Faculty Bibliography

Background: Diagnostic errors have a significant impact on our health care system with cognitive errors contributing to the majority of cases. Educators have theorized that interventions grounded in dual process theory (DPT) may improve the clinical reasoning (CR) process of physicians but little empirical evidence of this theory exists.
Method(s): This study was a quasi-experimental design in the New York University Internal Medicine Residency Program from June 2017- January 2018. We implemented two educational interventions in CR grounded in DPT during this 6-month period, leading to a natural experiment with three groups: no intervention (N = 25), partial intervention (received part 1, N = 23), and full intervention (received part 1 and part 2, N = 23). The educational interventions covered the concepts of DPT, impact of diagnostic errors, and case-based discussions introducing techniques to develop fast and slow thinking. We used the diagnostic thinking inventory (DTI) at baseline (a 41 item self-assessment questionnaire to assess one's approach to CR). At 6 months, participants completed a follow-up DTI and a post-survey assessing their ability to apply concepts to cases as well as workplace experiences of CR teaching. Participants who completed pre- and post-surveys were included in the analysis. Case examples were scored by two independent reviewers blinded to group status (Table). Differences between groups were analyzed using a one-way analysis of variance.
Result(s): Those in the full intervention group reported more teaching of DPT on attending rounds and in conference than the partial intervention and no intervention groups (60% often or always taught compared to 25% and 8.3%, p = 0.002; 73.3% often or always taught compared to 58.3% and 33.3%, p = 0.033, respectively). Otherwise workplace experiences were not significantly different between the groups. There was a significant difference between groups in ability to apply concepts to cases with a medium to large effect size (Table). There was also a significant difference in giving case examples in problem representation format with a large effect size (Table). There was no significant difference in change in DTI scores (mean change in score no intervention 7.0 (SD 16.3), partial intervention 8.8 (SD 9.8), full intervention 7.8 (SD 12.0), p = 0.946).
Conclusion(s): This study provides evidence that interns who participated in a CR curriculum grounded in DPT were effective in applying principles of CR in cases from their own clinical practice and supports the argument that we should be designing educational interventions in CR grounded in DPT. Subsequent studies would need to assess further impact on patient outcomes. (Figure Presented)

Learning Objective #1: Recognize the presentation and management of adrenal insufficiency (AI). Learning Objective #2: Express the importance of preventing premature closure and reevaluating clinical findings in an inadequately explained illness. CASE: A 19 year-old man with history of anorexia nervosa presented after collapse with pre-syncopal symptoms. He endorsed poor oral intake and a prodrome of weakness, lightheadedness, and vomiting without loss of consciousness. Additionally, he endorsed months of anorexia, fatigue, and weakness leading to several hospitalizations and a psychiatric admission for an eating disorder. On admission he had hypothermia, tachycardia, and hypotension minimally responsive to fluid. He was thin with signs of hypovolemia without objective weakness, focal findings of infection, or hyperpigmentation. Labs were notable for hyponatremia, hyperkalemia, and hypoglycemia. On admission he was diagnosed with hypovolemia and metabolic derangements secondary to an underlying eating disorder. A random serum cortisol level was found to be undetectable, as was a morning level. Adrenocorticotropin (ACTH) stimulation test revealed elevated ACTH with persistently suppressed serum cortisol, confirming primary AI. Intravenous (IV) corticosteroids were initiated with a rapid clinical response. An adrenal antibody titer returned positive. IMPACT: As is often the case, our team was presented with a patient with a provisional diagnosis. The challenge in such instances is to recognize incon-gruent data and to consider alternative explanations. We utilized the approach of "thinking-out-loud, "broadening our differential, and identifying features better explained by other conditions, including AI. The case reminds us of the pitfalls of premature closure and encourages the practice of "thinking-out-loud." DISCUSSION: Pre-syncope presents with a constellation of non-specific symptoms commonly encountered by general internists. Our patient's presentation yielded a broad differential spanning cardiovascular, infectious, and malignant etiologies, as well as hypovolemia secondary to anorexia nervosa, which anchored on the patient's prior diagnosis. By "thinking-out-loud, "our team recognized the electrolyte abnormalities and hypoglycemia to be consistent with AI. The Endocrine Society Clinical Practice Guidelines recommends sending diagnostic tests to exclude AI in all patients with compatible findings: volume depletion, hypotension, fever, abdominal pain, hyperpigmentation, hypoglyce-mia, or hyponatremia and hyperkalemia. Initial testing should include a morning cortisol which reflects peak levels, however, an undetectable level at any time is abnormal. In patients with symptoms consistent with severe AI or adrenal crisis, stress dose IV steroids should be initiated pending cortisol level results. In this case, IV steroids were not immediately initiated partly due to premature closure. It is important to maintain a low threshold to initiate stress dose steroids in patients with hemodynamic instability without a clear cause

