Faculty Bibliography

INTRODUCTION/BACKGROUND:Hospital and ambulatory care systems are rapidly building their virtual care capacity in response to the novel coronavirus (COVID-19) pandemic. The use of resident trainees in telemedicine is one area of potential development and expansion. To date, however, training opportunities in this field have been limited, and residents may not be adequately prepared to provide high-quality telemedicine care. AIM/OBJECTIVE:This study evaluates the impact of an adapted telemedicine Objective Structured Clinical Examination (OSCE) on telemedicine-specific training competencies of residents. SETTING/METHODS:Primary Care Internal Medicine residents at a large urban academic hospital. PROGRAM DESCRIPTION/METHODS:In March 2020, the New York University Grossman School of Medicine Primary Care program adapted its annual comprehensive OSCE to a telemedicine-based platform, to comply with distance learning and social distancing policies during the COVID-19 pandemic. A previously deployed in-person OSCE on the subject of a medical error was adapted to a telemedicine environment and deployed to 23 primary care residents. Both case-specific and core learning competencies were assessed, and additional observations were conducted on the impact of the telemedicine context on the encounter. PROGRAM EVALUATION/RESULTS:Three areas of telemedicine competency need were identified in the OSCE case: technical proficiency; virtual information gathering, including history, collateral information collection, and physical exam; and interpersonal communication skills, both verbal and nonverbal. Residents expressed enthusiasm for telemedicine training, but had concerns about their preparedness for telemedicine practice and the need for further competency and curricular development. DISCUSSION/CONCLUSIONS:Programs interested in building capacity among residents to perform telemedicine, particularly during the COVID-19 pandemic, can make significant impact in their trainees' comfort and preparedness by addressing key issues in technical proficiency, history and exam skills, and communication. Further research and curricular development in digital professionalism and digital empathy for trainees may also be beneficial.

Objectives While the need to address patients' social determinants of health (SDoH) is widely recognized, less is known about physicians' actual clinical problem-solving when it comes to SDoH. Do physicians include SDoH in their assessment strategy? Are SDoH incorporated into their diagnostic thinking and if so, do they document as part of their clinical reasoning? And do physicians directly address SDoH in their "solution" (treatment plan)? Methods We used Unannounced Standardized Patients (USPs) to assess internal medicine residents' clinical problem solving in response to a patient with asthma exacerbation and concern that her moldy apartment is contributing to symptoms - a case designed to represent a clear and direct link between a social determinant and patient health. Residents' clinical practices were assessed through a post-visit checklist and systematic chart review. Patterns of clinical problem solving were identified and then explored, in depth, through review of USP comments and history of present illness (HPI) and treatment plan documentation. Results Residents fell into three groups when it came to clinical problem-solving around a housing trigger for asthma: those who failed to ask about housing and therefore did not uncover mold as a potential trigger (neglectors - 21%; 14/68); those who asked about housing in negative ways that prevented disclosure and response (negative elicitors - 24%, 16/68); and those who elicited and explored the mold issue (full elicitors - 56%; 28/68). Of the full elicitors 53% took no further action, 26% only documented the mold; and 21% provided resources/referral. In-depth review of USP comments/explanations and residents' notes (HPI, treatment plan) revealed possible influences on clinical problem solving. Failure to ask about housing was associated with both contextual factors (rushed visit) and interpersonal skills (not fully engaging with patient) and with possible differences in attention ("known" vs. unknown/new triggers, usual symptoms vs. changes, not attending to relocation, etc.,). Use of close-ended questions often made it difficult for the patient to share mold concerns. Negative responses to sharing of housing information led to missing mold entirely or to the patient not realizing that the physician agreed with her concerns about mold. Residents who fully elicited the mold situation but did not take action seemed to either lack knowledge or feel that action on SDoH was outside their realm of responsibility. Those that took direct action to help the patient address mold appeared to be motivated by an enhanced sense of urgency. Conclusions Findings provide unique insight into residents' problem solving processes including external influences (e.g., time, distractions), the role of core communication and interpersonal skills (eliciting information, creating opportunities for patients to voice concerns, sharing clinical thinking with patients), how traditional cognitive biases operate in practice (premature closure, tunneling, and ascertainment bias), and the ways in which beliefs about expectancies and scope of practice may color clinical problem-solving strategies for addressing SDoH.

