Faculty Bibliography

OBJECTIVE:Presenting the diagnosis of psychogenic nonepileptic seizures (PNES) can be a difficult task, but disclosing this information effectively is important to optimize patient outcomes. We sought to develop a standardized method to teach neurology residents how to introduce the diagnosis of PNES via an objective structured clinical examination (OSCE) with a standardized patient (SP). METHODS:In conjunction with the New York University School of Medicine Simulation Center (NYSIM), we designed an OSCE in which a resident had to inform a SP of her diagnosis of PNES and discuss a treatment plan. The SP was provided with details to gradually disclose depending on what the resident said about the history of her episodes, triggers for her episodes and her history of sexual abuse. Each encounter was observed by an attending physician who provided real-time feedback to the resident after the session. Additionally, the SP completed an objective written checklist of items the resident should have covered in the session and gave them verbal feedback. RESULTS:Twenty-six adult neurology (n = 22), child neurology (n = 3), and neuropsychiatry (n = 1) residents participated in this OSCE in 2018 and 2019, with full data available for 25 participants. Residents reported the OSCE was very useful (mean Likert score of 4.9/5). They felt moderately prepared (mean Likert score 3.8/5) and rated their performance as a mean of 3.3/5. On the SP's checklist, most residents were rated as Well Done in the domains of information gathering, relationship development, and education and counseling. Only in the domain of psychosocial assessment were most residents rated as Not Done (only 7/25 inquired about past trauma as a risk factor for PNES). SIGNIFICANCE/CONCLUSIONS:The OSCEs are a feasible and useful way to teach neurology residents about discussing PNES, as they allow for provision of real-time practice and feedback in a safe environment without real patients.

Background: The transition from medical student to intern presents a major patient safety concern. Our institution implemented an immersive First Night OnCall (FNOC) simulation to support transitioning trainees and cultivate a culture of safety.
Objective(s): Engage pediatric interns in a pediatric focused FNOC simulation to ensure readiness to recognize and address common safety issues in practice.
Method(s): Interns were asked to recognize patient safety hazards in a simulated patient room and participate in case based safety discussions. Interns then participated in GOSCEs (Group Observed Standardized Clinical Encounters). GOSCEs tasked trainees to obtain informed consent, evaluate a decompensating patient, recognize a mislabeled culture bottle, and give an effective patient handoff. Faculty debriefed all activities. Learners completed pre and post program assessments and a program evaluation.
Result(s): Twenty incoming interns completed FNOC. Only 11% reported any prior formal training in patient safety. Interns recognized 46% of the environmental patient safety hazards. Out of the 5 GOSCE groups, 3 called a rapid response team, 3 noted the label error for the culture bottle, and 3 obtained complete informed consent. After FNOC, 92% of interns reported increased comfort (4 or 5 on 1-5 scale) in speaking to a supervisor, escalating a situation, and reporting a medical error. All interns agreed that the case based safety discussions and the patient safety room increased readiness for internship. Almost all of the interns (85%) agreed or strongly agreed that FNOC was an effective way to learn patient safety, a good approach to improve readiness, fun, and engaging.
Conclusion(s): Incoming interns are not consistently able to demonstrate common safety practices. Engaging, immersive, simulation based experiences like FNOC may reduce this variability, while simultaneously instilling aspirational institutional norms, promoting a culture of safety, and providing a framework for effective on-boarding strategies for new trainees.
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BACKGROUND: According to the 2017 American College of Gastroenterology (AGA) guidelines, therapeutic drug monitoring (TDM) of drug trough concentrations and anti-drug antibodies is recommended to optimize treatment with anti-tumor necrosis factor (TNF) agents and thiopurines1. Specifically, the AGA conditionally recommends reactive TDM in patients with active symptoms of inflammatory bowel disease (IBD) while on anti-TNF agents, as such testing is crucial for differentiating between mechanistic, non-immune mediated pharmacokinetic and immune-mediated pharmacokinetic drug failure, and allows providers to appropriately tailor treatment regimens. As such algorithms for monitoring therapies in IBD have evolved, it has become incumbent on physicians caring for these patients to develop techniques to engage in patient-centered care using the technique of shared decision making. Gastroenterology (GI) trainees may not be well versed in navigating these complex interpersonal skills. The Observed Structured Clinical Examination (OSCE) is a well-validated method of assessing core competencies of communication and professionalism. While it is traditionally used at the undergraduate medical education level, it has been used at the graduate level to address disease-specific competencies. Here, we discuss the use of an OSCE to assess the performance of GI fellows in engaging in shared decision-making on the topic of TDM for a patient with complex IBD refractory to treatment.
METHOD(S): Eleven second-year gastroenterology fellows from 4 GI fellowship programs participated in a 4 station OSCE. Previously validated OSCE checklists were used to assess the fellows' performance in IBD-specific cases, one of which will be discussed here. In the "Therapeutic Drug Monitoring" case, the objective for the fellows was to discuss the indications for infliximab trough and antibody testing and how results of this testing would impact treatment based on the AGA guidelines. Checklists were scored on a 3 and 5-point Likert Scale by the Standardized Patient (SP), mapped to the appropriate ACGME milestones by a GI medical educator and normalized on a scale from 0 to 9. Post-OSCE, the fellows were surveyed to assess their perspective on their performance as well as the exam's educational value.
RESULT(S): 6 ACGME milestones were assessed in this OSCE. Scores ranged from mean of 5.85 to 7.88. Fellows scored lowest on gathering and synthesizing essential and accurate information to define each patient's clinical problem(s) (PC1, mean score 5.85) with an average score of 5.85. They scored highest for overall clinical knowledge (MK1, mean score 7.88). Overall, 9/10 (90%) of fellows would be recommended for their interpersonal skills, but only 4/10 (40%) were deemed effective in their communication skills. The majority of fellows noted improvement in their understanding of when to use and how to interpret TDM after the exercise. CONCLUSION(S): This OSCE was designed to assess clinical and communication skills for gastroenterology surrounding the complex clinical arena of therapeutic drug monitoring utilizing crucial communication skills. The results suggest weaker performance linked to gathering and synthesizing clinical information, with stronger performance in clinical knowledge, developing management plans and various communication skills. This OSCE feedback and assessment can be used to develop targeted educational interventions to strengthen clinical and communication skills for providers