Background: In an effort to bolster medical student wellbeing and mitigate burnout, NYU School of Medicine (NYUSOM) launched a longitudinal resiliency curriculum, coupled with a wellbeing self-assessment tool. We aim to study its impact on the development of knowledge, self-awareness, and practices related to wellbeing and resiliency. Methods: MD AWARE (Medical Students Developing Awareness, Wellbeing, and Resilience) was launched in August 2017 for the incoming NYUSOM class. It involves six interactive sessions implemented at critical junctions over the first three years of medical school. Each session includes a short lecture, followed by a small group activity led by trained facilitators. At the start of each small group session, students are asked to complete an anonymous online survey (results only provided to student). The self-assessment includes 19 items adapted from three validated assessment tools measuring different aspects of wellbeing and burnout. Students immediately receive three scores with explanations of each and the opportunity to debrief in their small group. Thus far, the students have participated in the first two sessions. In the first, students were introduced to research on physician burnout, the protective effects of resilience, and practiced a gratitude exercise. In the second, students were introduced to mindful awareness to identifying cognitive distortions and practiced reframing negative inner dialogue. After each, students completed a retrospective pre/post survey, using a 4-point likert scale, assessing knowledge, self-awareness, and comfort/confidence in activities to promote wellbeing. Comparison between the survey results were calculated using pair t-test. Results: Survey results were available for 106/118 (90%) students participating in the first session and 55/114 (48%) participating in the second. Results of both pre/post surveys showed significant improvement (p=<.01) on every item. Notably, after the first session, students reported a substantial increase in their comfort acknowledging stressors (31.1% very comfortable pre-vs 61.1% post-) and seeking help when in need (18.1% very comfortable pre-vs 45.2% post-). After the second session, students reported increased comfort practicing mindful awareness (65.5% comfortable/very comfortable pre-vs 90.9% post-), increased confidence both identifying cognitive distortions (59.2% comfortable/very comfortable pre-vs 96.3% post-) and reframing negative responses (47.2% comfortable/very comfortable pre-vs 81.8% post-). Conclusions: While many schools have looked at ways to foster wellbeing in their medical students, our curriculum is unique in its longitudinal nature and use of repeated wellbeing self-assessments. Preliminary assessment demonstrates a positive impact on medical students' knowledge, self-awareness, and practices around wellbeing and resilience. Thus, our novel curriculum is a promising way to bolster resiliency skills and mitigate burnout in this vulnerable population

