Faculty Bibliography

The COVID-19 pandemic has dramatically disrupted the educational experience of medical trainees. However, a detailed characterization of exactly how trainees' clinical experiences have been affected is lacking. Here, we profile residents' inpatient clinical experiences across the four training hospitals of NYU's Internal Medicine Residency Program during the pandemic's first wave. We mined ICD-10 principal diagnosis codes attributed to residents from February 1, 2020, to May 31, 2020. We translated these codes into discrete medical content areas using a newly developed "crosswalk tool." Residents' clinical exposure was enriched in infectious diseases (ID) and cardiovascular disease content at baseline. During the pandemic's surge, ID became the dominant content area. Exposure to other content was dramatically reduced, with clinical diversity repopulating only toward the end of the study period. Such characterization can be leveraged to provide effective practice habits feedback, guide didactic and self-directed learning, and potentially predict competency-based outcomes for trainees in the COVID era.

Background/UNASSIGNED:During the rapid onset of the pandemic, clinicians transitioned from traditional outpatient practice to virtual modalities for providing routine care to patient panels. Like training programs nationwide, telemedicine training and assessment had not been systematically incorporated into our residency. In response, a scheduled Internal Medicine (IM) Objective Structured Clinical Examination (OSCE) was adapted to a remote modality to become virtual care-focused learning experience for trainees and to provide valuable feedback to educators. Methods/UNASSIGNED:Standardized Patients (SPs) rated residents on their communication (including information gathering, relationship development and patient education), patient activation and satisfaction, and telemedicine skills. Analyses included a comparison of domain scores for residents who participated in both the 2020 remote and 2019 in-person OSCEs, and a review of written resident comments about the virtual OSCE. Results/UNASSIGNED: = .008). Conclusion/UNASSIGNED:Our reformulated OSCE accomplished 3 goals including; (1) physically distancing residents from SPs per COVID regulations, (2) providing residents with the opportunity to practice critical virtual visit skills, and (3) alerting our educators to curricular improvement areas. Our methods are useful for other institutions and have applications to the larger medical education community.

LEARNING OBJECTIVES 1: Characterize internal medicine resident's inpatient clinical exposure across public, private, federal and community hospital settings. LEARNING OBJECTIVES 2: Identify disparities in resident's clinical exposure across sites to guide curriculum development and rational rotation scheduling. SETTING AND PARTICIPANTS: Experiential learning through patient care is the primary means by which Internal Medicine (IM) residents mature. Despite this, there is an unmet need to characterize how residents' diverse patient care activities inform their educational experience. This is especially true at NYU's IM Residency, which comprises over 200 residents across four distinct hospital systems, exposing residents to diverse, and often variable clinical content. We have previously described a 'crosswalk tool' which maps ICD10 diagnosis codes to one of 16 American Board of Internal Medicine (ABIM) medical content areas and one of 178 specific condition categories, to better characterize clinical exposure. Here, we translate resident-attributed principal ICD-10 discharge diagnosis codes from each of our Program's four training hospitals in Quarter 1 of AY2020 to profile the educational experience of residents at each site. DESCRIPTION: From July 1-Sept 30 2020, we mined principal ICD10 discharge diagnosis codes from resident teams at Bellevue Hospital (BH), a large public hospital; NYU Langone Hospital-Brooklyn (NYU-BK), an academic community hospital; NYU Lang one Hospitals-Manhattan (NYUMN), a large quaternary hospital; and VA NY Harbor Healthcare-Manhattan (VA), a Veteran's Affairs Hospital. We then applied diagnosis codes to the crosswalk tool to translate ICD10 codes into broad ABIM content areas and specific condition categories, yielding site-specific clinical content maps. EVALUATION: At each site there was notable enrichment in two specific content areas-Infectious Disease (ID) and Cardiovascular Diseases (CVD). However, there were striking differences in the frequency of these content areas across sites. Roughly 28% of all diagnoses fell under ID at NYU-BK and NYU-MN, with half that frequency at BH and VA. CVD diagnoses represented 40% of diagnoses at VA, while only 20% at NYU-BK, 25% at NYU-MN, and 30% at BH. For reference, CVD represents 14% and ID 9% of content on theABIM Certification Exam. There were uniformly low frequencies (<1%) of several less typical ABIM content areas, namely Optho, Derm, Allergy/ Immuno, OB/GYN, and ENT/Dental Med. The frequency of Psychiatry diagnoses, which houses substance use, was markedly higher at BH and NYU-BK than the other sites. There were several substantial differences in condition categories across sites, most notably within 'bacteremia and sepsis syndromes' and 'ischemic heart disease.' DISCUSSION / REFLECTION / LESSONS LEARNED: In this pilot we translate discharge data from four distinct hospital systems into an educational framework to characterize our resident's educational experience and in doing so unmask disparities in exposure that could drive rational changes in rotation schedules and didactic content selection

