Faculty Bibliography

RATIONALE, AIMS, AND OBJECTIVES:Shared decision making (SDM) is widely endorsed in clinical guidelines, yet clinicians may not use it consistently across different clinical problems. This study explores how SDM is influenced by the clinical topic under discussion. METHODS:Using unannounced standardized patients (USPs), we observed how resident physicians engaged in SDM during new patient visits involving both gastroesophageal reflux disease (GERD) and smoking cessation. Audio recordings were evaluated using the validated Observer OPTION-5 tool. RESULTS:SDM scores were significantly higher in smoking cessation discussions than in GERD management. Residents more frequently integrated patient preferences when discussing smoking but gave more information when managing GERD. CONCLUSIONS:Residents appeared to adjust their SDM behaviors based on topic, suggesting context-dependent application. Educational interventions should address this variability and promote balanced use of SDM across routine and behaviorally complex decisions.

INTRODUCTION/BACKGROUND:Telehealth has the potential to expand access to care, though barriers including insurance coverage, technology literacy, and personal preferences have been described since the pandemic induced uptick. Sexual and gender minoritized individuals (SGMs) face unique challenges which make telehealth a particularly promising care option. Regardless of population needs, research efforts looking at experiences and opportunities following multiple years of use are missing from the literature. Given that telehealth is here to stay, this study explores telehealth experiences, barriers, and preferences of SGM individuals 4 + years after rapid uptick to inform future efforts for the community. METHODS:Participants were recruited from an observational cohort study of SGM individuals. Eligible participants consented to follow-up contact and had previously used telehealth. Semi-structured interviews (N = 21) were conducted between March and April of 2024, covering telehealth use, barriers, and future directions. Interviews were recorded, transcribed, and thematically analyzed using a directed content analysis approach informed by prior literature. Coding was completed iteratively by four authors, with themes refined through group consensus, resulting in final recommendations for improving telehealth practice and engagement among SGM populations. RESULTS:The majority of participants were White (52%), cisgender men (90%) with at least some college education (90%), employed full-time (73%), and residing in the southern U.S (57%). Participants highlighted telehealth's benefits, including provider accessibility, convenience, and comfort discussing sexual health needs with affirming clinicians. They found telehealth particularly useful for medication management, mental health, and sexual health services. They also emphasized the importance of promoting telehealth as providing privacy, security, and culturally competent care, findings which underscore their utilization motivators and shed light on unique needs of the population. Participants recommended improvement opportunities, such as creating/expanding directories of LGBTQ + -friendly providers and increasing/tailoring community-targeted marketing through social media and physical spaces. DISCUSSION AND CONCLUSION/CONCLUSIONS:We interviewed a diverse group of SGM-identifying telehealth users to explore their experiences with telehealth-based care. Participants expressed ongoing interest in telehealth overall, but conversations highlighted future opportunities and provided clear next steps for research, practice, and marketing. Our findings provide valuable insight for the next era of telehealth use.

OBJECTIVE/UNASSIGNED:A growing body of literature seeks to understand how best to support students in their Professional Identity Formation (PIF) during medical school. Recent work has suggested the need for a longitudinal approach that supports development of and recognizes variation in professional identity (PI) reflecting individual differences in perspectives and goals. We sought to evaluate a longitudinal, formal PIF curriculum at our medical school through a qualitative analysis of learner perspectives. METHODS/UNASSIGNED:We invited third- and fourth-year medical students likely to have strong opinions on the PIF curriculum to participate in semi-structured interviews, aiming to capture diverse opinions and outliers to better understand its impact. Twenty students were invited to participate, and 15 students consented to participate. We took an inductive thematic approach to data analysis. The first three transcripts were read by coders before the coding process began. Readers then reread the transcripts and independently generated initial codes and then met to develop a consensus on codes and coding framework. The agreed-upon framework was then used to code the subsequent transcripts. RESULTS/UNASSIGNED:Our student interviews revealed a range of perspectives on the PIF curriculum as well as their PI. Five major themes within the data were identified, reflecting the developmental process of identity formation, the challenges and tensions that inform that development, and the impact of the curriculum on the learners' identity development. These themes are 1) deciphering the curriculum and curricular concepts, 2) grappling with the concept of PIF, 3) actively crafting an identity, 4) challenges to engaging with PIF curriculum, and 5) strengthening the curriculum. CONCLUSIONS AND PRACTICE IMPLICATIONS/UNASSIGNED:The development of a PI in budding physicians is complex, and students appreciate the ability to explicitly reflect on and shape their identity, while receiving support and feedback about the process from educators. A formal PIF curriculum that supports students in actively creating their PI provides them with a better understanding of the challenges involved and the scaffolding needed to develop a mature PI that aligns with both professional and personal values.

BACKGROUND:Graduate medical education (GME) on diversity, equity, and inclusion rarely teaches strategies for developing anti-racist mindsets and behaviors, and understanding of the impact of these programs and particular curricular components is lacking. OBJECTIVE:To evaluate the format, content, and impact of a longitudinal anti-racism conference series (ARC) on resident physicians within an urban internal medicine program through a qualitative analysis, with the goal of informing the development and implementation of other evidence-based anti-racism curricula in graduate medical education (GME). DESIGN/METHODS:The ARC consisted of eight mandatory, 60-min virtual conferences held between August 2020 and June 2021 within an internal medicine residency program's primary care track sub-group. The conference's content synthesized previous anti-racism curricula, scholarly readings, and practical experiences, and emphasized internal reflection and behavior change. PARTICIPANTS/METHODS:Thirty internal medicine resident physicians and six faculty members. MAIN MEASURES/METHODS:Seven voluntary, semi-structured, hour-long focus groups were conducted to document resident perspectives on the ARC's format, content, and impact of the curriculum on learner's professional and personal development. Constructivist grounded theory was used to analyze resident responses. KEY RESULTS/RESULTS:In total, 17/30 (57%) residents participated in focus groups. Analysis of course format, content, and impact revealed the following: (1) The most valued aspect of the course's instructional format was its perceived psychological safety. (2) Residents desired course content with more outward action steps than were offered. (3) Residents noted personal and professional impact across three main domains: intrapersonal, interpersonal, and institutional. CONCLUSIONS:In this longitudinal GME internal medicine anti-racism curriculum, participants felt that the curriculum format provided safe spaces to engage with topics on systemic racism and patient care, but content lacked sufficient action-oriented strategies. The curriculum's impact was multi-dimensional and could be studied more deeply in the future through simulation or direct observation.

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.

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/UNASSIGNED:The Professional Identity Essay (PIE) is a theory and evidence-based Medical Professional Identity Formation (MPIF) measure. We describe trajectories of PIE-measured MPIF over a 4-year US medical school curriculum. METHODS/UNASSIGNED:Students write PIEs at medical school orientation, clinical clerkships orientation, and post-advanced (near graduation) clerkship. A trained evaluator assigns an overall stage score to narrative responses to nine PIE prompts (inter-rater ICC 0.83, 95% CI [0.57 - 0.96], intra-rater ICC 0.85). Distribution of PIE stage scores across time points were analyzed in the aggregate and individual students were classified as Increase, Stable (no score change) or Decrease based on the trajectories of PIE stage scores over time. RESULTS/UNASSIGNED: CONCLUSIONS/UNASSIGNED:Medical students' PIE stage scores increase over time with three distinctive trajectories. Further study is needed to explore the utility of this method for formative assessment, program evaluation, and MPIF research.

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.