Faculty Bibliography

BACKGROUND:Suboptimal support for colleagues experiencing discrimination can adversely impact clinician well-being and patient care. AIM/OBJECTIVE:To describe resident performance and experience during an Objective Structured Clinical Examination (OSCE) case centered on supporting a trainee facing discrimination to inform enhanced, supportive learning environments. SETTING/METHODS:Formative, internal medicine OSCE at a simulation center. PARTICIPANTS/METHODS:148 second-year residents across 2018, 2019, 2021, 2022. PROGRAM DESCRIPTION/METHODS:Residents had 10 min to support a Muslim standardized intern (SI) experiencing discrimination from a patient. The SI rated resident performance across Supervision, Relationship Development, and Support domains and provided written feedback. Post-OSCE evaluations elicited resident reflections on case challenges. PROGRAM EVALUATION/RESULTS:Proficient residents (≥ 80% average score across domains, n = 85) performed better in all items, except in not acting defensive and collaborating with SI to develop follow-up plan, compared to non-proficient residents (n = 65). The SI described effective approaches to feeling supported, including using empathetic statements, stating personal stance on discrimination, exhibiting supportive body language, and verbalizing support. Stating knowledge of situation upfront was an area of improvement. Residents found engaging the distressed SI difficult. DISCUSSION/CONCLUSIONS:Use of an explicit discrimination OSCE case can help identify effective approaches to supporting targets of discriminatory patients to inform future training.

BACKGROUND:Unannounced standardized patients (USPs) have long been used to measure clinical performance in situ. These incognito actors capture data on clinician skills during an encounter, as well as patient experience more broadly. A robust USP program requires extensive preparation and standardization efforts. Given the widespread expansion of USPs for education, research, and improvement efforts, we conducted a systematic review with the goal of capturing the breadth of uses of USPs across settings, along with the standardization measures employed across studies. METHODS:In collaboration with a medical librarian, we conducted systematic searches across six databases. Two independent researchers screened each report for inclusion. Three coders extracted and reviewed study characteristics and data from the studies deemed eligible for inclusion. We extracted data on: target population, setting, and assessed skills. We also captured the reliability and fidelity measures described in each study, including USP detection, USP training methods, and assessment measures. RESULTS:128 articles were included. Individual clinicians were the most frequently targeted population (n = 114, 89 %). Common clinician roles included physicians (n = 92, 72 %) and pharmacists (n = 12, 9 %). The collective care team was the target in two studies (2 %), and systems and larger healthcare facilities were targeted in only 1 (1 %) and 13 (10 %) studies, respectively. Studies were primarily conducted in ambulatory settings (n = 118, 92 %). History gathering (n = 76, 59 %), communication (n = 55, 43 %), counseling (n = 51, 40 %), and patient education (n = 49, 38 %) were commonly assessed, as were correct diagnosis (n = 34, 27 %), appropriate ordering of labs/tests (n = 30, 23 %), referrals (n = 35, 27 %), and prescriptions (n = 36, 28 %). USP detection reporting was variable across studies; however, no detection information was provided for 48 studies. 62 % of articles reported incorporating a measure of reliability or fidelity into their study, while the remainder either failed to provide adequate information on use of these measures. CONCLUSIONS:We explored USP use across settings and describe the scope and limitations of the literature. USPs capture a range of data domains but a lack uniform report of reliability measures can potentially undermine findings. Future studies should incorporate and uniformly report out on detection, training, and assessment.

In this introduction, the guest editors of the "Next Era in Assessment" special collection frame the invited papers by envisioning a next era in assessment of medical education, based on ideas developed during a summit that convened professional and educational leaders and scholars. The authors posit that the next era of assessment will focus unambiguously on serving patients and the health of society, reflect its sociocultural context, and support learners' longitudinal growth and development. As such, assessment will be characterized as transformational, development-oriented and socially accountable. The authors introduce the papers in this special collection, which represent elements of a roadmap towards the next era in assessment by exploring several foundational considerations that will make the next era successful. These include the equally important issues of (1) focusing on accountability, trust and power in assessment, (2) addressing implementation and contextualization of assessment systems, (3) optimizing the use of technology in assessment, (4) establishing infrastructure for data sharing and data storage, (5) developing a vocabulary around emerging sources of assessment data, and (6) reconceptualizing validity around patient care and learner equity. Attending to these priority areas will help leaders create authentic assessment systems that are responsive to learners' and society's needs, while reaping the full promise of competency-based medical education (CBME) as well as emerging data science and artificial intelligence technologies.

