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Assessing professional identity formation and reflective capacity in medical students: Correlated, but not the same [Meeting Abstract]
Altshuler, L; Lusk, P; Monson, V; King, A; Kalet, A
BACKGROUND: A mature medical professional identity (PI) is a fundamental outcome of medical education (Irby and Hamstra, 2016) and medical schools across the country are developing approaches to support professional identity formation (PIF) in students. Reflective capacity, not just in the moment but as a broad skill, is key to core professional competency and may underlie PIF (Wald, 2015). Yet the relationship between reflective capacity and PIF is not well understood. Do these two concepts assess the same developmental capacity? Is reflective capacity a prerequisite for professional identity development? This pilot study is an initial attempt to explore this issue and to examine the relationship between written reflective capacity and professional identity development.
METHOD(S): As part of a professionalism curriculum medical students complete the Professional Identity Essay (PIE) at three time points: upon entrance to the school, after basic science courses, and after clinical rotations. The PIE (Bebeau and Lewis 2004), based on Kegan's developmental model (1982), requires responses to 9 prompts which elicit conceptions of the professional role. It is scored on a 5-point scale reflecting Kegan's 5 stages, with transitional stages captured by half-points. For this study, we randomly selected 20 PIE protocols from the 100 completed by the Class of 2020 after their basic science curriculum. These were scored by three raters (VM, AK, LA). Interrater reliability was established by reaching 100% agreement within one half stage on the PIE. The same raters scored the PIE protocols with the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT), following the scoring criteria (Wald 2010, Wald 2012). For both the PIE and REFLECT we averaged the three raters into a single score. A Pearson two-tailed correlation was then computed between the two scales.
RESULT(S): Completed scores on both measures were available for 19 of the 20 PIES. The range of PIE scores was 2.5-4, as would be expected of students at this point in their careers (Kalet 2018). REFLECT scores ranged 2-4. There was a statistically significant moderate positive correlation between the PIE and REFLECT (r=.628, p=.004), with REFLECT scores explaining 39% of the variance of PIE scores.
CONCLUSION(S): The correlation between PIE scores and REFLECT ratings suggests that the PIE captures and reflects some elements of learners' reflective capacity. However there remains a large component of the PIE score not explained by reflective capacity, which suggests that the PIE, as a standalone measure of PIF, demonstrates qualities beyond reflective capacity. Further investigation is warranted in order to tease out the interplay between these two concepts. Understanding the relationship between PIF and reflective capacity can inform educators in promoting a more nuanced and sophisticated PI development in students
EMBASE:633955737
ISSN: 1525-1497
CID: 4803452
Use of unannounced standardized patients and audit/feedback to improve physician response to social determinants of health [Meeting Abstract]
Zabar, S R; Wilhite, J; Hanley, K; Altshuler, L; Fisher, H; Kalet, A; Hardowar, K; Mari, A; Porter, B; Wallach, A; Gillespie, C
BACKGROUND: While much is known about the importance of addressing Social Determinants of Health (SDoH), less is known about how physicians elicit, respond to, and act upon their patients' SDoH information. We report on the results of a study that 1) sent Unannounced Standardized Patients (USPs) with programmed SDoH into clinics to assess whether providers uncovered, explored and acted upon the SDoH, 2) provided audit/feedback reports with educational components to clinical teams, and 3) tracked the impact of that intervention on provider response to SDoH.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well-visit), each with specific housing (overcrowding, late rent, and mold) and social isolation (shyness, recent break up, and anxiety) concerns that they shared if asked broadly about. USPs assessed team and provider SDoH practices (eliciting, acknowledging/exploring, and providing resources and/or referrals). 383 USP visits were made to residents in 5 primary care teams in 2 urban, safety- net clinics. 123 visits were fielded during baseline period (Feb 2017-Jan 2018); 185 visits during 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; and 75 follow-up phase visits were fielded (Apr-Dec 2019). Analyses compared rates of eliciting and responding to SDoH across the 3 periods (chi- square, z-scores). One team, by design, did not receive the intervention and serves as a comparison group.
