Faculty Bibliography

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

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

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: To foster patient engagement and trust, cardiovascular procedural informed consent (IC) discussions must go beyond the routine of risks vs benefits and incorporate shared decision making (SDM). Most trainees report learning the IC process through peer observation with little emphasis on skills that enable SDM. Experiential learning with immediate faculty feedback may make it more likely that fellows incorporate these critical advanced skills into their IC practice. Method(s): We developed 3 observed structured clinical examination (OSCE) cases designed to highlight all aspects of the IC discussion for invasive cardiac procedures. We adapted validated standardized patient checklists and created a faculty observation and feedback tool. After the program, fellows completed a survey assessing the likelihood they would incorporate SDM skills into their practice. Result(s): 28 cardiology fellows successfully completed the IC OSCE. Figure 1 demonstrates that while the majority of fellows reported already routinely discussing risks and alternatives a minority reported using patient engagement skills. The majority reported they are very likely to incorporate these assessments into practice. Conclusion(s): Cardiology fellows participating in this formative IC OSCE identified SDM skills they intend to incorporate into their IC discussion practice. The clinical impact of teaching high level learners important patient engagement skills via this approach should be further studied. [Figure presented]2019 American College of Cardiology Foundation. All rights reserved

OBJECTIVE:To provide evidence for the validity of an Introductory Clinical Experience (ICE) that was implemented as a baseline assessment of medical students' clinical communication skills to support progression of skills over time. METHODS:In this longitudinal study of communication skills, medical students completed the ICE, then a Practice of Medicine (POM) Objective Structured Clinical Exam 8 months later, and the Comprehensive Clinical Skills Exam (CCSE) 25 months later. At each experience, trained Standardized Patients assessed students, using the same behaviorally anchored checklist in 3 domains: Information Gathering, Relationship Development, and Patient Education and Counseling (PEC) with good internal reliability (.70-.87). Skills development patterns were described. ICE as a predictor of later performance was explored. Students' perspectives were elicited. RESULTS: = .48, large effect), in 4 patterns. ICE and POM scores predicted future communication skills. Most students recognized the educational value of ICE. CONCLUSION/CONCLUSIONS:Entering medical students' clinical communication skills increase over time on average and may predict future performance. PRACTICE IMPLICATIONS/CONCLUSIONS:Implementing an ICE is likely a valid strategy for monitoring progress and facilitating communication skills development.

BACKGROUND:Objective review of orthopedic resident medical records revealed significant variation in quality of clinical notes suggesting that the implementation of the electronic medical record (EMR) had altered resident perceptions of the purpose of clinical documentation. OBJECTIVE:The purpose of this study was to assess resident perceptions of the purpose and use of the EMR. METHODS:An 84-item survey was developed based on previously validated surveys. All 62 orthopedic residents within one academic institution completed the survey. Questions were divided into six domains and domain scores were calculated by summing responses within each domain; a more negative response on the Likert scale received a higher score. Scores were compared across postgraduate year (PGY). RESULTS:Survey results revealed that most residents agreed that they generally write good patient care notes, their notes contribute to the care of the patient, and as physicians they feel responsible for the accuracy of the information they enter into the EMR. However, residents were divided as to whether they have enough time to write a good patient care note. Domain scores did not significantly differ by PGY indicating that perceptions toward the EMR do not change even as residents increase their knowledge of orthopedics and become more skilled physicians. CONCLUSIONS:Although residents recognize that the information they enter in the EMR is valuable for patient care and safety, some feel unable to consistently utilize the EMR to its full potential due to time constraints.

BACKGROUND:We developed and implemented the Substance Abuse Research Education and Training (SARET) program for medical, dental, nursing, and social work students to address the dearth of health professionals pursuing research and careers in substance use disorders (SUD). SARET has two main components: (1) A novel online curriculum addressing core SUD research topics, to reach a large number of students. (2) A mentored summer research experience for in-depth exposure. METHODS:Modules were integrated into the curricula of the lead institution, and of five external schools. We assessed the number of web modules completed and their effect on students' interest in SUD research. We also assessed the impact of the mentorship experience on participants' attitudes and early career trajectories, including current involvement in SUD research. RESULTS:Since 2008, over 24,000 modules have been completed by approximately 9,700 individuals. In addition to integration of the modules into curricula at the lead institution, all five health-professional partner schools integrated at least one module and approximately 5,500 modules were completed by individuals outside the lead institution. We found an increase in interest in SUD research after completion of the modules for students in all four disciplines. From 2008-2015, 76 students completed summer mentorships; 8 students completed year-long mentorships; 13 published in SUD-related journals, 18 presented at national conferences, and 3 are actively engaged in SUD-related research. Mentorship participants reported a positive influence on their attitudes towards SUD-related clinical care, research, and inter-professional collaboration, leading in some cases to changes in career plans. CONCLUSIONS:A modular curriculum that stimulates clinical and research interest in SUD can be successfully integrated, into medical, dental, nursing, and social work curricula. The SARET program of mentored research participation fostered early research successes and influenced career choice of some participants. Longer-term follow-up will enable us to assess more distal careers of the program.