Faculty Bibliography

Objective/UNASSIGNED:Evidence-based medicine practices of medical students in clinical scenarios are not well understood. Optimal foraging theory (OFT) is one framework that could be useful in breaking apart information-seeking patterns to determine effectiveness and efficiency of different methods of information seeking. The aims of this study were to use OFT to determine the number and type of resources used in information seeking when medical students answer a clinical question, to describe common information-seeking patterns, and identify patterns associated with higher quality answers to a clinical question. Methods/UNASSIGNED:Medical students were observed via screen recordings while they sought evidence related to a clinical question and provided a written response for what they would do for that patient based on the evidence that they found. Results/UNASSIGNED:Half (51%) of study participants used only 1 source before answering the clinical question. While the participants were able to successfully and efficiently navigate point-of-care tools and search engines, searching PubMed was not favored, with only half (48%) of PubMed searches being successful. There were no associations between information-seeking patterns and the quality of answers to the clinical question. Conclusion/UNASSIGNED:Clinically experienced medical students most frequently relied on point-of-care tools alone or in combination with PubMed to answer a clinical question. OFT can be used as a framework to understand the information-seeking practices of medical students in clinical scenarios. This has implications for both teaching and assessment of evidence-based medicine in medical students.

Introduction/UNASSIGNED:Mentorship is crucial for academic success. And yet, there are few mentoring programs that address the needs of underrepresented, racially/ethnically diverse junior faculty conducting health-related research in the United States. Methods/UNASSIGNED:To expand mentoring capacity for these racially/ethnically diverse faculty, we developed a Peer Mentor Development Program (PMDP) to prepare near-peers, who have similar characteristics and personal experiences, to provide support to participants in an NIH-PRIDE funded Institute. The PMDP program is designed based on the 8-year experience of the Mentor Development Program of the NYU-Health and Hospitals Clinical Translational Science Institute. Annually, up to six alumni are selected into the PMDP, participate in the 12-hour program over 4 days, are paired with 1 to 3 scholar participants to mentor and join monthly PMDP conference calls during the ensuing year. Results/UNASSIGNED:We describe the program, participant experience and lessons learned from our first 18 peer mentors in three PMDP cohorts. Additionally, all 18 peer mentors completed a post-evaluation survey to assess the program. Overall, peers agreed that participating in the PMDP enhanced most of the specific skills targeted. Participants rated 53%-86% of skills as "more than before" participating in PMDP, demonstrating the appreciation and impact of the program. Conclusions/UNASSIGNED:The PMDP may be a model for higher education and academic medicine programs committed to mentoring and retaining racially/ethnically diverse faculty and ultimately contributing to reducing entrenched health disparities between majority and minority populations.

INTRODUCTION/BACKGROUND:Two developing forces have achieved prominence in medical education: the advent of competency-based assessments and a growing commitment to expand access to medicine for a broader range of learners with a wider array of preparation. Remediation is intended to support all learners to achieve sufficient competence. Therefore, it is timely to provide practical guidelines for remediation in medical education that clarify best practices, practices to avoid, and areas requiring further research, in order to guide work with both individual struggling learners and development of training program policies. METHODS:Collectively, we generated an initial list of Do's, Don'ts, and Don't Knows for remediation in medical education, which was then iteratively refined through discussions and additional evidence-gathering. The final guidelines were then graded for the strength of the evidence by consensus. RESULTS:We present 26 guidelines: two groupings of Do's (systems-level interventions and recommendations for individual learners), along with short lists of Don'ts and Don't Knows, and our interpretation of the strength of current evidence for each guideline. CONCLUSIONS:Remediation is a high-stakes, highly complex process involving learners, faculty, systems, and societal factors. Our synthesis resulted in a list of guidelines that summarize the current state of educational theory and empirical evidence that can improve remediation processes at individual and institutional levels. Important unanswered questions remain; ongoing research can further improve remediation practices to ensure the appropriate support for learners, institutions, and society.

INTRODUCTION/BACKGROUND:Systems-based Practice 3 (SBP 3) in the orthopedic residency developmental milestones evaluates residents' knowledge, understanding, and utilization of the electronic medical record (EMR). In order to better assess SBP 3, we conducted a review of residents' clinical notes in order to quantify the current state of orthopedic residents' documentation in the EMR. The purpose of this study was to objectively evaluate orthopedic resident documentation in the EMR. METHODS:Orthopedic resident medical notes from a single orthopedic residency at one academic medical center were scored by faculty members who had directly observed the clinical encounter. These notes were then independently scored by one investigator (N.F.) using clinical contentspecific, objective criteria. Sixty-five medical records were reviewed. All 62 orthopedic residents anonymously completed an 84-question survey on the value of EMR utilization and documentation within the medical record. RESULTS:Many key elements necessary to diagnosing a patient's injury and developing a treatment plan were often omitted (e.g., "Mechanism of Injury" in 32.3% of records), and the majority of notes did not include "Decision Making and Patient Preference" (95.2%) or "Risks/Benefits of Surgery" (93.7%). However, 95.2% of residents agreed that their notes reflect their medical knowledge and 96.8% agreed that their notes reflect their clinical reasoning. DISCUSSION/CONCLUSIONS:The results of this objective review revealed significant deficits in orthopedic resident documentation not identified by faculty observers.

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.