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health (SDoH), less is known about how physicians elicit, respond to, and act upon their patients' SDoH information. We report on the results of a study that 1) sent Unannounced Standardized Patients (USPs) with programmed SDoH into clinics to assess whether providers uncovered, explored and acted upon the SDoH, 2) provided audit/feedback reports with educational components to clinical teams, and 3) tracked the impact of that intervention on provider response to SDoH.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well-visit), each with specific housing (overcrowding, late rent, and mold) and social isolation (shyness, recent break up, and anxiety) concerns that they shared if asked broadly about. USPs assessed team and provider SDoH practices (eliciting, acknowledging/exploring, and providing resources and/or referrals). 383 USP visits were made to residents in 5 primary care teams in 2 urban, safety- net clinics. 123 visits were fielded during baseline period (Feb 2017-Jan 2018); 185 visits during intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed; and 75 follow-up phase visits were fielded (Apr-Dec 2019). Analyses compared rates of eliciting and responding to SDoH across the 3 periods (chi- square, z-scores). One team, by design, did not receive the intervention and serves as a comparison group.
RESULT(S): Among the intervention teams, the rate of eliciting the housing SDoH increased from 46% at baseline to 59% during the intervention period (p=.045) and also increased, but not significantly, for the social issue (40% to 52%, p=.077). There was a significant increase from baseline to intervention in providing resources/referrals for housing (from 7% to 24%, p=.001) and for social isolation (from 13% to 24%, p=.042) (mostly resources, very few referrals were made). The comparison team's rates followed a different pattern: eliciting the housing issue and the social isolation issue decreased from baseline to the intervention period (housing: 61% to 45%; social isolation: 39% to 33% of visits) and the rate of providing resources/referrals stayed steady at 13% for both. In the cases where SDoH were most clinically relevant, baseline rates of identifying the SDoH were high (>70%) but rates of acting on the SDoH increased significantly from baseline to intervention. Increases seen in the intervention period were not sustained in the follow-up period.
CONCLUSION(S): Giving providers SDoH data along with targeted education was associated with increased but unsustained rates of eliciting and responding to housing and social issues. The USP methodology was an effective means of presenting controlled SDoH and providing audit/feedback data. Ongoing education and feedback may be needed

BACKGROUND: Social determinants of health (SDoH) play a significant role in health outcomes, but little is known about care teams' attitudes about addressing SDoH. Our safety-net clinic has begun to implement SDoH screening and referral systems, but efforts to increase clinical responses to SDoH necessitates an understanding of how providers and clinical teams see their roles in responding to particular SDoH concerns.
METHOD(S): An annual survey was administered (anonymously) to clinical care teams in an urban safety-net clinic from 2017-2019, asking about ten SDoH conditions (mental health, health insurance, food, housing, transportation, finances, employment, child care, education and legal Aid). For each, respondents rated with a 4-point Likert-scale whether they agreed that health systems should address it (not at all, a little, somewhat, a great deal). They also indicated their agreement (using strongly disagree, somewhat disagree, somewhat agree, strongly agree) with two statements 1) resources are available for SDoH and 2) I can make appropriate referrals.
RESULT(S): 232 surveys were collected (103 residents, 125 faculty and staff (F/S), 5 unknown) over three years. Of note, mental health (84%) and health insurance (79%) were seen as very important for health systems to address, with other SDoH items seen as very important by fewer respondents. They reported little confidence that the health system had adequate resources (51%) and were unsure how to connect patients with services (39%). When these results were broken out by year, we found the following: In 2017 (n=77), approximately 35% of respondents thought the issues of employment, childcare, legal aid, and adult education should be addressed "a little," but in 2018 (n=81) and 2019 (n=74) respondents found the health system should be more responsible, with over 35% of respondents stating that these four issues should be addressed "somewhat" by health systems. In addition, half of respondents in 2019 felt that financial problems should be addressed "a great deal," up from 31% in 2017. Across all years, food, housing, mental health, and health insurance were seen as SDoH that should be addressed "a great deal". It is of note that respondents across all years reported limited understanding of referral methods and options available to their patients.
CONCLUSION(S): Many of the SDoH conditions were seen by respondents as outside the purview of health systems. However, over the three years, more members increased the number of SDoH conditions that should be addressed a "great deal." Responses also indicated that many of the team members do not feel prepared to deal with "unmet social needs". Additional examination of clinic SDoH coding, referral rates, resources, and team member perspectives will deepen our understanding of how we can cultivate a culture that enables team members to respond to SDoH in a way that is sensitive to their needs and patient needs