RESULT(S): Among the intervention teams, the rate of eliciting the housing SDoH increased from 46% at baseline to 59% during the intervention period (p=.045) and also increased, but not significantly, for the social issue (40% to 52%, p=.077). There was a significant increase from baseline to intervention in providing resources/referrals for housing (from 7% to 24%, p=.001) and for social isolation (from 13% to 24%, p=.042) (mostly resources, very few referrals were made). The comparison team's rates followed a different pattern: eliciting the housing issue and the social isolation issue decreased from baseline to the intervention period (housing: 61% to 45%; social isolation: 39% to 33% of visits) and the rate of providing resources/referrals stayed steady at 13% for both. In the cases where SDoH were most clinically relevant, baseline rates of identifying the SDoH were high (>70%) but rates of acting on the SDoH increased significantly from baseline to intervention. Increases seen in the intervention period were not sustained in the follow-up period.
CONCLUSION(S): Giving providers SDoH data along with targeted education was associated with increased but unsustained rates of eliciting and responding to housing and social issues. The USP methodology was an effective means of presenting controlled SDoH and providing audit/feedback data. Ongoing education and feedback may be needed
EMBASE:633958103
ISSN: 1525-1497
CID: 4803142
Understanding clinician attitudes toward screening for social determinants of health in a primary care safety-net clinic [Meeting Abstract]
Altshuler, L; Fisher, H; Mari, A; Wilhite, J; Hardowar, K; Schwartz, M D; Holmes, I; Smith, R; Wallach, A; Greene, R E; Dembitzer, A; Hanley, K; Gillespie, C; Zabar, S R
BACKGROUND: Social determinants of health (SDoH) play a significant role in health outcomes, but little is known about care teams' attitudes about addressing SDoH. Our safety-net clinic has begun to implement SDoH screening and referral systems, but efforts to increase clinical responses to SDoH necessitates an understanding of how providers and clinical teams see their roles in responding to particular SDoH concerns.
METHOD(S): An annual survey was administered (anonymously) to clinical care teams in an urban safety-net clinic from 2017-2019, asking about ten SDoH conditions (mental health, health insurance, food, housing, transportation, finances, employment, child care, education and legal Aid). For each, respondents rated with a 4-point Likert-scale whether they agreed that health systems should address it (not at all, a little, somewhat, a great deal). They also indicated their agreement (using strongly disagree, somewhat disagree, somewhat agree, strongly agree) with two statements 1) resources are available for SDoH and 2) I can make appropriate referrals.
RESULT(S): 232 surveys were collected (103 residents, 125 faculty and staff (F/S), 5 unknown) over three years. Of note, mental health (84%) and health insurance (79%) were seen as very important for health systems to address, with other SDoH items seen as very important by fewer respondents. They reported little confidence that the health system had adequate resources (51%) and were unsure how to connect patients with services (39%). When these results were broken out by year, we found the following: In 2017 (n=77), approximately 35% of respondents thought the issues of employment, childcare, legal aid, and adult education should be addressed "a little," but in 2018 (n=81) and 2019 (n=74) respondents found the health system should be more responsible, with over 35% of respondents stating that these four issues should be addressed "somewhat" by health systems. In addition, half of respondents in 2019 felt that financial problems should be addressed "a great deal," up from 31% in 2017. Across all years, food, housing, mental health, and health insurance were seen as SDoH that should be addressed "a great deal". It is of note that respondents across all years reported limited understanding of referral methods and options available to their patients.
CONCLUSION(S): Many of the SDoH conditions were seen by respondents as outside the purview of health systems. However, over the three years, more members increased the number of SDoH conditions that should be addressed a "great deal." Responses also indicated that many of the team members do not feel prepared to deal with "unmet social needs". Additional examination of clinic SDoH coding, referral rates, resources, and team member perspectives will deepen our understanding of how we can cultivate a culture that enables team members to respond to SDoH in a way that is sensitive to their needs and patient needs
EMBASE:633957743
ISSN: 1525-1497
CID: 4803172
Unannounced standardized patients as a measure of longitudinal clinical skill development [Meeting Abstract]
Altshuler, L; Wilhite, J; Mari, A; Chaudhary, S; Hardowar, K; Fisher, H; Hanley, K; Kalet, A; Gillespie, C; Zabar, S R
BACKGROUND: Unannounced Standardized Patients (USPs) provide opportunity to measure residents' clinical skills in actual practice. USPs, or secret shoppers, are trained to ensure accurate case portrayal across encounters, making them optimal for tracking changes in skills longitudinally. At present, little is known about how residents handle USP visits with repeat cases. This study examines variation in resident communication and global domain scores when visited by the sameUSPcase at two separate time points during residency training.