BACKGROUND: During the rapid onset of the pandemic, clinicians transitioned from traditional outpatient practice to telemedicine for triaging COVID-19 patients and providing routine care to patient panels. Telemedicine training and assessment had not been systematically incorporated into most residencies. In response, a scheduled Internal Medicine (IM) Objective Structured Clinical Examination (OSCE) was adapted to a telemedicineemphasized, virtual modality to become a just-in- time learning experience for trainees.
METHOD(S): Remote cases deployed on common web-based video conference platform included; (1) a potential COVID-19 triage, (2) educating on buprenorphine maintenance, (2) counselling on mammogram screening, and (3) addressing frustration with electronic health record documentation. Simulated Patients (SPs) rated residents on communication skills, patient activation and satisfaction, and case-specific telemedicine items. Analyses included a comparison of domain scores (mean % well done) for residents who participated in both the 2020 remote and 2019 in-person OSCEs, and a review of written resident feedback.
RESULT(S): Fewer than half (46%) of 2020's residents (n=23) performed well on the COVID-19 case's telemedicine skill domain. Residents excelled in using nonverbal communication to enrich on-camera communication (100%), but struggled with virtual physical exams (13%), gathering information (4%), and optimizing technology (4%). Residents expressed interest in more opportunity to practice telemedicine skills going forward. Residents' overall COVID-19 knowledge was fair (54% of items were rated as 'well done'). Fewer than half (45%) advised the SP that testing was not available at the time, but that he should call the city hotline for information, and about half (55%) provided quarantine/ home care instructions. In comparing 2020 (virtual) to 2019 (in-person) OSCE scores, residents who participated in both assessments (n=9) performed similarly on communication skills including information gathering (84% vs. 83%), and relationship development (93% vs. 92%), patient satisfaction (72% vs. 80%) and activation (65% vs. 66%). Patient education scores were significantly lower during the virtual OSCE (40% vs. 76%, P=.008).
CONCLUSION(S): Our reformulated OSCE accomplished three goals: (1) physically distancing residents from SPs, (2) providing residents the opportunity to practice critical telemedicine skills, and (3) alerting our educators to curricular improvement areas in virtual physical exam, patient education, gathering information and optimizing technology. Our methods are scalable at other institutions and have applications to the larger medical and clinical education community. LEARNING OBJECTIVE #1: Describe challenges and barriers to effective communication and clinical skill utilization during televisits. LEARNING OBJECTIVE #2: Understand resident physician practice patterns and communication regarding infectious disease

Background/UNASSIGNED:Telemedicine holds promise to bridge the transition of care between inpatient and outpatient settings. Despite this, the unique communication and technical skills required for virtual encounters are not routinely taught or practiced in graduate medical education (GME) programs. Objective/UNASSIGNED:To develop an objective structured clinical examination (OSCE) case to assess residents' telemedicine-specific skills and identify potential gaps in our residency program's curriculum. Methods/UNASSIGNED:As part of a multi-station OSCE in 2019, we developed a case simulating a remote encounter between a resident and a recently discharged standardized patient. We developed an assessment tool comprising specific behaviors anchored to "not done," "partly done," and "well done" descriptors to evaluate core communication and telemedicine-specific skills. Results/UNASSIGNED:Seventy-eight NYU internal medicine residents participated in the case. Evaluations from 100% of participants were obtained. Residents performed well in Information Gathering and Relationship Development domains. A mean 95% (SD 3.3%) and 91% (SD 4.9%) of residents received "well done" evaluations across these domains. A mean 78% (SD 14%) received "well done" within Education/Counseling domain. However, only 46% (SD 45%) received "well done" evaluations within the Telemedicine domain; specific weak areas included performing a virtual physical examination (18% well done) and leveraging video to augment history gathering (17% well done). There were no differences in telemedicine-specific skill evaluations when stratified by training track or postgraduate year. Conclusions/UNASSIGNED:We simulate a post-discharge virtual encounter and present a novel assessment tool that uncovers telemedicine-specific knowledge gaps in GME trainees.