BACKGROUND: Unannounced Standardized Patients (USPs) provide opportunity to measure residents' clinical skills in actual practice. USPs, or secret shoppers, are trained to ensure accurate case portrayal across encounters, making them optimal for tracking changes in skills longitudinally. At present, little is known about how residents handle USP visits with repeat cases. This study examines variation in resident communication and global domain scores when visited by the sameUSPcase at two separate time points during residency training.
METHOD(S): Primary care residents (n=46) were assessed twice by one of six standardized cases (asthma, fatigue, Hepatitis B concern, back pain, shoulder pain, or well visit) during the course of their residency, typically during their first and third training year. Upon visit completion, residents were rated using a behaviorally-anchored checklist. Communication domains assessed included info gathering (4 items), relationship development (5 items), and patient education (4 items). Other domains included patient activation (4 items) and satisfaction (4 items). Responses were scored as not done, partly done, or well done. Summary scores (mean % well done) were calculated by domain. All cases were combined to create composite scores, due to small sample sizes per case. First and second visit domain scores were compared using a t-test. Finally, we grouped high performers (80% or higher on communication scores during their first visit) because this measure demonstrated competency.
RESULT(S): With cases combined, there were no significant differences based on time of assessment and changes in score between first and second visit were small. 14/46 (30%) learners who performed well on composite overall communication scores (80% or higher) during their first visit outperformed poorer communicators in patient satisfaction (93% vs 61%, P<.001) and activation (48% vs 18%, P<.001). In subsequent visits, these high performers performed at a similar level to their fellow residents, with no significant differences noted. Further, when looking at individual trajectories, individual learner scores in the communication domain increased between visits for 21 learners (46%), decreased for 19 (41%), and stayed same for 7 (15%).
CONCLUSION(S): Results suggest that a learning curve occurs between assessments during the first year in residency and subsequent assessments. This could be due to an increased capacity to engage with a patient occurring training progression, or due to a better understanding of addressing common chief complaints presented with our USP cases. Understanding causes of individual-level score decreases will enable tailoring of educational interventions suitable for specific learner trajectories, as will a deeper dive into the impact of the clinical microsystem on performance. We predict a more nuanced understanding of these mediating factors through our plan of increasing our repeat visit sample size

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health, less is known about how members of the care team respond to patient-volunteered SDoH - especially when the determinant is related to financial insecurity. With increasing calls for universal screening for SDoH - what do teams do when a patient shares a financial concern? We report on the use of Unannounced Standardized Patients (USP) to assess how primary care teams respond to volunteered information about financial insecurity and whether an audit/ feedback intervention (with targeted education included) improved that response.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six common scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well visit). USPs volunteered a financial concern (fear of losing job, challenges with financially supporting parent, trouble meeting rent) to the medical assistant (MA) and then again to their provider and assessed the response of both the MA (did they acknowledge and/ or forward the information to the provider?) and the provider (did they acknowledge/ explore and/or provide resources/referrals?). A total of 383 USP visits were delivered to 5 care teams in 2 safety-net clinics. Providers were medicine residents. 123 visits were fielded during the baseline period (Feb 2017-Jan 2018); 185 visits during the intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed. 75 follow-up phase visits were fielded (Apr- Dec 2019). Analyses compared rates of MA and provider response to the volunteered financial insecurity issue across the 3 periods (chi-square, z-scores).
RESULT(S): The baseline rate of responding in some way to the volunteered information was high for both the MA (86% acknowledged) and the providers (100% responded). These overall rates of response did not change substantially or significantly across the three time periods (MA: Intervention period = 87%, Follow- Up period=90%; Provider: Intervention period=98%; Follow-Up period=98%). Rates of acting upon the volunteered information also remained quite consistent across the time periods: from 29 to 35% of MA forwarded the information to the provider across the 3 time periods and from 22 to 28% of providers in each intervention period gave the patient resources or a referral (mostly resources).
CONCLUSION(S): Our findings highlight the importance of patients directly telling team members about a financial concern. Future research should explore whether screening tools are effective in instigating a response. Audit/feedback reports with targeted educational components did not appear to influence the teams' response unlike what we found for housing and social concerns that had to be elicited. Whether this is due to differences in volunteered vs. elicited SDoH or to the nature of the SDoH (financial vs housing/social) warrants further investigation