Background Clinical reasoning (CR) is a core competency in medical education. Few studies have examined efforts to train faculty to teach CR and lead CR curricula in medical schools and residencies. In this report, we describe the development and preliminary evaluation of a faculty development workshop to teach CR grounded in CR theory. Methods Twenty-six medicine faculty (nine hospitalists and 17 subspecialists) participated in a workshop that introduced a framework to teach CR using an interactive, case-based didactic followed by role-play exercises. Faculty participated in pre- and post-Group Observed Structured Teaching Exercises (GOSTE), completed retrospective pre-post assessments (RPPs), and made commitment to change statements (CTCs). Results In the post-GOSTE, participants significantly improved in their use of problem representation and illness scripts to teach CR. RPPs revealed that faculty were more confident in their ability and more likely to teach CR using educational strategies grounded in CR educational theory. At 2-month follow-up, 81% of participants reported partially implementing these teaching techniques. Conclusions After participating in this 3-h workshop, faculty demonstrated increased ability to use these teaching techniques and expressed greater confidence and an increased likelihood to teach CR. The majority of faculty reported implementing these newly learned educational strategies into practice.

Introduction/UNASSIGNED:Despite a decline, smoking rates have remained high, especially in communities with lower income, education, and limited insurance options. Evidence shows that physician-initiated counseling on smoking cessation is effective and saves lives, and that specific skills are needed to appropriately lead this type of patient-physician communication. Residency is a critical moment for future physicians and may be the optimal time to learn, practice, and refine this skillset. Unannounced Standardized Patients (USPs) have been found to be effective, incognito evaluators of resident practices. Methods/UNASSIGNED:This study introduced rigorously trained actors (USPs) into two urban, safety-net clinics to assess resident ability to engage, activate, and counsel a pre-contemplative smoker. A complementary chart review assessed appropriate documentation in the patient's electronic health record (EHR) and its relationship to counseling style and prescribing practices. Results/UNASSIGNED:Resident scores (% well done) on patient education and engagement were low (33% and 23%, respectively). Residents who coupled cessation advice with an open discussion style activated their patients more than those who solely advised cessation across all comparable measures. On EHR documentation, residents who accurately documented smoking history were more likely to directly advise their patient to quit smoking when compared to residents who did not document (t(97) = 2.828, p = .006, Cohen's D = 0.56). Conclusions/UNASSIGNED:Results highlight the need to reinforce training in patient-centered approaches including motivational interviewing, counseling, and shared decision-making. Future research should focus on the effects of smokers in pre-contemplation on physician counseling style and examine the relationship between medical training and provider communication to guide interventions.

