Faculty Bibliography

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

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

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: 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

Corrigendum to: Jeffrey A. Wilhite*, Khemraj Hardowar, Harriet Fisher, Barbara Porter, Andrew B. Wallach, Lisa Altshuler, Kathleen Hanley, Sondra R. Zabar and Colleen C. Gillespie. Clinical problem solving and social determinants of health: a descriptive study using unannounced standardized patients to directly observe how resident physicians respond to social determinants of health. Diagnosis 2020, Volume 7, Issue 3, pages 313-324. https://urldefense.proofpoint.com/v2/url?u=https-3A__doi.org_10&d=DwIBAg&c=j5oPpO0eBH1iio48DtsedeElZfc04rx3ExJHeIIZuCs&r=CY_mkeBghQnUPnp2mckgsNSbUXISJaiBQUhM-Uz9W58&m=TyoCBAKzCpBZ4-uIICybN67eGKr9ePdBC-WexDhSuSM&s=-H9hUl6CWWk07_DiPQFbSmQyI2qWxw4tQLZIEBIpIVY&e= . 1515/dx-2020-0002. Unfortunately, a typographic error in the results portion of the abstract was missed during final stages of proofing and editing. The count of full elicitors should read as 38/68 rather than 28/68, and the % of negative elicitors is 23%. The corrected results read as follows: 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 - 23%, 16/68); and those who elicited and explored the mold issue (full elicitors - 56%; 38/68).
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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.