BACKGROUND: Moral distress is defined as a situation in which an individual believes they know the ethically appropriate action to take but are unable to take that action. The concept of moral distress is increasingly recognized as an important mediator of occupational stress and burnout in medicine, particularly in the nursing profession. However, there is a dearth of literature on moral distress among physician trainees, with the majority focused on dilemmas in end-of-life care. This study explores the phenomenon of moral distress among internal medicine trainees, with particular focus on drivers, situational contexts, and adaptive strategies such as coping mechanisms.
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants, and was identified across four major domains: personal values and morals, professional competency and training challenges, interpersonal relationships and conflicts, and systems/structural issues. Participants identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, as well as between private, public, and government- run hospital facilities. Participants described a number of adaptive mechanisms for managing moral distress, including social support and connectivity, humor, and disassociation.
CONCLUSION(S): Physician trainees experience considerable moral distress across multiple domains during the course of their training. They also develop unique adaptive strategies and copingmechanisms tomanage and learn from distressing experiences. This improved understanding ofmoral distress among physician trainees, particularly drivers and protective factors, has important implications for the training of physicians, and may have a role in promoting wellness and resilience among physicians across the training and professional pipeline

BACKGROUND: Moral distress is defined as a situation in which an individual believes they know the ethically appropriate action to take but are unable to take that action. The concept ofmoral distress is increasingly recognized as an important mediator of occupational stress and burnout in healthcare, particularly in the nursing literature. However, there is a dearth of literature focusing on moral distress among physician trainees, particularly as regards the clinical training environment. This study explores the phenomenon of moral distress among internal medicine trainees, with an emphasis on the contexts of clinical training and professional role development.
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants. Trainees identified several drivers of moral distress that were unique to their professional development as clinicians and their role as trainees/ learners within clinical teams, including: feelings of inadequacy in clinical or procedural skills, being asked to performduties outside of their scope of practice, discomfort with the idea of 'practicing' skills on patients, poor team communication, disagreements with senior team members, experiences of disempowerment as junior team members, and overwhelming or inappropriate administrative or non-clinical burdens. Participants also identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, aswell as between private, public, and government-run hospital facilities.
CONCLUSION(S): Physician trainees experience considerable moral distress in the context of their professional development, with unique drivers of moral distress identified in the training and clinical team context. This improved understanding of factors unique to the trainees' experience has implications for tailoring educational experiences as professional development activities, as well as potential wellness- and resilience-building among physician trainees. It may also inform the training of physician leaders and seniors clinicians who engage with trainees in learning and clinical environments

BACKGROUND: The importance of addressing patients' social determinants of health (SDoH) is widely recognized, but less is known about how physicians specifically elicit, respond to, and document these determinants. We sought to describe resident practices when caring for a patient whose SDoH is integral to accurate diagnosis and treatment using Unannounced Standardized Patients (USPs).
METHOD(S): USPs were used (n=68) to assess how medicine residents responded to the consistent portrayal of a patient with asthma exacerbation and concern that her living situation (moldy, dilapidated housing) might be contributing to her symptoms. USPs, or "secret shoppers", were sent to two of New York's safety-net hospitals. Resident practices were assessed by the USP during a post-visit behaviorally-anchored checklist (7 items) and through a systematic chart review (3 items). Checklist items included whether or not a provider explored and fully elicited the USPs concerns, how they responded once shared, and what the provider actually did in response. Chart review items included whether or not a provider documented their patient's housing concerns in the history of present illness (HPI), problem list, or through use of a billingrelated Z-code.
RESULT(S): 68/79 consented residents participated: 11 PGY1 (16%), 31 PGY2 (46%), and 26 PGY3 (38%). 65% (44/68) of residents elicited the patient's housing SDoH and of those, 75% (33/44) responded by acknowledging/exploring and providing notes/practical support. 30% (10/33) connected the patient to informative resources or direct referral. Less than half (14/33; 42%) of those who acknowledge/explored documented appropriately in the EMR. No residents documented housing in the problem list or with a housing-related ICD10 Z-code. Of the 14 high performers, 6 successfully elicited, acknowledged, and documented housing concerns for one of our other five SDoH cases. More than half (55%) of the residents who elicited housing information connected the mold to the asthma exacerbation as a possible trigger, either during clinical interaction or in documentation. All but one (93%) of those who el icited, acknowledged, and documented made this connection.
CONCLUSION(S): Using USPs to directly observe resident practice behaviors in gathering information about, documenting and taking action on a consistently portrayed SDoH case closely linked to clinical symptoms is the first piece of the puzzle needed to better understand education and training that prepares physicians to address SDoH. Our study identifies practice gaps at all stages - adequately collecting information, understanding the clinical/ treatment consequences of, effectively responding to needs, and in documentation of SDoH. Future research should explore the influence of the clinical microsystem (e.g., SDoH screening tools, available resources and referrals, and workflows) on physician SDoH-related practices