Faculty Bibliography

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.

Corrigendum to: Jeffrey A. Wilhite*, Khemraj Hardowar, Harriet Fisher, Barbara Porter, Andrew B. Wallach, Lisa Altshuler, Kathleen Hanley, Sondra R. Zabar and Colleen C. Gillespie. Clinical problem solving and social determinants of health: a descriptive study using unannounced standardized patients to directly observe how resident physicians respond to social determinants of health. Diagnosis 2020, Volume 7, Issue 3, pages 313-324. https://urldefense.proofpoint.com/v2/url?u=https-3A__doi.org_10&d=DwIBAg&c=j5oPpO0eBH1iio48DtsedeElZfc04rx3ExJHeIIZuCs&r=CY_mkeBghQnUPnp2mckgsNSbUXISJaiBQUhM-Uz9W58&m=TyoCBAKzCpBZ4-uIICybN67eGKr9ePdBC-WexDhSuSM&s=-H9hUl6CWWk07_DiPQFbSmQyI2qWxw4tQLZIEBIpIVY&e= . 1515/dx-2020-0002. Unfortunately, a typographic error in the results portion of the abstract was missed during final stages of proofing and editing. The count of full elicitors should read as 38/68 rather than 28/68, and the % of negative elicitors is 23%. The corrected results read as follows: Residents fell into three groups when it came to clinical problem-solving around a housing trigger for asthma: those who failed to ask about housing and therefore did not uncover mold as a potential trigger (neglectors - 21%; 14/68); those who asked about housing in negative ways that prevented disclosure and response (negative elicitors - 23%, 16/68); and those who elicited and explored the mold issue (full elicitors - 56%; 38/68).
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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

Intro/Background: Opioid-related emergency department (ED) visits continue to rise at an alarming rate with 5% annual mortality observed among overdose survivors. Mortality was 60% lower among those receiving pharmacotherapy for opioid use disorder (OUD) in the subsequent year; however, only 1/3 did. Despite D'Onofrio's landmark study demonstrating that initiating buprenorphine and referral in the ED for treatment for OUD is feasible, highly effective, and cost-effective, this life-saving medication is rarely initiated in EDs. Purpose/Objective: Barriers to treatment exist at the patient, provider, and systems levels and include longstanding practice norms, limited experience using medications whose properties are often misunderstood, and the impact stigma has on patients seeking and providers offering treatment. We developed and piloted an experiential education session to mitigate these barriers and increase the likelihood that emergency providers will initiate buprenorphine for patients with OUD in the ED.
Method(s): We created a three case Group Objective Structured Clinical Examination (GOSCE) using standardized patients (SPs) trained to portray three commonly encountered patients with OUD. One participant interacts with one SP (8-10 minutes) while two other participants observe with a faculty member, followed by a 20 minute debrief. Participants are tasked to: a) Assess for ED-initiated buprenorphine and b) Discuss the patients' substance use; provide counseling and education where appropriate. Participants completed pre/post-GOSCE surveys. Outcomes (if available): Thirty-nine emergency medicine providers completed the GOSCE. Prior to the session, 50% had never administered buprenorphine to any patient, 35% in 1-2 patients, and 14% in 3 or more patients. Participants reported an increase in comfort administering buprenorphine comparing pre- and post OSCE surveys; 3.81 to 8.03 respectively (1 = not comfortable, 10 = very comfortable), p<0.001. Reported comfort discussing substance use disorders trended positively from 6.94 to 8.29 without achieving statistical significance.
Summary: It is paramount that emergency medicine providers use all available tools and skills to address the current opioid epidemic. Despite evidence of the benefit of buprenorphine, it remains severely underutilized in the ED. Nationally only 0.9% of emergency physicians are X-waivered to prescribe buprenorphine. In our cohort, 50% had never administered buprenorphine to any ED patient. The primary goal of this experiential education session was to increase the likelihood that emergency providers will administer and initiate BUP treatment for patients with OUD in the ED. The three unique cases provided an intense simulated experience each with challenges often faced in the ED. Case 1: 28 year old man who is anxious to leave the ED after emerging from an opioid overdose after treatment with intranasal naloxone by EMS; Case 2: 35 year old man requesting detox admission from "Oxy"; Case 3: 24 year old woman who is requesting/demanding opioid pain medication after drainage of an abscess resulting from injection drug use. The structured debrief focused on enhancing emergency providers' ability to properly screen and treat patients with buprenorphine as well as improving communication skills discussing OUD. Our results demonstrated that the GOSCE effectively increased providers' reported comfort administering buprenorphine. Qualitative data suggests the session helped facilitate the use of non-stigmatizing language when discussing OUD, acquire strategies on how to discuss buprenorphine and OUD, and positively changed perceptions of buprenorphine & OUD. Participants also found it useful to have difficult patient conversations in the simulation followed by immediate constructive feedback in the debrief. Future study includes examining performance of participants rated by SPs, assessing self-reported comfort and rates of buprenorphine initiation among trainees at six months following the GOSCE. Also, we will track global and individual provider rates of buprenorphine administration and prescribing in our EDs through electronic health record abstraction