lower at 31%, we feel the even distribution across PGYs provided depth and breadth to the data obtained. Additionally, there is a difference in number of residents responding from each school, due to a combination of size of residency and the response rate. Those institutions with more responses did influence the overall percentages shown in Table 1, but the trend across years of training was not driven by number of responses per site. Our data are also based on self-reporting and could be subject to recall bias. Although our quantitative analysis was organized into defined themes and subsequent domains, we recognize that there is overlap in the themes and domains.

      Conclusion

      At 10 medical schools, resident learners identify the need for education in triaging skills. Consistent standards for curricula and rotations have not been created, leading to educational gaps and increasing levels of anxiety as residents progress through training. We recommend an emphasis on systems-based knowledge with a focus on local contextual considerations, and interpersonal communication aimed at conflict resolution and collaboration.

      Appendix Resident Survey of Triaging Role

      References

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      2. World Health Organization. Technical series on safer primary care: transitions of care. December 2016. Available at:https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599-eng.pdf. Accessed February 10, 2022.

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        Hospitalists as triagists: description of the triagist role across academic medical centers.
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        Characterizing the role of the "triagist": reasons for triage discordance and impact on disposition.
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