Faculty Bibliography

BACKGROUND:Despite evidence of socio-demographic disparities in outcomes of COVID-19, little is known about characteristics and clinical outcomes of patients admitted to public hospitals during the COVID-19 outbreak. OBJECTIVE:To assess demographics, comorbid conditions, and clinical factors associated with critical illness and mortality among patients diagnosed with COVID-19 at a public hospital in New York City (NYC) during the first month of the COVID-19 outbreak. DESIGN/METHODS:Retrospective chart review of patients diagnosed with COVID-19 admitted to NYC Health + Hospitals / Bellevue Hospital from March 9th to April 8th, 2020. RESULTS:A total of 337 patients were diagnosed with COVID-19 during the study period. Primary analyses were conducted among those requiring supplemental oxygen (n = 270); half of these patients (135) were admitted to the intensive care unit (ICU). A majority were male (67.4%) and the median age was 58 years. Approximately one-third (32.6%) of hypoxic patients managed outside the ICU required non-rebreather or non-invasive ventilation. Requirement of renal replacement therapy occurred in 42.3% of ICU patients without baseline end-stage renal disease. Overall, 30-day mortality among hypoxic patients was 28.9% (53.3% in the ICU, 4.4% outside the ICU). In adjusted analyses, risk factors associated with mortality included dementia (adjusted risk ratio (aRR) 2.11 95%CI 1.50-2.96), age 65 or older (aRR 1.97, 95%CI 1.31-2.95), obesity (aRR 1.37, 95%CI 1.07-1.74), and male sex (aRR 1.32, 95%CI 1.04-1.70). CONCLUSION/CONCLUSIONS:COVID-19 demonstrated severe morbidity and mortality in critically ill patients. Modifications in care delivery outside the ICU allowed the hospital to effectively care for a surge of critically ill and severely hypoxic patients.

Introduction: Educators have theorized that interventions grounded in dual process theory (DPT) and script theory (ST) may improve the diagnostic reasoning process of physicians but little empirical evidence exists. Methods: In this quasi-experimental study, we assessed the impact of a clinical reasoning (CR) curriculum grounded in DPT and ST on medicine residents participating in one of three groups during a 6-month period: no, partial, or full intervention. Residents completed the diagnostic thinking inventory (DTI) at baseline and 6 months. At 6 months, participants also completed a post-survey assessing application of concepts to cases. Results: There was a significant difference between groups in application of concepts (no intervention 1.6 (0.65) compared to partial 2.3 (0.81) and full 2.2 (0.91), p = 0.05), as well as describing cases in problem representation format (no intervention 1.2 (0.38) and partial 1.5 (0.55) compared to full 2.1 (0.93), p = 0.004). There was no significant difference in change in DTI scores (no intervention 7.0 (16.3), partial 8.8 (9.8), full 7.8 (12.0)). Conclusions: Residents who participated in a CR curriculum grounded in DPT and ST were effective in applying principles of CR in cases from their practice. To our knowledge, this is the first workplace-based CR educational intervention study showing differences in the reasoning process residents apply to patients.

Background Clinical reasoning (CR) is a core competency in medical education. Few studies have examined efforts to train faculty to teach CR and lead CR curricula in medical schools and residencies. In this report, we describe the development and preliminary evaluation of a faculty development workshop to teach CR grounded in CR theory. Methods Twenty-six medicine faculty (nine hospitalists and 17 subspecialists) participated in a workshop that introduced a framework to teach CR using an interactive, case-based didactic followed by role-play exercises. Faculty participated in pre- and post-Group Observed Structured Teaching Exercises (GOSTE), completed retrospective pre-post assessments (RPPs), and made commitment to change statements (CTCs). Results In the post-GOSTE, participants significantly improved in their use of problem representation and illness scripts to teach CR. RPPs revealed that faculty were more confident in their ability and more likely to teach CR using educational strategies grounded in CR educational theory. At 2-month follow-up, 81% of participants reported partially implementing these teaching techniques. Conclusions After participating in this 3-h workshop, faculty demonstrated increased ability to use these teaching techniques and expressed greater confidence and an increased likelihood to teach CR. The majority of faculty reported implementing these newly learned educational strategies into practice.