It is highly unusual for learners to leave medical training in the United States even though some individuals' goals may change and others may not achieve expected competence. There are a number of possible reasons for this: (1) students may feel that they have progressed too far into their careers and amassed too much debt to leave medical training; (2) students may be allowed to graduate despite marginal performance; and (3) students may have entered medical training with risk factors for poor performance that were not addressed. As stewards of the educational process, medical educators have an ethical obligation to students and the public to create off-ramps, or points along the educational continuum at which learners can reassess their goals and educators can assess competence, that allow students to leave medicine.Given the nationwide focus on physician health and wellness, the authors believe the creation of options to leave medical training without compromising one's self-esteem or incurring unmanageable debt (i.e., compassionate off-ramps) is a moral imperative. The practice of medicine should not be an exercise in survival; it should allow people to develop and thrive over the course of their careers. Offering students options to make use of the medical competencies they have accumulated in other attractive careers would enable medical educators to behave compassionately toward individual students and fulfill their societal obligation to graduate competent and committed physicians. To this end, the authors present six recommendations for consideration.

Background: For quality care, physicians must be skilled in diagnosing and treating chronic pain. Some studies have shown gender differences in how providers manage pain. And more broadly, female providers provide more patient-centered communication which in turn has been linked to patient activation and satisfaction with care. We explore, using Unannounced Standardized Patients (USPs), whether resident physician gender is associated with the core underlying skills needed to effectively diagnose and management chronic pain: communication, patient centeredness, and patient activation.
Method(s): We designed two USP cases and sent these undercover patients into primary care clinics at two urban, safety-net clinics. The USP cases were similar: a 30-35 y.o. male, presented as a new patient to the clinic with either shoulder pain induced by heavy lifting or knee pain due to a recreational sports injury. USPs completed a post-visit checklist that assessed patient satisfaction (4 items), patient activation (3 items), and communication skills (13 items) using a behaviorally-anchored scale (not done or partly done vs. well done). Summary scores were calculated for each of the three domains. Residents provided consent for their educational data to be used for research as part of an IRB-approved medical education registry.
Result(s): A total of 135 USP visits (80 female providers, 55 male) occurred between 2012 and 2018. Female providers saw 41 shoulder pain and 39 knee pain cases while male providers saw 21 shoulder and 34 knee cases. ANOVA was used to assess differences in summary scores by provider gender (male vs female) and by case portrayed (knee vs shoulder). Skills did not differ significantly by whether knee or shoulder pain case. Gender effects were not seen for patient centeredness or for patient activation; however female providers performed significantly better at relationship development (83% vs males 72% shoulder pain; 70% vs 66% knee pain case; p<.001) and information gathering (86% vs. males 72% shoulder pain; 79% vs66% in knee case; p<.016). Male providers, however, performed slightly better in patient education and counseling (65% vs 63% for shoulder and 38% vs 33% for knee cases; p<.001).
Conclusion(s): Developing a relationship and gathering information are critical to pain management and female residents performed better than male residents in these areas. Male providers performed slightly better than women in patient education and provider gender was not associated with any differences in patient centeredness or activation. In the future, we plan to link these underlying skills to pain management decisions, documentation and ultimately to patient outcomes. We suspect that patient activation may best be measured at follow-up, something not possible with our current USP methodology. Gender differences could be viewed as striking in the context of our relatively homogeneous sample (medicine residency program) and shared clinical environment/healthcare system

Background: Asthma education should focus on patient self-management support. Objective structured clinical examinations (OSCEs), as measured by standardized patients (SPs), provide a controlled, simulated setting for timed competency assessments while Unannounced Standardized Patients (USPs) measure clinical skills transfer in real world clinical settings. Both enable us to assess skills critical for providing quality care to patients. Learners seeing USPs have added real world stressors such as clinical load. This study describes differences in education and activation skills in two assessment contexts.
Method(s): A cohort of primary care residents (n=20) were assessed during two time points: an OSCE and a USP visit at an urban, safety-net clinic from 2009-2010. Residents consented to use of their de-identified routine educational data for research. The SP and USPs presented with the same case; a female asthmatic patient with limited understanding of illness management and concern over symptom exacerbation. Providers were rated using a behaviorally-anchored checklist upon visit completion. Competency domains assessed included patient education (4 items) and activation (4 items). Within the education domain, items included illness management, while the activation domain items assessed resident communication/counseling style. Responses were scored as not done or well done. Summary scores (mean % well done) were calculated by domain. OSCE vs USP means were compared using a paired samples t-test.
Result(s): Residents were more likely to offer an oral steroid as treatment in the OSCE case (50% vs. 35% for USPs), but performed better with USPs on most other items including domain scores. Residents seeing a USP scored significantly higher on five out of eight individual assessment items (p<.05) including recommending a spacer, helping a patient understand their condition, making patients feel like they can take control of their own health, helping a patient understand illness management, and having a patient leave feeling confident in finding solutions independently. Inhaler technique was assessed rarely in either setting (OSCE: 15%, USP: 5%). Domain summary scores (% well done) from the OSCE (activation: 12%, education: 31%) were lower than USP scores (activation: 84%, education: 37%), with differences in overall activation scores being significant (t(19)=-8.905, p<.001).
Conclusion(s): OSCEs are a widely accepted tool for measuring resident competency in a standardized environment but may be focused primarily on knowledge and technical skills. While SPs are trained to be as objective as possible, rater bias might impact scores. USPs may provide more nuanced assessments of communication skills in a setting with reduced time constraints. Next steps include examining attitudes toward OSCEs vs the clinical setting, looking at impact of provider gender, and examining setting-specific issues that promote or hinder high quality care