The Jeremiah A. Barondess Fellowship in the Clinical Transaction: A Q and A with Dr. Brian Garibaldi
Since 2016, the ACGME and the New York Academy of Medicine (NYAM) have annually presented the Jeremiah A. Barondess Fellowship in the Clinical Transaction. This award for early-career faculty members in internal medicine was created to honor the visionary role of Jeremiah A. Barondess, MD, former NYAM president. It includes funding of $50,000 over two years and is intended to perpetuate Dr. Barondess’ dedication to the clinical transaction by inviting both clinical faculty members and medical students to participate in an ongoing program to preserve the integrity of the patient-physician relationship in the face of continuing change in the practice of medicine.
In 2016, Brian Garibaldi, MD, MEHP, FACP, FRCP (E) was awarded the inaugural Barondess Fellowship. Dr. Garibaldi is the Charles Horace Mayo Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the Northwestern University Feinberg School of Medicine, and the director of the newly established Center for Bedside Medicine. We asked Dr. Garibaldi to talk about the award and share its impact on his career.
ACGME: What prompted you to apply for the Jeremiah A. Barondess Fellowship in the Clinical Transaction?
Dr. Garibaldi: At the time the Barondess Fellowship was established, there were not many funding opportunities to focus on bedside clinical skills teaching and assessment. My mentor, Dr. Sanjay Desai, who was the program director of the Osler residency program at Johns Hopkins at the time, learned about the Fellowship through his own connection with Dr. Barondess (a former Osler residency alumnus!) and suggested I consider applying. I am so glad that I did!
ACGME: Can you tell us about your Barondess-supported project?
Garibaldi: My Barondess Fellowship[-supported project] focused on building a formative clinical skills assessment that used encounters with real patients with real findings on history and physical to understand where we are as a community with our bedside clinical skills, and to provide concrete feedback to both learners and faculty members to improve those skills. With the help of the Barondess Fellowship, we created the Assessment of Physical Exam and Communication Skills (APECS), which is now administered at three residency programs in the US, with plans to expand to several more this year. Through APECS, we have gathered a data set showing that physical exam technique and identifying physical findings are tightly linked and significantly associated with including the correct diagnosis on a differential (i.e., the physical exam is highly relevant in modern medicine). We have discovered several easily correctable and common mistakes in the physical exam that have informed both individual learning plans and programmatic initiatives to improve clinical skills. We have incorporated telemedicine and point-of-care technology, such as ultrasound, into the clinical encounter. We have also built a community of educators, in collaboration with the Society of Bedside Medicine, who are dedicated to research, education, and innovation on the role of the clinical encounter in 21st century medicine.
ACGME: Can you tell us about your experience applying for the Fellowship?
Garibaldi: The application itself was straight forward and made it clear that the selection committee was interested in the individual candidate as much as the actual project proposal.
ACGME: How do you view the future of medicine (or the future of the patient/physician relationship) and how does this project fits into either?
Garibaldi: I think we are a crossroads in medicine. Technological advancements have moved clinicians further and further away from the bedside. Our learners spend as little as 12 percent of their time in direct contact with patients and [patients’] families. This has led to a decline in fundamental skills, such as the physical exam, which can only be practiced in the presence of patients. And this decline has consequences in terms of both diagnostic error and the erosion of trust in the doctor-patient relationship. The alarming rise in stress and burnout among physicians, particularly [residents and fellows], is probably linked to the inordinate amount of time spent caring for the digital representation of a patient in the electronic health record (EHR; the so-called “iPatient”) and the lack of time spent caring directly for individuals. But I am an optimist. I think the road back to the bedside is through technology. Point-of-care devices, such as digital stethoscopes and ultrasound machines, have revolutionized the way we make diagnoses and teach traditional physical exam skills at the bedside. They also get learners incredibly excited to go to the bedside, where they are then able to appreciate the power of being “present” with their patients. Artificial intelligence (AI) will likely alleviate some of the administrative burdens of the EHR and allow physicians to spend more time engaging directly with patients. AI algorithms will also likely aid in asking the right questions during history-taking and directing physicians to select the appropriate diagnostic tests (including specific physical exam maneuvers) at the bedside. The current challenge is to figure out how to combine traditional talk and touch with newer tech to create the bedside of the future that works for patients and health care practitioners alike. Our new Center of Bedside Medicine at Northwestern is poised to tackle this issue.
ACGME: What has been the most rewarding part of the Barondess experience for you?
Garibaldi: The most rewarding part of the Barondess Fellowship has been the community created by the NYAM and ACGME around the program. I have greatly enjoyed getting to know Dr. Barondess and being able to share with him the successes of the Fellowship and to get his advice on how to tackle new challenges and opportunities. It has been a privilege to serve on the selection committee for the Fellowship for the last several years under the leadership of Dr. David Siscovick. The committee is a wonderfully diverse and talented group. I have also really enjoyed getting to know all the other Barondess Fellows.
ACGME: How important was the funding in helping you to focus on your project?
Garibaldi: The Barondess Fellowship directly led to our new Center of Bedside Medicine at Northwestern University. The protected time for the project, as well as the mentorship of the committee, helped us build our initial bedside medicine program, which then led to other exciting opportunities, such as an American Medical Association Reimagining Residency Award and the creation of the Society of Bedside Medicine with colleagues from across the globe. The importance of a two-year experience to really build and implement a project can’t be overstated.
ACGME: What would you tell someone who is thinking about applying for the Barondess Fellowship?
Garibaldi: I would definitely apply! The Fellowship is more than just a two-year funded project (which is amazing, by the way). It is a community of wonderful clinician educators who are dedicated to making sure that the clinical transaction meets the needs of patients, physicians, and communities.
Learn more about the Jeremiah A. Barondess Fellowship in the Clinical Transaction on the NYAM website. Applications for the 2025-2027 Fellowship are open now through December 20, 2024 – apply today!