Background: To bolster medical student wellbeing and combat burnout, the NYU School of Medicine (NYUSOM) implemented a longitudinal resiliency curriculum coupled with a wellbeing self-assessment tool. We qualitatively studied the impact of this curriculum on knowledge, self-awareness, and behaviors related to wellbeing and resiliency.
Method(s): The MD AWARE curriculum was launched in August 2017 for the NYUSOM class of 2020. Six sessions were implemented at critical junctions of their training. Each session includes a short lecture, followed by a small group activity led by trained facilitators. At the start of each session, students complete an anonymous online self-assessment adapted from three validated assessment tools measuring different aspects of wellbeing and burnout. Students immediately receive scores with explanations and benchmarks of each and then debrief in their small group. After each MD AWARE session, students completed a retrospective pre/post evaluation survey. Focus Groups (FG) were held in December 2017 (after Sessions 1& 2) to gain richer insight into the impact of the curriculum and self-assessment tool. A purposeful sampling strategy with maximal variation was employed to recruit participants; 10 students participated in each FG. Qualitative data was gathered through the surveys and the FG. The FG were recorded and transcribed. Each FG had 2 project staff members and post-session debriefing. Member-checking was also used. Responses were subsequently coded and analyzed by two experienced faculty members (a third colleague assisted in theme triangulation). An iterative data analysis strategy was applied. Throughout the analysis, an audit trail, frequent memo writing and a reflexivity journal was maintained.
Result(s): Themes: Community Building: Connecting with another student it was helpful for my wellbeing Skill and Knowledge Acquisition and Application: The main sort of takeaway is you need to be aware of (Burnout) and if you need help there are resources Importance of Faculty Development: I think that a prep session between those who designed the curriculum and those who facilitate the small-groups could go a long way towards creating the environment I imagine was originally intended Value of Refection: The score didn't add much It was more about the act of answering the questions than the number that came out of it NYU Administration Values Medical Student Wellbeing: Just the fact that NYU has this program and is making it part of orientation already speaks volumes about its priorities: that we matter
Conclusion(s): Thematic analysis of the impact of MD AWARE indicated that it provides concrete information on resources available to the students. Additionally, the students value both protected time with their peers and for self-refection. Lastly, although care must to be taken in selecting faculty to facilitate the small groups, the mere existence of the longitudinal curriculum signaled that the NYUSOM administration values medical student wellbeing

Learning Objective #1: Identify non-HACEK gram-negative endocarditis early in its clinical course. Learning Objective #2: Recognize the morbidity and mortality of Escherichia coli endocarditis. CASE: A 54 year-old Hispanic man with no known past medical history presented with one month of constitutional symptoms: unintentional weight loss, anorexia, fatigue, and arthralgias. On admission, he was febrile, tachycardic, and breathing comfortably on room air. The exam was otherwise significant for a thin stature with temporal wasting, thrush, a lateral tongue ulcer, a raised non-blanching erythematous macular rash on sun-exposed areas of the extremities, and erythematous papules on the hands. There were no murmurs detected on cardiac auscultation. Initial labs were significant for anemia and leukopenia. A broad differential diagnosis initially included malignancy, rheumatologic disease, and systemic infection. Work-up revealed positive anti-Smith and anti ds-DNA antibodies, C3/C4 hypocomplementemia, and a pericardial effusion on transthoracic echocardiogram (TTE). He was diagnosed with systemic lupus erythematous (SLE), and started on hydroxychloroquine and steroids with improvement. On hospital day three, blood cultures grew Escherichia coli (E. coli) in four bottles, with an unclear source with aseptic urine and no localizing symptoms. CT scans of the head, chest, abdomen, and pelvis were notable for multiple peripherally located pulmonary airspace opacities concerning for septic emboli. A TTE was negative for vegetation, but given the high clinical suspicion for endocarditis, notwithstanding the rarity of E. coli as a pathologic organism, transesophageal echocardiogram (TEE) was pursued. TEE revealed a mobile echodensity on the aortic valve consistent with vegetation. The patient completed four weeks of ceftriaxone to treat E. coli endocarditis. IMPACT/DISCUSSION: E. coli bacteremia is common; however, due to decreased adherence of the organism to the endocardium, infective endocarditis from E. coli is rare, accounting for 0.51% of cases. Risk factors include immunocompromised states. Our patient was leukopenic from SLE. Sources of infection are often gastrointestinal and urinary. However, as in our patient, initial source is unclear in approximately half of cases. Murmur is often absent, and the disease is more common in native valves than prosthetic or degenerative valves. For these reasons, diagnosis is difficult. One study reported at least one month from onset to clinical diagnosis in 90% of patients with non-HACEK gram-negative endocarditis. However, given its high surgical intervention rate (42%), high complication rate (including heart failure and abscess), and high mortality rate of 21% (drastically higher than the 4% from HACEK gram-negative endocarditis), clinicians should maintain a high degree of suspicion to make this diagnosis early.
Conclusion(s): E. coli endocarditis is rare, occurs in immunocompro-mised patients, and is difficult to diagnose. However, given its high morbidity and mortality, timely recognition is critical

