Faculty Bibliography

OBJECTIVE:New York City was the epicenter of the outbreak of the 2019 coronavirus disease (COVID-19) pandemic in the United States. As a large, quaternary care medical center, NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients during this time. Clinical leadership effectively identified, oriented, and rapidly deployed a "COVID Army," consisting of non-hospitalist physicians, to meet the needs of the patient influx. We share feedback from our providers on our processes and offer specific recommendations for systems experiencing a similar influx in the current and future pandemics. METHODS:To assess the experiences and perceived readiness of these physicians (n = 183), we distributed a 32-item survey between March and June of 2020. Thematic analyses and response rates were examined to develop results. RESULTS:Responses highlighted varying experiences and attitudes of our frontline physicians during an emerging pandemic. Thematic analyses revealed a series of lessons learned, including the need to (1) provide orientations, (2) clarify roles/workflow, (3) balance team workload, (4) keep teams updated on evolving policies, (5) make team members feel valued, and (6) ensure they have necessary tools available. CONCLUSIONS:Lessons from our deployment and assessment are scalable at other institutions.

QUALITY ISSUE:The emergence of COVID-19 highlights the necessity of rapidly identifying and isolating potentially infected individuals. Evaluating this preparedness requires an assessment of the full clinical system, from intake to isolation. INITIAL ASSESSMENT:Unannounced Standardized Patients (USPs) present a nimble, sensitive methodology for assessing this readiness. CHOICE OF SOLUTION:Pilot the Unannounced Standardized Patient methodology, which employs an actor trained to present as a standardized, incognito potentially infected patient, to assess clinical readiness for potential COVID-19 patients at an urban, community safety-net clinic. IMPLEMENTATION:The Unannounced Standardized Patient was trained to present at each team's front desk with the complaint of feeling unwell (reporting a fever of 101 degrees Fahrenheit in the past 24 hours) and exposure to a roommate recently returned from Beijing. The Unannounced Standardized Patient was trained to complete a behaviorally-anchored assessment of the care she received from the clinical system. EVALUATION:There was clear variation in care Unannounced Standardized Patients received; some frontline clerical staff followed best practices; others did not. Signage and information on disease spread prevention publicly available was inconsistent. Qualitative comments shared by the Unannounced Standardized Patients and those gathered during group debrief reinforced the experiences of the Unannounced Standardized Patients and hospital leadership. LESSONS LEARNED:Unannounced Standardized Patients revealed significant variation in care practices within a clinical system. Utilization of this assessment methodology can provide just-in-time clinical information about readiness and safety practices, particularly during emerging outbreaks. Unannounced Standardized Patients will prove especially powerful as clinicians and systems return to outpatient visits while remaining vigilant about potentially infected individuals.

OBJECTIVES/OBJECTIVE:Resident assessment tends to consist of multiple-choice examinations, even in nuanced areas, such as quality assurance. Internal medicine and many other specialties use objective structured clinical examinations, or OSCEs, to evaluate residents. We adapted the OSCE for pathology, termed the Objective Structured Pathology Examination (OSPE). METHODS:The OSPE was used to evaluate first- and second-year residents over 2 years. The simulation included an anatomic pathology sign-out session, where the resident could be evaluated on diagnostic skills and knowledge of key information for cancer staging reports, as well as simulated frozen-section analysis, where the resident could be evaluated on communication skills with a "surgeon." The OSPE also included smaller cases with challenging quality issues, such as mismatched slides or gross description irregularities. All cases were scored based on the Pathology Milestones created by the Accreditation Council for Graduate Medical Education. RESULTS:Using this OSPE, we were able to demonstrate that simulated experiences can be an appropriate tool for standardized evaluation of pathology residents. CONCLUSIONS:Yearly evaluation using the OSPE could be used to track the progress of both individual residents and the residency program as a whole, identifying problem areas for which further educational content can be developed.