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.

BACKGROUND: Virtual Urgent Care (VUC) is a now a common modality for providing real-time assessment and treatment of common medical problems. However, most providers have not had formal telemedicine training or clinical experience. Faculty have little experience with this new modality of healthcare delivery. We created an experiential onboarding program in which standardized patients (SPs) are deployed into a VUC platform to assess and deliver feedback to physicians in an effort to provide individual- level quality assurance and identify programlevel areas for improvement.
METHOD(S): We simulated a synchronous urgent care evaluation of a 25- year-old man with lingering upper respiratory tract symptoms refractory to over-the-counter medications. The SP was trained to strongly request an antibiotic prescription. A mock entry in the electronic medical record, available to providers during the visit, provided demographic, prior medical, pharmacy and allergy information. The encounter was scheduled into a regular 30-minute appointment slot during a routine 8-hour shift. We developed a behaviorally- anchored assessment tool to evaluate core communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' SPs provided post-encounter verbal feedback to urgent care providers (UCPs), who received a summary report and had an opportunity provide structured feedback regarding the case. A single SP performed 20 / 21 visits.
RESULT(S): Twenty-one UCPs, with 2 to 23 years of clinical experience, participated in an announced scheduled visit. UCPs performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. All UCPs provided appropriate management plans and did not give antibiotics. In contrast, Education and Counseling skills were less strong (32% 'well done'). Within this domain, few received 'well done' for checking understanding (14%); conveying small bits of information and summarizing to ensure clarity (9%). Most (71% well done) collaborated with the SP in discussing next steps. Specific telemedicine skills were infrequently used: only 19% performed a virtual physical exam, 24% utilized the audio/video interface to augment information gathering, 14% optimized technical aspects by assessing sound, video or ensuring a backup plan should video fail. A subset of UCPs (n=9) provided structured feedback regarding the case. 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improved telehealth skills.
CONCLUSION(S): This experiential virtual urgent care onboarding program utilizing standardized announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. These findings form the basis for dedicated training for virtual urgent care providers to assure quality across the program

Intro/Background: Virtual Urgent Care (VUC) is now a common modality for providing real-time assessment and treatment of common low acuity medical problems. However, most physicians have not had formal telemedicine training or clinical experience and therefore lack proficiency with this new modality of healthcare delivery. We created an experiential onboarding program deploying standardized patients (SPs) into a VUC platform to assess and deliver feedback to physicians, providing individual-level quality assurance and identifying program-level areas for improvement. Purpose/Objective: The objective of this program was to create an experiential training module for physicians as part of their VUC onboarding process with the goal of quality assurance and patient safety. The onboarding experience incorporated common standards for doctor-patient communication as well as the unique skills necessary for the practice of telemedicine. The encounters were unobserved by other faculty, providing participants with a safe and confidential environment to receive feedback on their communication and telemedicine skills.
Method(s): We simulated a synchronous urgent care evaluation of a 25-year-old man with lingering viral upper respiratory tract symptoms refractory to over-thecounter medications. SP training included strongly requesting an antibiotic prescription. A mock electronic medical record encounter provided physicians with demographic and prior medical history. The announced SP appointment occurred during a routine VUC shift. Our behaviorally-anchored assessment tool evaluated communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' Outcomes (if available): Twenty-one physicians provided appropriate management without prescribing antibiotics. Physicians performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. In contrast, Education and Counseling skills were less strong (32% 'well done'); few received 'well done' for checking understanding (14%); conveying and summarizing information (9%). Telemedicine skills were infrequently used: 19% performed virtual physical exam, 24% utilized audio/video interface to augment information gathering, 14% assessed sound, video or ensured backup plan should video fail.
Summary: This experiential virtual urgent care onboarding program utilizing standardized patient announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. Participating VUC physicians had 2 to 23 years of clinical experience. Results illustrate that irrespective of experience, telemedicine visits create a unique set of challenges to the traditional way physicians are taught to engage with their patients. Overall, the onboarding exercise was well received by participating physicians. At the conclusion of the visit, SPs provided immediate verbal feedback to urgent care physicians, who received a summary report and had an opportunity provide structured feedback regarding the case. A subset of urgent care physicians (n=9) provided feedback regarding the case; 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improve telehealth skills. Our innovative onboarding program utilizing highly trained standardized patients can uncover potential gaps in telemedicinespecific skills and form the basis for dedicated training for virtual urgent care physicians to assure quality and patient safety