Faculty Bibliography

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): In order to describe quality improvement (QI) methods for health systems, we report on 10-years of using Unannounced Standardized Patient (USP) visits as the core of a program of education, training, and improvement in a system serving vulnerable patients in partnership with an academic medical center. LEARNING OBJECTIVES 1: Consider methods for supporting learning healthcare systems LEARNING OBJECTIVES 2: Identify performance data to improve care DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The IOM defines a Learning Healthcare System (LHCS) as one in which science, informatics, incentives and culture are aligned for continuous improvement and innovation and where best practices are seamlessly embedded in the delivery process and new knowledge is captured as an integral by-product of the delivery experience. As essential as electronic health records are to LHCS, such data fail to capture all actionable information needed to sustain learning within complex systems. USPs are trained actors who present to clinics, incognito, to portray standardized chief complaints, histories, and characteristics. We designed and delivered USP visits to two urban, safety net clinics, focusing on assessing physician, team, and clinical micro system functioning. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICHWILL BE USEDTOEVALUATE PROGRAM/INTERVENTION): Behaviorally anchored assessments are used to assess core clinical skills (e.g., communication, information gathering, patient education, adherence to guidelines, patient centeredness, and patient activation). Team functioning assessments include professionalism and coordination. Micro system assessment focuses on safety issues like identity confirmation, hand washing, and navigation. Data from these visits has been provided to the residency, primary care teams, and to leadership and have been used to drive education, team training, and QI. FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): 1111 visits have been sent to internal medicine and primary care residents and their teams/clinics. At the resident level, needs for additional education and training in depression management, opioid prescribing, smoking cessation, and patient activation were identified and informed education. Chart reviews found substantial variation in ordering of labs and tests. At the team level, USPs uncovered needs for staff training, enhanced communication, and better processes for eliciting and documenting Social Determinants of Health (SDoH). Audit/feedback reports on provider responses to embedded SDoH combined with targeted education/resources, were associated with increased rates of eliciting and effectively responding to SDoH. In the early COVID wave, USPs tested clinic response to a potentially infectious patient. Currently, USPs are being deployed to understand variability in patients' experience of telemedicine given the rapid transformation to this modality. Finally, generalizable questions about underlying principles of medical education and quality improvement are being asked & answered using USP data to foster deeper understanding of levers for change. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY): A comprehensive USP program can provide unique insights for driving QI and innovation and help sustain a LHCS

INTRODUCTION/BACKGROUND:Hospital and ambulatory care systems are rapidly building their virtual care capacity in response to the novel coronavirus (COVID-19) pandemic. The use of resident trainees in telemedicine is one area of potential development and expansion. To date, however, training opportunities in this field have been limited, and residents may not be adequately prepared to provide high-quality telemedicine care. AIM/OBJECTIVE:This study evaluates the impact of an adapted telemedicine Objective Structured Clinical Examination (OSCE) on telemedicine-specific training competencies of residents. SETTING/METHODS:Primary Care Internal Medicine residents at a large urban academic hospital. PROGRAM DESCRIPTION/METHODS:In March 2020, the New York University Grossman School of Medicine Primary Care program adapted its annual comprehensive OSCE to a telemedicine-based platform, to comply with distance learning and social distancing policies during the COVID-19 pandemic. A previously deployed in-person OSCE on the subject of a medical error was adapted to a telemedicine environment and deployed to 23 primary care residents. Both case-specific and core learning competencies were assessed, and additional observations were conducted on the impact of the telemedicine context on the encounter. PROGRAM EVALUATION/RESULTS:Three areas of telemedicine competency need were identified in the OSCE case: technical proficiency; virtual information gathering, including history, collateral information collection, and physical exam; and interpersonal communication skills, both verbal and nonverbal. Residents expressed enthusiasm for telemedicine training, but had concerns about their preparedness for telemedicine practice and the need for further competency and curricular development. DISCUSSION/CONCLUSIONS:Programs interested in building capacity among residents to perform telemedicine, particularly during the COVID-19 pandemic, can make significant impact in their trainees' comfort and preparedness by addressing key issues in technical proficiency, history and exam skills, and communication. Further research and curricular development in digital professionalism and digital empathy for trainees may also be beneficial.

