Faculty Bibliography

BACKGROUND: Interprofessional collaboration (IPC) is essential for quality care. Understanding residents' level of competence is a critical first step to designing targeted curricula and workplace learning activities. In this needs assessment, we measured residents' IPC competence using specifically designed Objective Structured Clinical Exam (OSCE) cases and surveyed residents regarding training needs. METHODS: We developed three cases to capture IPC competence in the context of physician-nurse collaboration. A trained actor played the role of the nurse (Standardized Nurse - SN). The Interprofessional Education Collaborative (IPEC) framework was used to create a ten-item behaviorally anchored IPC performance checklist (scored on a three-point scale: done, partially done, well done) measuring four generic domains: values/ethics; roles/responsibilities; interprofessional communication; and teamwork. Specific skills required for each scenario were also assessed, including teamwork communication (SBAR and CUS) and patient-care-focused tasks. In addition to evaluating IPC skills, the SN assessed communication, history-taking and physical exam skills. IPC scores were computed as percent of items rated well done in each domain (Cronbach's alpha > 0.77). Analyses include item frequencies, comparison of mean domain scores, correlation between IPC and other skills, and content analysis of SN comments and resident training needs. RESULTS: One hundred and seventy-eight residents (of 199 total) completed an IPC case and results are reported for the 162 who participated in our medical education research registry. IPC domain scores were: Roles/responsibilities mean = 37 % well done (SD 37 %); Values/ethics mean = 49 % (SD 40 %); Interprofessional communication mean = 27 % (SD 36 %); Teamwork mean = 47 % (SD 29 %). IPC was not significantly correlated with other core clinical skills. SNs' comments focused on respect and IPC as a distinct skill set. Residents described needs for greater clarification of roles and more workplace-based opportunities structured to support interprofessional education/learning. CONCLUSIONS: The IPC cases and competence checklist are a practical method for conducting needs assessments and evaluating IPC training/curriculum that provides rich and actionable data at both the individual and program levels.

BACKGROUND: In the patient-centered medical home model of health care, both health care providers (HCPs) and patients must understand their respective roles and responsibilities, view the other as a partner, and use communication skills that promote shared decision making. This is particularly necessary in chronic conditions where outcomes depend on behavior change and in underserved populations where the burden of chronic disease is high. OBJECTIVE: The objectives of this study are to determine if a Patient Empowerment Program (PEP) (1) is acceptable to patients and feasible across multiple clinical sites; (2) will increase patient preference for control in medical decision making, improve patient perceptions of patient-HCP communication, and increase patient activation; (3) is associated with an increase in diabetes self-management behaviors; and (4) has an effect on hemoglobin A1c (HbA1c) level. METHODS: This study recruited English-speaking adult patients with type 2 diabetes mellitus from three urban clinical sites in New York City and randomized them to an immediate intervention group that completed the PEP intervention or a deferred intervention group that served as a wait-list control and completed the PEP intervention after 3-4 months. The PEP intervention consists of two facilitated small group sessions. Session 1 focuses on defining HCP and patient roles in the medical encounter by introducing ideal communication behaviors in each role and by providing both positive and negative examples of patient-HCP encounters. Session 2 focuses on practicing communication skills by role-playing with actors who serve as standardized health care providers. After the role play, participants set goals for their own health care and for future interactions with their HCPs. Outcome measures include the Patient Activation Measure; Ask, Understand, Remember Assessment; Krantz Health Opinion Survey; SF-12v2 Health Survey; Diabetes Self-Management Questionnaire; and HbA1c. These measures will be assessed at the time of enrollment, after the waiting period (deferred intervention only), and then postintervention at 1 week, 3 months, and 6 months. RESULTS: Study recruitment occurred from November 2014 to June 2015, with a total of 80 patients enrolled. To date, 45 participants have attended at least one session of the PEP intervention. Further intervention sessions and post-intervention follow-up are ongoing, with data collection set to be completed in April 2016 and results of data analysis available by June 2016. CONCLUSIONS: From preliminary participant self-report data, our PEP intervention is acceptable to low-income, low-health literate patients and feasible to hold across multiple clinical sites. Participants have reported learning specific ways to change their behaviors at their next HCP visit (eg, stating their opinions, asking more questions). With the forthcoming quantitative data on participant attitudinal and behavior change, the PEP intervention may ultimately empower participants within the medical encounter and improve health outcomes.

Remediation in medical education, the process of facilitating corrections for physician trainees who are not on course to competence, predictably consumes significant institutional resources. Although remediation is a logical consequence of mandating, measuring, and reporting clinical competence, many program leaders continue to take an unstructured approach toward organizing effective, efficient plans for struggling trainees, almost all of who will become practicing physicians. The following 12 tips derive from a decade of remediation experience at each of the authors' three institutions. It is informed by the input of a group of 34 interdisciplinary North American experts assembled to contribute two books on the subject. We intend this summary to guide program leaders to build better remediation systems and emphasize that developing such systems is an important step toward enabling the transition from time-based to competency-based medical education.