BACKGROUND:Point-of-care ultrasound (POCUS) is becoming widely adopted with increasing accessibility of courses. Little is known about the optimal design of the introductory course or longitudinal training programs targeting hospitalists that are critical to success. METHODS:Hospitalists at four academic sites participated in a two-day introductory course and a longitudinal phase comprising clinical POCUS practice, clip uploading with online feedback, hands-on teaching, and monthly ultrasound conferences. Assessments were performed immediately before and after the two-day course and after 1 year. RESULTS:Knowledge increased from baseline to post two-day course (median score 58 and 85%, respectively, p < 0.001) and decreased slightly at 1 year (median score 81%, p = 0.012). After the two-day introductory course, the median score for hands-on image acquisition skills, the principal metric of participant success, was 75%. After 1 year, scores were similar (median score 74%). Confidence increased from baseline to post two-day course (1.5 to 3.1 on a 4 point Likert scale from Not at all confident (1) to Very confident (4), p < 0.001), and remained unchanged after 1 year (2.73). Course elements correlating with a passing score on the final hands-on test included number of clip uploads (r = 0.85, p,0.001), attendance at hands-on sessions (r = 0.7, p = 0.001), and attendance at monthly conferences (r = 0.50, p = 0.03). CONCLUSIONS:The I-ScaN POCUS training program increased hospitalist knowledge, skill and confidence with maintained skill and confidence after 1 year. Uploading clips and attending hands-on teaching sessions were most correlative with participant success.

INTRODUCTION: Clinicians caring for critically-ill patients must be able to discuss prognosis and deliver bad news. To teach Neurology residents how to do this, we designed an objective structured clinical examination (OSCE) case in which trainees discussed prognosis with a standardized patient (SP).
METHOD(S): In 2017, in conjunction with the NYU School of Medicine Simulation Center, neurology faculty designed an OSCE case in which a resident was tasked with informing a SP her father had severe global hypoxic ischemic injury. The SP was instructed to assess the resident's ability to 1) explain the neurologic findings and 2) to respond to an emotional outburst. A neurology attending observed the encounter via one-way glass. After a 10-minute encounter, the resident was provided 5 minutes of feedback. The residents were surveyed on how prepared they felt for the OSCE, how useful it was, how they rated their performance, and how much they learned from the activity via a Likert scale from 1 (worst) to 5 (best) and free text response. The SP completed a behavioral anchored checklist to assess the residents' ability to gather information, develop a relationship, provide education and counseling, present bad news, and maintain professionalism.
RESULT(S): 57 third and fourth year neurology residents completed the case from 2018-2020, 54 (95%) of whom completed the post-OSCE survey. Residents reported feeling moderately prepared (mean Likert score 3.7/5) and rated their performance as average (3.4/5). Overall they found the case to be very helpful (4.6/5). Several reported difficultly with 1) addressing a complex medical case in a limited amount of time 2) reacting appropriately to an emotional family member and 3) avoiding medical jargon. The SP reported that residents performed well in the realms of non-verbal behavior enriched communication, being non-judgmental, not interrupting, acknowledging emotion, and avoiding medical jargon. Areas in which there was room for improvement included collaborating with the SP to decide upon next steps, identifying a support system, and asking "what is going through your mind right now?".
CONCLUSION(S): OSCE cases can be used to teach clinicians how to discuss prognosis and break bad news. Feedback about this simulation was positive, however its efficacy has yet to be evaluated

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.

Objective structured clinical examinations (OSCEs) provide a controlled, simulated setting for competency assessments, while unannounced simulated patients (USPs) measure competency in situ or real-world settings. This exploratory study describes differences in primary care residents' skills when caring for the same simulated patient case in OSCEs versus in a USP encounter. Data reported describe a group of residents (n=20) who were assessed following interaction with the same simulated patient case in two distinct settings: an OSCE and a USP visit at our safety-net clinic from 2009 to 2010. In both scenarios, the simulated patient presented as an asthmatic woman with limited understanding of illness management. Residents were rated through a behaviourally anchored checklist on visit completion. Summary scores (mean % well done) were calculated by domain and compared using paired sample t-tests. Residents performed significantly better with USPs on 7 of 10 items and in two of three aggregate assessment domains (p<0.05). OSCE structure may impede assessment of activation and treatment planning skills, which are better assessed in real-world settings. This exploration of outcomes from our two assessments using the same clinical case lays a foundation for future research on variation in situated performance. Using both assessments during residency will provide a more thorough understanding of learner competency.