Objectives While the need to address patients' social determinants of health (SDoH) is widely recognized, less is known about physicians' actual clinical problem-solving when it comes to SDoH. Do physicians include SDoH in their assessment strategy? Are SDoH incorporated into their diagnostic thinking and if so, do they document as part of their clinical reasoning? And do physicians directly address SDoH in their "solution" (treatment plan)? Methods We used Unannounced Standardized Patients (USPs) to assess internal medicine residents' clinical problem solving in response to a patient with asthma exacerbation and concern that her moldy apartment is contributing to symptoms - a case designed to represent a clear and direct link between a social determinant and patient health. Residents' clinical practices were assessed through a post-visit checklist and systematic chart review. Patterns of clinical problem solving were identified and then explored, in depth, through review of USP comments and history of present illness (HPI) and treatment plan documentation. Results 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 - 24%, 16/68); and those who elicited and explored the mold issue (full elicitors - 56%; 28/68). Of the full elicitors 53% took no further action, 26% only documented the mold; and 21% provided resources/referral. In-depth review of USP comments/explanations and residents' notes (HPI, treatment plan) revealed possible influences on clinical problem solving. Failure to ask about housing was associated with both contextual factors (rushed visit) and interpersonal skills (not fully engaging with patient) and with possible differences in attention ("known" vs. unknown/new triggers, usual symptoms vs. changes, not attending to relocation, etc.,). Use of close-ended questions often made it difficult for the patient to share mold concerns. Negative responses to sharing of housing information led to missing mold entirely or to the patient not realizing that the physician agreed with her concerns about mold. Residents who fully elicited the mold situation but did not take action seemed to either lack knowledge or feel that action on SDoH was outside their realm of responsibility. Those that took direct action to help the patient address mold appeared to be motivated by an enhanced sense of urgency. Conclusions Findings provide unique insight into residents' problem solving processes including external influences (e.g., time, distractions), the role of core communication and interpersonal skills (eliciting information, creating opportunities for patients to voice concerns, sharing clinical thinking with patients), how traditional cognitive biases operate in practice (premature closure, tunneling, and ascertainment bias), and the ways in which beliefs about expectancies and scope of practice may color clinical problem-solving strategies for addressing SDoH.

BACKGROUND: Moral distress is defined as a situation in which an individual believes they know the ethically appropriate action to take but are unable to take that action. The concept ofmoral distress is increasingly recognized as an important mediator of occupational stress and burnout in healthcare, particularly in the nursing literature. However, there is a dearth of literature focusing on moral distress among physician trainees, particularly as regards the clinical training environment. This study explores the phenomenon of moral distress among internal medicine trainees, with an emphasis on the contexts of clinical training and professional role development.
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants. Trainees identified several drivers of moral distress that were unique to their professional development as clinicians and their role as trainees/ learners within clinical teams, including: feelings of inadequacy in clinical or procedural skills, being asked to performduties outside of their scope of practice, discomfort with the idea of 'practicing' skills on patients, poor team communication, disagreements with senior team members, experiences of disempowerment as junior team members, and overwhelming or inappropriate administrative or non-clinical burdens. Participants also identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, aswell as between private, public, and government-run hospital facilities.
CONCLUSION(S): Physician trainees experience considerable moral distress in the context of their professional development, with unique drivers of moral distress identified in the training and clinical team context. This improved understanding of factors unique to the trainees' experience has implications for tailoring educational experiences as professional development activities, as well as potential wellness- and resilience-building among physician trainees. It may also inform the training of physician leaders and seniors clinicians who engage with trainees in learning and clinical environments

BACKGROUND: Moral distress is defined as a situation in which an individual believes they know the ethically appropriate action to take but are unable to take that action. The concept of moral distress is increasingly recognized as an important mediator of occupational stress and burnout in medicine, particularly in the nursing profession. However, there is a dearth of literature on moral distress among physician trainees, with the majority focused on dilemmas in end-of-life care. This study explores the phenomenon of moral distress among internal medicine trainees, with particular focus on drivers, situational contexts, and adaptive strategies such as coping mechanisms.
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants, and was identified across four major domains: personal values and morals, professional competency and training challenges, interpersonal relationships and conflicts, and systems/structural issues. Participants identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, as well as between private, public, and government- run hospital facilities. Participants described a number of adaptive mechanisms for managing moral distress, including social support and connectivity, humor, and disassociation.
CONCLUSION(S): Physician trainees experience considerable moral distress across multiple domains during the course of their training. They also develop unique adaptive strategies and copingmechanisms tomanage and learn from distressing experiences. This improved understanding ofmoral distress among physician trainees, particularly drivers and protective factors, has important implications for the training of physicians, and may have a role in promoting wellness and resilience among physicians across the training and professional pipeline

BACKGROUND: The importance of addressing patients' social determinants of health (SDoH) is widely recognized, but less is known about how physicians specifically elicit, respond to, and document these determinants. We sought to describe resident practices when caring for a patient whose SDoH is integral to accurate diagnosis and treatment using Unannounced Standardized Patients (USPs).
METHOD(S): USPs were used (n=68) to assess how medicine residents responded to the consistent portrayal of a patient with asthma exacerbation and concern that her living situation (moldy, dilapidated housing) might be contributing to her symptoms. USPs, or "secret shoppers", were sent to two of New York's safety-net hospitals. Resident practices were assessed by the USP during a post-visit behaviorally-anchored checklist (7 items) and through a systematic chart review (3 items). Checklist items included whether or not a provider explored and fully elicited the USPs concerns, how they responded once shared, and what the provider actually did in response. Chart review items included whether or not a provider documented their patient's housing concerns in the history of present illness (HPI), problem list, or through use of a billingrelated Z-code.
RESULT(S): 68/79 consented residents participated: 11 PGY1 (16%), 31 PGY2 (46%), and 26 PGY3 (38%). 65% (44/68) of residents elicited the patient's housing SDoH and of those, 75% (33/44) responded by acknowledging/exploring and providing notes/practical support. 30% (10/33) connected the patient to informative resources or direct referral. Less than half (14/33; 42%) of those who acknowledge/explored documented appropriately in the EMR. No residents documented housing in the problem list or with a housing-related ICD10 Z-code. Of the 14 high performers, 6 successfully elicited, acknowledged, and documented housing concerns for one of our other five SDoH cases. More than half (55%) of the residents who elicited housing information connected the mold to the asthma exacerbation as a possible trigger, either during clinical interaction or in documentation. All but one (93%) of those who el icited, acknowledged, and documented made this connection.
CONCLUSION(S): Using USPs to directly observe resident practice behaviors in gathering information about, documenting and taking action on a consistently portrayed SDoH case closely linked to clinical symptoms is the first piece of the puzzle needed to better understand education and training that prepares physicians to address SDoH. Our study identifies practice gaps at all stages - adequately collecting information, understanding the clinical/ treatment consequences of, effectively responding to needs, and in documentation of SDoH. Future research should explore the influence of the clinical microsystem (e.g., SDoH screening tools, available resources and referrals, and workflows) on physician SDoH-related practices