This study examined the direct and indirect effects of medical clerkship students' prior knowledge, self-regulation and motivation on learning performance in complex multimedia learning environments. The data from 386 medical clerkship students from six medical schools were analysed using structural equation modeling. The structural model revealed that medical students' prior knowledge directly positively affected their learning outcome, self-efficacy and performance approach goal orientation. The learners' self-regulation had a significant positive direct effect on learning outcome. The learners' mastery goal orientation directly affected their learning outcome. Interestingly, inconsistent with our hypothesis, the learners' performance approach goal orientation showed a significant negative direct effect on learning outcome, and performance avoidance goal orientation had a significant positive effect on learning outcome. These findings help develop a more comprehensive understanding of the role of individual characteristics on learning performance of complex tasks in multimedia learning environments.

PROBLEM: Efforts to evaluate and optimize the effectiveness of medical education have been limited by the difficulty of designing medical education research. Longitudinal, epidemiological views of educational outcomes can help overcome limitations, but these approaches require "bigger data"-more learners, sources, and time points. The rich data institutions collect on students and residents can be mined, however, ethical and practical barriers to using these data must first be overcome. APPROACH: In 2008, the authors established the Research on Medical Education Outcomes (ROMEO) Registry, an educational data registry modeled after patient registries. New York University School of Medicine students, residents, and fellows provide consent for routinely collected educational, performance, quality improvement, and clinical practice data to be compiled into a deidentified, longitudinal database. As of January 2015, this registry included 1,225 residents and fellows across 12 programs (71% consent rate) and 841 medical students (86% consent rate). Procedures ensuring voluntary informed consent are essential to ethical enrollment and data use. Substantial resources are required to provide access to and manage the data. OUTCOMES: The registry supports educational scholarship. Seventy-two studies using registry data have been presented or published. These focus on evaluating the curriculum, quality of care, and measurement quality and on assessing needs, competencies, skills development, transfer of skills to practice, remediation patterns, and links between education and patient outcomes. NEXT STEPS: The authors are working to integrate assessment of relevant outcomes into the curriculum, maximize both the quantity and quality of the data, and expand the registry across institutions.

Standardized patients (SPs) are a widely used, valid, and reliable means of teaching and evaluating healthcare providers (HCPs) across all levels of training and across multiple domains of both clinical and communication skills. Most research on SP programs focuses on outcomes pertinent to the learners (i.e., HCPs) rather than how this experience affects the SPs themselves. This review seeks to summarize the current literature on the risks and benefits of being an SP. We reviewed the literature on the effects that simulation has on adults, children/adolescents, and medical professionals who serve as SPs, in addition to real patients (RPs) who are involved in teaching by sharing their medical histories and experiences. To collect the literature, we conducted two separate systematic searches: one for SPs and one for RPs. Following the searches, we applied standardized eligibility criteria to narrow the literature down to articles within the scope of this review. A total of 67 studies were included that focused on the outcomes of SPs or RPs. The benefits for those portraying SP roles include improved health knowledge and attitudes, relationships with their HCPs, and changed health behaviors. Negative effects of being an SP include anxiety, exhaustion/fatigue, and physical discomfort immediately following a simulation, but the literature to date appears to indicate that there are no long-lasting effects. These findings are consistent across age groups and the type of role being simulated. They are also supported by studies of RPs who are involved in medical education. Overall, the benefits of being an SP appear to outweigh the known risks. However, there are significant limitations in the current literature, and additional studies are needed to better characterize the SP experience.

BACKGROUND: Obesity affects 37 % of patients at Veterans Health Administration (VHA) medical centers. The VHA offers an intensive weight management program (MOVE!) but less than 10 % of eligible patients ever attend. However, VHA patients see their primary care provider about 3.6 times per year, supporting the development of primary care-based weight management interventions. To address gaps in the literature regarding Veterans' experiences with weight management and determine whether and how to develop a primary care-based weight management intervention to both improve obesity counseling and increase attendance to MOVE!, we conducted a qualitative study to assess: 1) Veterans' personal experiences with healthy weight-related behavior change (including barriers and facilitators to behavior change and experiences with primary care providers, staff, and the MOVE! program), and 2) potential new approaches to improve weight management within primary care at the VHA including goal setting and technology. METHODS: Overweight/obese VHA patients (aged 18-75, BMI greater than 30 or greater than 25 with at least 1 co-morbidity) were recruited for focus group sessions stratified by gender, MOVE! referral, and attendance. Each session was facilitated by a trained moderator, audio-recorded, and professionally transcribed. Using an iterative coding approach, two coders separately reviewed and coded transcripts, and met frequently to negotiate codes and synthesize emerging themes. RESULTS: Of 161 eligible patients, 54 attended one of 6 focus groups (2 female, 4 male, 9-11 participants per session): 63 % were male, 46 % identified as African-American, 32 % White/Caucasian, 74 % were college-educated or higher, and 61 % reported having attended MOVE!. We identified two major themes: Impact of Military Service and Promotion and Sustainability of Healthy Behaviors. After service in a highly structured military environment, Veterans had difficulty maintaining weight on their own. They perceived physical activity as having more impact than diet, but chronic pain was a barrier. We identified individual/interpersonal-, community/environment-, and healthcare system-related factors affecting healthy behaviors. We also received input about Veteran's preferences and experiences with technology and setting health goals. CONCLUSIONS: Unique factors influence weight management in Veterans. Findings will inform development of a technology-assisted weight management intervention with tailored counseling and goal-setting within primary care at the VHA.