METHOD(S): Primary care residents (n=46) were assessed twice by one of six standardized cases (asthma, fatigue, Hepatitis B concern, back pain, shoulder pain, or well visit) during the course of their residency, typically during their first and third training year. Upon visit completion, residents were rated using a behaviorally-anchored checklist. Communication domains assessed included info gathering (4 items), relationship development (5 items), and patient education (4 items). Other domains included patient activation (4 items) and satisfaction (4 items). Responses were scored as not done, partly done, or well done. Summary scores (mean % well done) were calculated by domain. All cases were combined to create composite scores, due to small sample sizes per case. First and second visit domain scores were compared using a t-test. Finally, we grouped high performers (80% or higher on communication scores during their first visit) because this measure demonstrated competency.
RESULT(S): With cases combined, there were no significant differences based on time of assessment and changes in score between first and second visit were small. 14/46 (30%) learners who performed well on composite overall communication scores (80% or higher) during their first visit outperformed poorer communicators in patient satisfaction (93% vs 61%, P<.001) and activation (48% vs 18%, P<.001). In subsequent visits, these high performers performed at a similar level to their fellow residents, with no significant differences noted. Further, when looking at individual trajectories, individual learner scores in the communication domain increased between visits for 21 learners (46%), decreased for 19 (41%), and stayed same for 7 (15%).
CONCLUSION(S): Results suggest that a learning curve occurs between assessments during the first year in residency and subsequent assessments. This could be due to an increased capacity to engage with a patient occurring training progression, or due to a better understanding of addressing common chief complaints presented with our USP cases. Understanding causes of individual-level score decreases will enable tailoring of educational interventions suitable for specific learner trajectories, as will a deeper dive into the impact of the clinical microsystem on performance. We predict a more nuanced understanding of these mediating factors through our plan of increasing our repeat visit sample size
EMBASE:633957642
ISSN: 1525-1497
CID: 4803202
Home is where the mold grows: Using unannounced standardized patients to understand clinical reasoning and social determinants of health [Meeting Abstract]
Wilhite, J; Zabar, S R; Hardowar, K; Fisher, H; Altshuler, L; Mari, A; Ansari, F; Porter, B; Wallach, A; Hanley, K; Gillespie, C
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
EMBASE:633955908
ISSN: 1525-1497
CID: 4803402
Do providers document social determinants? our emrs say.! [Meeting Abstract]
Wilhite, J; Zabar, S R; Hanley, K; Altshuler, L; Fisher, H; Kalet, A; Hardowar, K; Mari, A; Porter, B; Wallach, A; Gillespie, C
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
EMBASE:633955731
ISSN: 1525-1497
CID: 4803462
What happens when a patient volunteers a financial insecurity issue? Primary care team responses to social determinants of health related to financial concerns [Meeting Abstract]
Zabar, S R; Wilhite, J; Hanley, K; Altshuler, L; Fisher, H; Kalet, A; Hardowar, K; Mari, A; Porter, B; Wallach, A; Gillespie, C
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
EMBASE:633957366
ISSN: 1525-1497
CID: 4803272
Describing faculty exemplars of medical professionalism [Meeting Abstract]
Lusk, P; Altshuler, L; Monson, V; Buckvar-Keltz, L; Crowe, R; Tewksbury, L; Poag, M; Harnik, V; Rivera, R; Kalet, A
BACKGROUND: Internalizing a strong medical professional identity (PI) is a critical part of medical education. Recent studies of medical students have documented that students' PI, measured by the Professional Identity Essay (PIE), a reflective writing assessment of PI based on Kegan's theory of adult development and Bebeau's developmental model of PI, vary and are impacted by education. Little is known about the PI of exemplary professional physicians. We sought to: 1) describe the PI of physicians who exemplify the highest principles of the medical profession, and 2) evaluate NYU faculty identified as professional exemplars by peers to provide data and demonstrate clear role models for learners METHODS: We elicited nominations for professional exemplar physicians from NYU faculty, chief residents, and 4th-year students, using the definition of professionalism developed by Colby and Damon (1992). Participants were recruited after receiving at least 3 nominations; select participants who received 1 or 2 nominations were also recruited to diversify the participants in terms of specialty, years of practice, gender and race.We also used snowball techniques to get nominations fromstudy participants. After consenting, faculty received the 11-question PIE. We analyzed demographic data of nominated faculty and completed a content analysis of the PIE.