LEARNING OBJECTIVE #1: Recognize the inciting factors of orthodeoxia with a patent foramen ovale. CASE: An 82 year-old presented with acute onset hypoxia upon extubation after a laparoscopic gastrectomy. She had positional episodes of desaturation to 79% when sitting up, with other vitals signs normal and no dyspnea. Her oxygen saturation was 91% on 2L nasal cannula when supine. Her lungs were clear to auscultation bilaterally. PaO2 was 45mmHg on roomair and increased to only 74 mmHg with 100% O2. Initial transthoracic echocardiogram with bubble study demonstrated a patent foramen ovale (PFO) with normal right atrial and pulmonary artery pressures and function. She had a stable 4.1 cm ascending thoracic aortic aneurysm and multiple, stable hepatic cysts. She was diagnosed with Platypnea-Orthodeoxia Syndrome (POS) due to PFO and underwent successful percutaneous transfemoral closure of the defect. Upon discharge, she was saturating 97% on room air, regardless of position. IMPACT: While PFOs can be seen in up to 29% of the general population, orthodeoxia is much more rare, with less than 200 cases described in the literature. With the elderly population increasing, the incidence of aortic aneurysms and other cardiovascular conditions distorting previously silent PFOs may increase as well, so it is important to maintain a high index of suspicion and perform the gold standard diagnostic test early: echocardiography with bubble study. DISCUSSION: Orthodeoxia, or the arterial deoxygenation that accompanies the positional change from supine to erect, requires two conditions to coexist: an anatomical component (interatrial communication such as a patent foramen ovale [PFO] or atrial septal defect [ASD]) and a functional component that redirects shunted blood flow through the atrial septum. These functional defects can either preferentially direct blood flow through the anatomical defect or cause a transient increase in right atrial pressure, reversing the leftright gradient. The former can be caused by conditions that direct the jet of deoxygenated blood through the interatrial communication by repositioning the atrial septum, such as an ascending aortic aneurysm, intracardiac lipoma, hepatic cyst distorting the right atrium, or aortic valve replacement. Conditions which transiently increase right sided pressures include pulmonary embolism, pulmonary hypertension, pericardial effusion, pneumonectomy, chronic obstructive pulmonary disease and constrictive pericarditis. Measured right sided pressures are typically normal in POS. The pathophysiology in our patient is likely due to her thoracic aortic aneurysm, elongating in the erect position and stretching the interatrial septum and PFO. While a possibility, it is unlikely her hepatic cysts contributed to her presentation as they were small and there has only been one case report of a large liver cyst causing this presentation

LEARNING OBJECTIVE #1: Recognize the clinical presentation and physical exam findings of chronic tophaceous gout LEARNING OBJECTIVE #2: Discuss the management and complications of tophaceous gout CASE: A 40 year-old man with no past medical history presented with 8 months of worsening pain and deforming growths in multiple joints. He first noticed intermittent pain and swelling in the heels of both feet 2 years prior to admission, which progressed to constant pain in his feet, knees, hands, and elbows. Starting 8 months ago, distinct nodules formed on the affected joints; these occasionally burst and released a "toothpaste-like" discharge. He increasingly had difficulty walking and using his hands. The patient had not sought any medical care since emigrating from Mexico 8 years ago, due to lack of insurance. On exam, he had diffuse subcutaneous nodules on the feet, ankles, knees, elbows, earlobes, and hands, most concentrated in the joint spaces. They were firm, non-tender, and yellow to white in color. One nodule was draining a chalky white exudate. He had numerous cyst-like lesions on the shaft of the penis, restricting movement of the foreskin. Range of motion was severely impaired in all extremities. He had a uric acid level of 10.4, alkaline phosphatase of 164, and C-reactive protein of 16.5. Rheumatologic serologies were negative. X-rays of the affected joints showed osteopenic bone, with areas of periarticular erosions, joint space narrowing, and subchondral sclerosis with overlying tophi, all consistent with advanced gout. Fluid from the draining tophus revealed large collections of monosodium urate crystals. IMPACT: This case is a reminder that physicians should be prepared to recognize and manage not only acute gout flares, but also advanced presentations of chronic gout. Particularly when working in populations with limited healthcare access, the diagnosis and treatment of gout may be considerably delayed. Perhaps more importantly from an internist's perspective, recognizing and treating the sequelae and comorbidities of gout may reduce morbidity and mortality in these patients. DISCUSSION: In gout patients, the presence of one or more tophi is an indication to begin urate-lowering therapy (ULT), using xanthase-oxidase inhibitors, which decrease production of urate, and uricosuric agents, which increase renal excretion of uric acid. ULT targets a serum urate of <6 mg/dL; in severe cases, a target of <5 mg/dL is often used. If serum urate remains elevated on both agents, the next step is to add pegloticase, a recombinant uricase that converts urate into the renally cleared allantoin. Even with optimal control of hyperuricemia, tophi may persist for years before disappearing. Notably, all gout patients are at increased risk for cardiovascular disease, metabolic syndrome, and renal disease. However, patients with tophi have additional complications of joint and bone destruction, compressive neuropathies, and ulceration and infection of the tophi. The presence of tophi is also an independent predictor of mortality