Faculty Bibliography

The objective of this study was to compare unannounced standardized patient (USP) and patient reports of care. Patient satisfaction surveys and USP checklist results collected at an urban, public hospital were compared to identify items included in both surveys. Qualitative commentary was reviewed to better understand USP and patient satisfaction survey data. Analyses included χ² and Mann-Whitney U test. Patients provided significantly higher ratings on 10 of the 11 items when compared to USPs. USPs may provide a more objective perspective on a clinical encounter than a real patient, reinforcing the notion that real patients skew overly positive or negative.

INTRODUCTION/BACKGROUND:COVID-19 forced health systems to rapidly implement telehealth for routine practice, often without sufficient training or standards. We conducted a longitudinal survey of physicians to explore changes in their perceptions of the challenges and benefits of telehealth and identify recommendations for future practice. METHODS:An anonymous online survey was distributed to a cohort of internal medicine physicians in May to June 2020 and March to June 2021. Changes in responses between 2020 and 2021 and by site (private vs. public) were described. These findings, along with those of a thematic analysis of open-ended responses to questions on telehealth experiences, informed a set of recommendations. RESULTS: = 0.027). Physicians' open-ended responses identified recommendations for further improving the design and use of telehealth. DISCUSSION/CONCLUSIONS:Results suggest that physician experience with telehealth improved but opportunities for training and improved integration remain. Longitudinal assessment can deepen understanding of the evolution of telehealth care.

BACKGROUND:The need to engage adults, age 65 and older, in clinical trials of conditions typical in older populations, (e.g. hypertension, diabetes mellitus, Alzheimer's disease and related dementia) is exponentially increasing. Older adults have been markedly underrepresented in clinical trials, often exacerbated by exclusionary study criteria as well as functional dependencies that preclude participation. Such dependencies may further exacerbate communication challenges. Consequently, the evidence of what works in subject recruitment is less generalizable to older populations, even more so for those from racial and ethnic minority and low-income communities. METHODS:To support capacity of research staff, we developed a virtual, three station simulation (Group Objective Structured Clinical Experience-GOSCE) to teach research staff communication skills. This 2-h course included a discussion of challenges in recruiting older adults; skills practice with Standardized Participants (SPs) and faculty observer who provided immediate feedback; and debrief to highlight best practices. Each learner had opportunities for active learning and observational learning. Learners completed a retrospective pre-post survey about the experience. SP completed an 11-item communication checklist evaluating the learner on a series of established behaviorally anchored communication skills (29). RESULTS:In the research staff survey, 92% reported the overall activity taught them something new; 98% reported it provided valuable feedback; 100% said they would like to participate again. In the SP evaluation there was significant variation: the percent well-done of items by case ranged from 25-85%. CONCLUSIONS:Results from this pilot suggest that GOSCEs are a (1) acceptable; (2) low cost; and (3) differentiating mechanism for training and assessing research staff in communication skills and structural competency necessary for participant research recruitment.

OBJECTIVE:Curricula designed to teach and assess the communication skills of pediatric residents variably integrates the parent perspective. We compared pediatric residents' communication skills in an objective structured clinical exam (OSCE) case as assessed by Family Faculty (FF), parents of pediatric patients, versus standardized patients (SP). METHODS:Residents participated in an OSCE case with a SP acting as a patient's parent. We compared resident performance as assessed by FF and SP with a behaviorally-anchored checklist. Items were rated as not done, partly done or well done, with well-done indicating mastery. The residents evaluated the experience. RESULTS:42 residents consented to study participation. FF assessed a lower percentage of residents as demonstrating skill mastery as compared to SP in 19 of the 23 behaviors. There was a significant difference between FF and SP for Total Mastery Score and Mastery of the Competency Scores in three domains (Respect and Value, Information Sharing and Participation in Care and Decision Making). The majority of residents evaluated the experience favorably. CONCLUSION/CONCLUSIONS:Involving parents of pediatric patients in the instructive and assessment components of a communication curriculum for pediatric residents adds a unique perspective and integrates the true stakeholders in parent-physician communication.