Discrimination toward trainees is a pervasive problem, with surveys showing it is often perpetrated by patients. For several years, residents and faculty in an internal medicine residency have participated in a workshop offering a framework for responding to discriminatory behavior by patients. As part of a larger effort to reinforce this teaching and promote an inclusive environment, the authors pursued a multi-pronged simulation curriculum that could be incorporated into graduate medical education programs across their institution. First, the authors conducted trainee and faculty focus groups to better understand their experiences. Qualitative data was collected, including recommendations for responding to discrimination, characteristics of the most common experiences, and trainees' own ideas for worthwhile simulation scenarios. Trainees and faculty were then brought together in a collaborative process to co-develop simulation cases that were later implemented in curricula across multiple learner levels, specialties, and contexts. Participants in these simulations reported improved comfort in responding to discrimination in the moment and/or in the wake of such incidents. Through trainee-faculty collaboration, the project yielded authentic and impactful simulation experiences for learners, while also giving trainees an opportunity to turn previous trauma into constructive learning opportunities that promote an inclusive environment.

INTRODUCTION AND PROBLEM STATEMENT/UNASSIGNED:A chief resident's role incorporates administrative, academic, and interpersonal responsibilities essential to managing a successful residency program. However, rising chief residents receive little formal exposure to leadership training. OBJECTIVES/UNASSIGNED:To (1) define leadership styles; (2) understand the effect of cultural competence on leadership styles; (3) learn effective methods to advocate as the chief resident; (4) provide effective peer feedback; (5) provide effective supervisor feedback; (6) learn effective conflict management; (7) ensure psychological safety. METHODS AND CURRICULUM DESCRIPTION/UNASSIGNED:We developed a 1-day curriculum combining didactics and simulation activities for our program's rising chief residents. Implementation of our curricular design included a morning session focusing on small groups and didactic-based lectures on specific topics pertinent to leadership, along with a debriefing of a psychometric evaluation tool administered before the curriculum day. The simulation activity consisted of 3 group objective structured clinical examination (G-OSCE) scenarios: (1) providing a struggling junior trainee with feedback; (2) debriefing an adverse clinical outcome as the team leader; (3) navigating a challenging situation with a supervising physician. Standardized participants were surveyed for specific objectives. Learners completed precurricular and postcurricular surveys on their familiarity and preparedness for their chief year. RESULTS AND ASSESSMENT DATA/UNASSIGNED:= 0.421), learner-reported use of wellness resources was noted to be reduced after the curricular intervention and remains a result of further interest for exploration. DISCUSSION AND LESSONS LEARNED/UNASSIGNED:A 1-day leadership development curriculum combining didactics and simulation is an effective means of preparing rising chief residents to succeed in their transition to this leadership role.

OBJECTIVES/OBJECTIVE:Communication and other clinical skills are routinely assessed in medical schools using Objective Structured Clinical Examinations (OSCEs) so routinely that it can be difficult to monitor and maintain validity. We report on the accumulation of validity evidence for the Clinical Communication Skills Assessment Tool (CCSAT) based on its use with 9 cohorts of medical students in a high stakes OSCE. METHODS:) based on continuous quality improvement and use of the CCSAT for feedback, remediation, curricular design, and research. RESULTS:Implementation of the CCSAT over time has facilitated our communication skills curriculum and training. Thoughtful case development and investment in standardized patient training has contributed to data quality. Item analysis supports our behaviorally anchored scale (not done, partly and well done) and the skills domains suggested by an a priori evidence-based clinical communication model were confirmed via analysis of actual student data. Evidence synthesized across the frameworks suggests consistent validity of the CCSAT for generalization inferences (that it captures the construct), responsiveness (sensitivity to change/difference), content validity/internal structure, relationships to other variables, and consequences/implications. More evidence is needed to strengthen validity of CCSAT scores for understanding extrapolation inferences and real-world implications. CONCLUSIONS AND PRACTICE IMPLICATIONS/CONCLUSIONS:This pragmatic approach to evaluating validity within a program of assessment serves as a model for medical schools seeking to continuously monitor the quality of clinical skill assessments, a need made particularly relevant since the US NBME no longer requires the Step 2 Clinical Skills exam, leaving individual schools with the responsibility for ensuring graduates have acquired the requisite core clinical skills. We document strong evidence for CCSAT validity over time and across cohorts as well as areas for improvement and further examination.