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health, less is known about how members of the care team respond to patient-volunteered SDoH - especially when the determinant is related to financial insecurity. With increasing calls for universal screening for SDoH - what do teams do when a patient shares a financial concern? We report on the use of Unannounced Standardized Patients (USP) to assess how primary care teams respond to volunteered information about financial insecurity and whether an audit/ feedback intervention (with targeted education included) improved that response.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six common scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well visit). USPs volunteered a financial concern (fear of losing job, challenges with financially supporting parent, trouble meeting rent) to the medical assistant (MA) and then again to their provider and assessed the response of both the MA (did they acknowledge and/ or forward the information to the provider?) and the provider (did they acknowledge/ explore and/or provide resources/referrals?). A total of 383 USP visits were delivered to 5 care teams in 2 safety-net clinics. Providers were medicine residents. 123 visits were fielded during the baseline period (Feb 2017-Jan 2018); 185 visits during the intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed. 75 follow-up phase visits were fielded (Apr- Dec 2019). Analyses compared rates of MA and provider response to the volunteered financial insecurity issue across the 3 periods (chi-square, z-scores).
RESULT(S): The baseline rate of responding in some way to the volunteered information was high for both the MA (86% acknowledged) and the providers (100% responded). These overall rates of response did not change substantially or significantly across the three time periods (MA: Intervention period = 87%, Follow- Up period=90%; Provider: Intervention period=98%; Follow-Up period=98%). Rates of acting upon the volunteered information also remained quite consistent across the time periods: from 29 to 35% of MA forwarded the information to the provider across the 3 time periods and from 22 to 28% of providers in each intervention period gave the patient resources or a referral (mostly resources).
CONCLUSION(S): Our findings highlight the importance of patients directly telling team members about a financial concern. Future research should explore whether screening tools are effective in instigating a response. Audit/feedback reports with targeted educational components did not appear to influence the teams' response unlike what we found for housing and social concerns that had to be elicited. Whether this is due to differences in volunteered vs. elicited SDoH or to the nature of the SDoH (financial vs housing/social) warrants further investigation

BACKGROUND: There's been a recent shift toward addressing social determinants of health (SDoH) during the clinical encounter through discussion and documentation. SDoH documentation in the problem list and through billing-related z-code use is necessary for accurate, individual patient and population level tracking andmay improve quality of care.We sought to better understand if/how providers document their patient's SDoH when elicited during a clinical visit.
METHOD(S): Unannounced Standardized Patients (USPs) were sent to two safety-net clinics to assess how medicine residents care for a new patient presenting with one of six unique chief complaints, and accompanying underlying financial, housing, and social concerns. USPs assessed resident practices after the encounter through a behaviorally anchored checklist and systematic chart review. USPs volunteered financial concerns while housing insecurity and social isolation needed to be elicited by the provider. Checklist items assessed if the USP was able to fully disclose their SDoH to the provider. Provider documentation in the electronic medical record (EMR) in one of three spaces: the history of present illness (HPI), the problem list, or through use of a social determinant-specific Zcode was examined when a USP was able to share their concerns.
RESULT(S): 384 USP visits were sent to medical residents from 2017 to 2019. USPs were able to share their financial concerns during 84% of the encounters, but were less likely to be able to share their housing or social concerns with providers (35% and 28%, respectively). Documentation in the HPI and treatment list remained low across cases (<15%) and only one Z-code was used across all visits. On an individual case level, providers addressed housing insecurity most frequently in the asthma case (discussion 65%; documentation: HPI 39%, Plan 16%) and social isolation in the fatigue case (discussion 57%; documentation: HPI 49%, Plan 2%). Providers were least likely to discuss and document SDoH for patients presenting with acute pain.
CONCLUSION(S): In clinical scenarios where SDoH concerns were elicited, residents documented SDoH in less than half of visits. Omission of SDoH not only effects clinical care but also panel management and SDoH population-level estimations. New education strategies are needed to address resident's ability to elicit and accurately document SDoH