Introduction:The known markers of insulin resistance in obese children are well studied. However, they require serial measurements and complicated calculations. The objective is to study IGFBP-1 and its relation with other known risk measures. Materials and Methods:The study included 98 New York City school students of diverse ethnic/racial backgrounds (57 males and 41 females), 11-15 years of age. Subjects were enrolled in a cross-sectional study, and anthropometric measures were collected. They underwent fasting intravenous glucose tolerance tests (IVGTT), and glucose, insulin, lipids, IGFBP-1, adiponectin and inflammatory markers were collected. Results:The subjects were stratified into 3 groups based upon the BMI Z-score. Out of all the subjects, 65.3% were in the group with a BMI Z-score <1 SDS, 16.3% subjects were in the group with a BMI Z-score of 1 to 2 SDS, and 18.4% of the subjects were in the group with a BMI Z-score of more than 2 SDS. The group with a BMI Z-score of more than 2 SDS had increased waist circumference (WC), body fat, increased fasting insulin, and triglycerides (TG). This group had decreased levels of adiponectin and HDL and low IGFBP-1 as compared to the group with BMI <1 SDS. The group with a BMI Z-score of 1 to 2 SDS had a decreased level of IGFBP-1 as compared to the group with a BMI Z-score less than 1 SDS. IGFBP-1 inversely correlated with age, WC, BMI, body fat, TG, and insulin levels. IGFBP-1 positively correlated with adiponectin and HDL levels. Conclusion:IGFBP-1 in children can identify the presence of insulin resistance in the group with BMI 1 to 2 SDS, even before the known markers of insulin resistance such as elevated triglycerides and even before decreased HDL and adiponectin levels are identified.

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.

BACKGROUND: NYU uses the same 14-item checklist for assessing medical student communication skills across our curriculum, which includes highquality Objective Structured Clinical Skills Exams throughout the first three years of medical school: a 3-station Introductory Clinical Experience OSCE (ICE), a 3-station end-of-clinical skills OSCE (Practice of Medicine; POM); and an 8-station, high- stakes OSCE (Comprehensive Clinical Skills Exam; CCSE) after core clerkship. We describe how skills change throughout school and explore how patterns vary by cohort (class) in ways that could be explained by admissions criteria, measurement quality, and/or curriculum changes.
METHOD(S): Three domains are assessed: Info gathering (6 items), relationship development (5 items); and patient education & counseling (3 items). Checklist items use a 3-point scale (not done, partly, well done) with behavioral anchors. Internal consistency (Cronbach's alpha) exceeds .75 for all subdomains and across all years. Domains are supported by Confirmatory Factor Analysis. Mean average % well done was calculated across cases and individuals for each subdomain in an OSCE and compared over the OSCEs and between 8 classes of medical school students entering from 2009 to 2016 (graduating 2013 to 2020) (n=1569).
RESULT(S): Cohorts showed similar patterns communication skills trajectories - improvement over time. Despite changes in admissions criteria and processes, cohorts did not differ in terms of demographics, undergraduate GPA, or MCAT scores. Variability in scores decreased in all cohorts over time while communication improved. Patient education & counseling was significantly and substantially lower than other domains. In terms of cohort effects, communication scores for the entering class of 2013 at the start of medical school (ICE OSCE) were significantly higher than the previous 4. At the end of MS2, scores were similar for cohorts for info gathering and relationship development domains (and high, mean range=77-87% well done) but patient education & counseling varied: Improvement from the 1st to 3rd cohort and then decline for the last 5 cohorts. Within the CCSE (8-station pass/fail, MS3), communication scores increased steadily across entering classes, especially from cohort 4 on. These changes over time and between cohorts were mapped onto a priori descriptions of curricular, measurement and admission changes.
CONCLUSION(S): Our cohort data showed interesting and complex patterns. This study reinforces some limitations of linking curriculum to performance (e.g., no direct measures of the curriculum in terms of content, process and intensity over time, limited data on what makes cohorts different, variable measurement over time, and being unable to control for broader trends likely to influence both cohort and time effects) while also demonstrating the promise of longitudinal perspectives on the development of core competencies. LEARNING OBJECTIVE #1: Understand cohort performance in relation to curricular trends. LEARNING OBJECTIVE #2: Describe variation in performance