BACKGROUND: Primary care (PC) residency training is a period that provides opportunity to develop skills required for independent practice. Unannounced Standardized Patients (USPs), or secret shoppers, are a controlled measure of clinical skills in actual practice. We sought to describe differences in core clinical communication skills over the last decade for PC residents.
METHOD(S): USPs presented as a new patient for a comprehensive visit while portraying one of six unique, outpatient cases (with either chronic or acute symptomology). Actors received extensive training to ensure accurate case portrayal. Each completed a post-visit, behaviorally anchored checklist (not, partly, or well done) in order to provide extensive, actionable feedback. A standardized checklist was used, consisting of individual items across domains including information gathering, relationship development, patient education, activation and satisfaction. Chronbach's alpha for domains ranged from 0.62- 0.89. Summary scores (mean % well done) were calculated by domain and compared by year for all learners and by PGY within year for the primary care (PC) residency. Differences were assessed using ANOVA. Case portrayal accuracy was ensured using audio tape review.
RESULT(S): 396 visits were conducted with PC residents in our urban, safetynet hospital system between 2013 and 2020. While looking across the 8 years, there was variation in mean scores per domain, though Kruskal-Wallis H test did not show any statistical difference. Relationship development and info gathering were the highest rated skills, at 75% and 76% well done, respectively, on average. Patient satisfaction and activation remained uniformly low across years, with scores averaging 36% and 39% well done, respectively. Multi-variate analysis showed no significant changes across domains by cohort (grad year) and PGY levels. Further, there were no significant differences by PGY year or cohort in terms of scoring using a two-way ANOVA, though there was a slight upward trend in relationship development skills since 2017 for all PGY levels. There were similar trends in most domains, with 2020 scores being higher than previous years. There were no significant differences across domains while looking at PGY1 learners only.
CONCLUSION(S): While there were no significant differences in scores, we can postulate that PC residents enter the residency with consistent foundational communication skills, possibly attributable to training. We elected to use the visit itself as the unit of analysis, which does not allow us to tease out differences in individual learners. We also have small sample sizes for earlier years of the USP visit program, which may hinder results. Regardless, results warrant further research in order to gain a more thorough understanding, possibly in relation to curricular trends. Further study will look at individual resident differences and ideally provide insight into curricular improvement areas. LEARNING OBJECTIVE #1: Describe assessment measures LEARNING OBJECTIVE #2: Explore clinical competency

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: Healthcare systems rose to the challenges of COVID-19 by creating or expanding telehealth programs to ensure that patients could access care from home. Traditionally, though, physicians receive limited formal telemedicine training, which made preparedness for this transition uneven. We designed a survey for General Internal Medicine (GIM) physicians within our diverse health system to describe experiences with providing virtual patient care; with the ultimate goal of identifying actionable recommendations for health system leaders and medical educators.
METHOD(S): Surveys were sent to all faculty outpatient GIM physicians working at NYU Langone Health, NYC Health + Hospitals/Bellevue and Gouverneur, and the VA NY Harbor Health System (n=378) in May & June of 2020. Survey items consisted of Likert and open-ended questions on experience with televisits (13 items) and attitudes toward care (24 items). Specific questions covered barriers to communication over remote modalities.
RESULT(S): 195/378 (52%) responded to the survey. 96% of providers reported having problems establishing a connection from the patient's end while 84% reported difficultly establishing connection on the provider's end. Using interpreter services over the phone was also problematic for providers, with 38% reporting troubles. Regarding teamness, 35% of physicians found it difficult to share information with healthcare team members during virtual visits and 42% found it difficult to work collaboratively with team members, both when compared to in-person visits. When subdivided, 24% of private and 40% of public providers found info sharing more difficult (p<0.04). 31% of private providers and 45% of public found team collaboration more difficult (ns). Physicians also identified challenges in several domains including physical exams (97%), establishing relationships with new patients (74%), taking a good history (48%), and educating patients (35%). In thematic analysis of open-ended comments, themes emerged related to technological challenges, new systems issues, and new patient/provider communication experiences. Positives noted by physicians included easier communication with patients who often struggle with keeping in-person appointments, easier remote monitoring, and a more thorough understanding of patients' home lives.
CONCLUSION(S): Provider experience differences were rooted in the type of technology employed. Safety-net physicians conducted mostly telephonic visits while private outpatient physicians utilized video visits, despite both using the same brand of electronic medical record system. As we consider a new normal and prolonged community transmission of COVID-19, it is essential to establish telemedicine training, tools, and protocols that meet the needs of both patients and physicians across diverse settings. LEARNING OBJECTIVE #1: Describe challenges and barriers to effective communication and clinical skill utilization during televisits LEARNING OBJECTIVE #2: Conceptualize recommendations for educational curricula and health service improvement areas