Background: Diagnostic tests account directly for 5% of healthcare costs, but influence decisions constituting 70% of health spending. Only 5% of ordered labs are actually " high value," depending on clinical circumstances. Low-value tests, defined as not appropriate for a given clinical scenario, are ordered in one in five clinic visits. Up to $ 750 billion is spent on these low-value tests, contributing to the estimated one-quarter to one-third of healthcare spending is on wasteful services. We sought to quantify test-specific low-value ordering behaviors in urban outpatient clinics across three standardized patient cases.
Method(s): Unannounced standardized patients (USPs-highly trained actors portraying patients with standardized case presentations) were introduced into medicine residents' primary care clinics in a large urban, safety net hospital over the past five years. The USPs simulated three common outpatient clinical scenarios: a " Well" visit, a visit with a chief complaint of " Fatigue," and a visit with a diagnosis of " Asthma." Diagnostic orders were extracted via retrospective chart review for these standardized visits. For each scenario, appropriateness of diagnostic testing was determined by reference to United States Preventative Services Task Force (USPSTF) and relevant specialty society clinical practice guidelines (CPGs). " Wasteful" (over-ordered) tests were defined as those not explicitly indicated for the given scenario. Costs were derived from GoodRx.com according to local ZIP codes.
Result(s): The most commonly wasteful tests for the Asthma case were CBC (8% of 170 visits) and Chem-7 (6%), though the relative risk of over-ordering TSH was 3.8x that of other scenarios. The most commonly over-ordered tests for the Fatigue case were LFTs (14% of 148 visits) and HBV (5%), with LFTs ordered up to 15-fold more frequently than in other scenarios. The most commonly over-ordered tests for the Well case were BMP (35% of 124 visits), CBC (15%), LFTs (15%), and HBV (11%) ordered at rates up to 6.3x, 2.0x, 14.2x, and 7.4x higher than other scenarios. Finally, the average per patient excess costs were $ 8.27 (+/-$ 1.76), $ 6.79 (+/-$ 4.5), and $ 23.5 (+/-$ 9.34) for Asthma, Fatigue, and Well cases respectively.
Conclusion(s): Inappropriateness in test ordering patterns were observed through USP simulated cases. Certain tests (CBC, BMP, LFTs, and HBV) were more likely used wastefully across cases. Between cases, specific tests were ordered in an inappropriate manner (such as TSH for Asthma, LFTs for Fatigue, and BMP for Well visits). The per patient direct cost of low value testing rose above $ 20 per visit for the Well visit, though the Fatigue case exhibited the most variation. Notably, this excludes downstream (indirect) costs inestimatable from standardized encounters alone. Knowledge of wasteful utilization patterns associated with specific clinical scenarios can guide interventions targeting appropriate use of testing

Background: Inter-provider variability is a major source of low-value care. The dissemination of clinical practice guidelines (CPGs) has targeted this variability, yet 44% of physicians are non-adherent to CPG. This may be due to factors including exceptionalism and incentive misalignment that present a conflict between comprehensiveness and prudence in work-up. A subset of super-utilizers are notable outliers: fewer than 0.5% of physicians account for 10% of healthcare costs. Super-utilizers order labs, request consults, order imaging, and prescribe medications at rates 30%, 140%, 14%, and 25% higher than the general population. We sought to quantify provider-specific low-value test ordering behaviors across three cases.
Method(s): Unannounced standardized patients (USPs) were trained for standardized simulation of three clinical scenarios: a "Well" visit, a chief complaint of "Fatigue," and a diagnosis of "Asthma." USPs were introduced into medicine residents' clinics in a large urban, safety-net hospital. Diagnostic orders were extracted via retrospective chart review. Scenario-specific appropriateness of diagnostic testing was determined by referencing United States Preventative Services Task Force (USPSTF) and specialty society CPGs. "Excessive" tests were those not explicitly indicated for a given scenario in either USPSTF or society CPGs (versus "indicated" tests). "Discretionary" tests were those conditionally indicated, pending patient-specific factors (such as hemoglobin A1C, pending BMI).
Result(s): One or more excessive tests were ordered in 44%, 22%, and 17% of Well (n=124), Fatigue (n=148), and Asthma (n=148) encounters respectively. Percent of orders that were excessive were 18%, 8%, and 10%, respectively. On average, 1.3 (+/-1.7) excessive orders were made. Within each case, rates of excessive ordering were positively correlated with rates of indicated and discretionary ordering, and negatively correlated with rates of omitting indicated tests. For example, in Fatigue, the correlation between excessive and indicated orders was 0.38, between excessive and discretionary orders rates was 0.59, and between excessive and omitted-indicated tests was-0.25 (all p< 0.05). A similar, statistically-significant pattern was found for the other two cases. 10 (21%) and 4 (8%) of 48 residents completing all scenarios demonstrated excessive ordering at rates atleast 1 and 2 standard deviations above the mean, respectively.
Conclusion(s): Introducing USPs representing clinical scenarios revealed marked inter-provider variability. Positive associations between rates of excessive, discretionary and indicated ordering suggest tendencies for comprehensiveness over prudence. Over one-fifth of residents completing all 3 cases were high-utilizers, and nearly one in ten were super-utilizers. Awareness of provider-level ordering tendencies can guide education and interventions supporting appropriate diagnostic use