RESULT(S): 206 individual faculty were nominated at least one time by 70 community members. 32 individuals were recruited to the study; to date 22 have completed the PIE. The 206 nominees/22 participants represent: 34/12 specialties, average years in practice 17.6/23.8, range of years in practice 62 for nominees/44 for participants. We identified 3 primary themes through the content analysis: (1) Response to Expectations, "Everything. The profession demands everything.As much as this profession takes fromme, it is dwarfed by what I have received in return." (2) Response to Failure: "I fail to live up to expectations every day. Some days thismotivatesme, other days I disappoint myself." (3) Learning from Others: "I view teaching as integral to medical professionalism." There was a range of developmental levels in the responses with some focusing more on external rather than internal motivations: "I can say that the [malpractice] process for me was very threatening, emotionally consuming and had the potential to alter professional behavior in the wrong way."
CONCLUSION(S): Nominated faculty represented a diverse group with respect to PI. Many participants demonstrated great professionalism and a sense of internal PI in responses to the PIE questions, while others focused onmore externalmotivations to drive their professional behaviors. Further analysis is needed to define the qualities of a true exemplary professional. The range of responses of the exemplars can both serve as role models for learners and provide multiple pathways for learners and faculty to strengthen their own professional identities
EMBASE:633955861
ISSN: 1525-1497
CID: 4803412
Development and maintenance of a medical education research registry
Wilhite, Jeffrey A; Altshuler, Lisa; Zabar, Sondra; Gillespie, Colleen; Kalet, Adina
BACKGROUND:Medical Education research suffers from several methodological limitations including too many single institution, small sample-sized studies, limited access to quality data, and insufficient institutional support. Increasing calls for medical education outcome data and quality improvement research have highlighted a critical need for uniformly clean and easily accessible data. Research registries may fill this gap. In 2006, the Research on Medical Education Outcomes (ROMEO) unit of the Program for Medical Innovations and Research (PrMEIR) at New York University's (NYU) Robert I. Grossman School of Medicine established the Database for Research on Academic Medicine (DREAM). DREAM is a database of routinely collected, de-identified undergraduate (UME, medical school leading up to the Medical Doctor degree) and graduate medical education (GME, residency also known as post graduate education leading to eligibility for specialty board certification) outcomes data available, through application, to researchers. Learners are added to our database through annual consent sessions conducted at the start of educational training. Based on experience, we describe our methods in creating and maintaining DREAM to serve as a guide for institutions looking to build a new or scale up their medical education registry. RESULTS:At present, our UME and GME registries have consent rates of 90% (n = 1438/1598) and 76% (n = 1988/2627), respectively, with a combined rate of 81% (n = 3426/4225). 7% (n = 250/3426) of these learners completed both medical school and residency at our institution. DREAM has yielded a total of 61 individual studies conducted by medical education researchers and a total of 45 academic journal publications. CONCLUSION/CONCLUSIONS:We have built a community of practice through the building of DREAM and hope, by persisting in this work the full potential of this tool and the community will be realized. While researchers with access to the registry have focused primarily on curricular/ program evaluation, learner competency assessment, and measure validation, we hope to expand the output of the registry to include patient outcomes by linking learner educational and clinical performance across the UME-GME continuum and into independent practice. Future publications will reflect our efforts in reaching this goal and will highlight the long-term impact of our collaborative work.
PMCID:7305610
PMID: 32560652
ISSN: 1472-6920
CID: 4510572
In the room where it happens: do physicians need feedback on their real-world communication skills? [Editorial]
Zabar, Sondra; Hanley, Kathleen; Wilhite, Jeffrey A; Altshuler, Lisa; Kalet, Adina; Gillespie, Colleen
PMID: 31704892
ISSN: 2044-5423
CID: 4186612