Background: Faculty development programs (FDP) in medical education can increase clinician educators' (CE) confidence in teaching and improve their teaching skills. The impact of FDP on faculty's role as educators and sense of an educator community is less well understood. Identification with a community of educators (COE) can enhance teaching in the workplace along with personal and professional growth. We evaluated the impact of participation in the Education for Educators program (E4E) on these issues. E4E is a yearlong FDP designed to enhance teaching confidence and skill in a variety of venues; improve ability to assess learners; promote an environment of academic inquiry with trainees at different levels; and create a COE.
Method(s): An annual needs assessment of key stakeholders including medical school deans, program directors, and participants forms the basis for the E4E curriculum. The program begins with a Group Observed Structured Teaching Experience (GOSTE) followed by three 3-hour workshops which pair a clinical and teaching topic. After each workshop, participants complete " commitment to change" statements and take part in peer-to-peer (P2P) observations wherein participants observe each other teaching in their usual teaching environment. The program concludes with structured debriefs and an assessment of participants' perception of their role as educators and their sense of an educator community. Participants reported how participation in E4E impacted their teaching and what new skills they implemented. Structured phone conversations assessed the same information one-year after completing the program.
Result(s): Fifty-one CEs completed the program in two cohorts (2016-17 and 2017-18), 60% of whom were women. Participants included 20 hospitalists and 31 subspecialists, averaging 8 years in practice (range 1-28) and spending an average of 63% of their time in patient care (range 10-100%). Thirty-eight participants (75%) completed the immediate post-program debrief sessions. Participants reported a renewed identification with their role as an educator. They cited a change in perspective to become more reflective and focused on teaching and recognized that their teaching skills can in fact be improved. Many reported time constraints as a barrier to teaching. They noted an increased identification with their COE, stating that they now had peers and mentors with whom to discuss teaching challenges. To date, phone interviews have been completed with three participants at one-year of follow-up. The preliminary Results show a sustained impact on educators' roles and belonging to a COE. They also reported ongoing use of specific skills including resilience strategies, and planning teaching sessions.
Conclusion(s): Longitudinal FDP in medical education for CE can lead to a greater appreciation for the role of an educator, and identification with a COE. Investment in longitudinal FDP may have lasting impact on the clinical learning environment and the identity of faculty as an educator

Problem: Much of the medical education literature on clinical reasoning (CR) comes from primarily English-speaking countries. It is less clear how these educational interventions translate to environments with non-native English speakers, and in clinical systems where there is higher patient volumes.
Purpose(s): To implement a CR session for 6th year medical students at a university hospital in Istanbul, Turkey. Description of Program: In November, 2018 we conducted a 3-hour session on CR at Koc University in Istanbul developed from a curriculum at our home institution in the United States. In an interactive case-based didactic, students were introduced to the CR concepts of problem representation (PR), illness scripts, and diagnostic time outs. Students then applied these concepts to a case during facilitated small group breakouts. Outcomes Twenty-four 6th year medical students participated. Retrospective pre-post self-assessments of confidence in and likelihood of using CR concepts on an eight-point Likert scale were completed, and qualitative data on use in clinical practice were obtained. Results were analyzed using a paired t-test. After participating in this session, students were more confident in and more likely to use all domains of the CR framework taught with large effect sizes in eight of ten domains (Figure 1). A common theme in the qualitative data was that the use of PR would be helpful to communicate about patients efficiently in the busy clinical environment.
Discussion(s): Teaching CR skills translated well to an international setting. Critical to the session's success was demonstrating relevance to the local institution's clinical environment, in particular taking into account the higher patient volume experienced by providers, and changing the attitude that better decision-making does not necessarily take longer. The impact of culture and environment was evidenced by what the students found to be most effective-use of PR to communicate efficiently about patients in a busy clinical environment-which is different from our experiences teaching this in the US where learners often highlight the utility of the diagnostic time out. Significance of Findings Our findings speak to the need to contextualize CR concepts within the local learning culture to define relevance and meet the learners' needs. (Figure Presented)