Background: Newly recruited clinicians have heterogeneous Backgrounds and experiences and need a substantive introduction to their new institution's patient communication expectations and safety culture and standards for clinician performance. We describe a unique onboarding program designed to ensure that newly hired clinicians receive actionable, behaviorally specific feedback from the patients' perspective to support a satisfying transition to the new work environment, enhance patient experience and reduce the need to punitively react to complaints once they have started.
Method(s): During the 2-hour onboarding, participants complete 3, 10-minute Objective Structured Clinical Exam cases designed to assess how they address a medical error, manage the patient's discharge goals of care, and respond to an impaired learner. During each encounter, participants interact with highly trained Standardized Patients (SPs) or Standardized Learners (SLs) who use behaviorally-anchored checklists to evaluate provider performance on communication and case-specific skills. Following each encounter, participants complete a self-assessment while the SPs/SLs complete a behavior-specific checklist, after which the two discuss the encounter and the SL/SP provides confidential and actionable feedback. At the end, participants are encouraged to set individual learning goals to implement in their daily work, complete a program evaluation, and engage in a debrief with experienced facilitators. Participants also receive their SP checklists in addition to an institutional guide containing relevant resources and contacts.
Result(s): Over 2 years, 57 faculty members representing 6 clinical sites participated in the onboarding program. They are heterogeneous with respect to general and case specific performance on these SP/SL cases. For example, 86% adequately elicited the SP/SLs story during the discharge case compared to 66% in the other two cases, 77% addressed pain management (a key patient goal), while 44% did not discuss important medication side effects. Participants have universally found this onboarding to be useful and relevant; 98% agreed/strongly agreed that the program was an effective way to reinforce good habits in patient and learner communication, 96% felt it enhanced confidence about their ability to communicate effectively, and 96% felt it reinforced the institutional culture of safety. All 56 participants who completed the evaluation agreed/strongly agreed that the event was engaging and well-designed, and 93% felt it was a good use of their time and would recommend the program.
Conclusion(s): Traditional orientations are not well recalled and do not address knowledge and skills in real-time. Although it requires additional resources, participants are enthusiastic about our low-stakes introduction to the institution's expectations. This program sets high standards and introduces a new model for skills-based onboarding which may lead to measurably improved patient outcomes

BACKGROUND:Few programs train residents in recognizing and responding to distressed colleagues at risk for suicide. AIM/OBJECTIVE:To assess interns' ability to identify a struggling colleague, describe resources, and recognize that physicians can and should help colleagues in trouble. SETTING/METHODS:Residency programs at an academic medical center. PARTICIPANTS/METHODS:One hundred forty-five interns. PROGRAM DESIGN/UNASSIGNED:An OSCE case was designed to give interns practice and feedback on their skills in recognizing a colleague in distress and recommending the appropriate course of action. Embedded in a patient "sign-out" case, standardized health professionals (SHP) portrayed a resident with depressed mood and an underlying drinking problem. The SHP assessed intern skills in assessing symptoms and directing the resident to seek help. PROGRAM EVALUATION/RESULTS:Interns appreciated the opportunity to practice addressing this situation. Debriefing the case led to productive conversations between faculty and residents on available resources. Interns' skills require further development: while 60% of interns asked about their colleague's emotional state, only one-third screened for depression and just under half explored suicidal ideation. Only 32% directed the colleague to specific resources for his depression (higher among those that checked his emotional state, 54%, or screened for depression, 80%). DISCUSSION/CONCLUSIONS:This OSCE case identified varying intern skill levels for identifying and assessing a struggling colleague while also providing experiential learning and supporting a culture of addressing peer wellness.