PURPOSE/OBJECTIVE:As the COVID-19 pandemic forced most colleges and universities to go online, student health centers rapidly shifted to telehealth platforms without frameworks for virtual care provision. An urban student health center implemented a needs assessment involving unannounced standardized patients (USPs) to evaluate the integration of a new telehealth workflow and clinicians' virtual communication skills. METHODS:From April to May 2021, USPs conducted two video visits with 12 primary care and four women's health clinicians (N = 16 clinicians; 32 visits). Cases included (1) a 21-year-old female presenting for birth control with a positive Patient Health Questionaire-9 and (2) a 21-year-old male, who vapes regularly, with questions regarding safe sex with men. Clinicians were evaluated using a checklist completed by the USP immediately following the visit and a systematic chart review of the electronic health record. RESULTS:USP feedback indicates most clinicians received high ratings for general communication skills but may benefit from educational intervention in several key telemedicine skills. Clinicians struggled with using nonverbal signals to enrich communication (47% well done), acknowledging emotions (34% well done), and using video for information gathering (34% well done). Low rates of standard screenings (e.g., 63% administered the PHQ-2, <50% asked about alcohol use) suggested protocols for in-person care were not easily incorporated into telehealth practices, and clinicians may benefit from enhanced care team support. Performance reports were shared with clinicians and leadership postvisit. DISCUSSION/CONCLUSIONS:Results suggest project design and implementation is scalable and feasible for use at other institutions, offering a structured methodology that can improve general student health care.

BACKGROUND AND OBJECTIVE/UNASSIGNED:Incidence rates for prostate cancer (PCa) diagnosis and mortality are higher for Black men. It is unknown whether similar disparities exist in survivorship care. We assessed the delivery and quality of survivorship care for Black men undergoing PCa therapy in terms of the burden of and treatment for urinary adverse events (UAEs) and erectile dysfunction (ED). METHODS/UNASSIGNED:We queried Optum Clinformatics data for all patients diagnosed with PCa from January 1, 2002 to December 31, 2017 and identified those who underwent primary PCa treatment. Index cohorts were identified in each year and followed longitudinally until 2017. Data for UAE diagnoses, UAE treatments, and ED treatments were analyzed in index cohorts. Cox proportional-hazards regression models were used to examine associations of race with UAE diagnosis, UAE treatment, and ED treatment. KEY FINDINGS AND LIMITATIONS/UNASSIGNED:We identified 146, 216 patients with a PCa diagnosis during the study period, of whom 55, 149 underwent primary PCa treatment. In the primary treatment group, 32.7% developed a UAE and 28.2% underwent UAE treatment. The most common UAEs were urinary incontinence (11%), ureteral obstruction/stricture (4.5%), bladder neck contracture (4.5%), and urethral stricture (3.7%). The most common UAE treatments were cystoscopy (13%), suprapubic tube placement (6%), and urethral dilation (5%). Overall, UAE diagnosis rates were higher for Black patients, who had significantly higher risk of urethral obstruction, rectourethral fistula, urinary incontinence, cystitis, urinary obstruction, and ureteral fistula. Overall, UAE treatment rates were lower for Black patients, who had significantly higher risk of fecal diversion and/or rectourethral fistula repair (adjusted hazard ratio [aHR] 1.71, 95% confidence interval [CI] 1.04-2.79). Regarding ED treatments, Black patients had higher risk of penile prosthesis placement (aHR 1.591, 95% CI 1.26-2.00) and intracavernosal injection (aHR 1.215, 95% CI 1.08-1.37). CONCLUSIONS AND CLINICAL IMPLICATIONS/UNASSIGNED:Despite a high UAE burden, treatment rates were low in a cohort with health insurance. Black patients had a higher UAE burden and lower UAE treatment rates. Multilevel interventions are needed to address this stark disparity. ED treatment rates were higher for Black patients. PATIENT SUMMARY/UNASSIGNED:We reviewed data for patients treated for prostate cancer (PCa) and found that 32.7% were diagnosed with a urinary adverse event (UAE) following their PCa treatment. The overall treatment rate for these UAEs was 28.2%. Analysis by race showed that the UAE diagnosis rate was higher for Black patients, who were also more likely to receive treatment for erectile dysfunction.