Faculty Bibliography

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

Background: Inter-provider variability is a major source of low-value care. The dissemination of clinical practice guidelines (CPGs) has targeted this variability, yet 44% of physicians are non-adherent to CPG. This may be due to factors including exceptionalism and incentive misalignment that present a conflict between comprehensiveness and prudence in work-up. A subset of super-utilizers are notable outliers: fewer than 0.5% of physicians account for 10% of healthcare costs. Super-utilizers order labs, request consults, order imaging, and prescribe medications at rates 30%, 140%, 14%, and 25% higher than the general population. We sought to quantify provider-specific low-value test ordering behaviors across three cases.
Method(s): Unannounced standardized patients (USPs) were trained for standardized simulation of three clinical scenarios: a "Well" visit, a chief complaint of "Fatigue," and a diagnosis of "Asthma." USPs were introduced into medicine residents' clinics in a large urban, safety-net hospital. Diagnostic orders were extracted via retrospective chart review. Scenario-specific appropriateness of diagnostic testing was determined by referencing United States Preventative Services Task Force (USPSTF) and specialty society CPGs. "Excessive" tests were those not explicitly indicated for a given scenario in either USPSTF or society CPGs (versus "indicated" tests). "Discretionary" tests were those conditionally indicated, pending patient-specific factors (such as hemoglobin A1C, pending BMI).
Result(s): One or more excessive tests were ordered in 44%, 22%, and 17% of Well (n=124), Fatigue (n=148), and Asthma (n=148) encounters respectively. Percent of orders that were excessive were 18%, 8%, and 10%, respectively. On average, 1.3 (+/-1.7) excessive orders were made. Within each case, rates of excessive ordering were positively correlated with rates of indicated and discretionary ordering, and negatively correlated with rates of omitting indicated tests. For example, in Fatigue, the correlation between excessive and indicated orders was 0.38, between excessive and discretionary orders rates was 0.59, and between excessive and omitted-indicated tests was-0.25 (all p< 0.05). A similar, statistically-significant pattern was found for the other two cases. 10 (21%) and 4 (8%) of 48 residents completing all scenarios demonstrated excessive ordering at rates atleast 1 and 2 standard deviations above the mean, respectively.
Conclusion(s): Introducing USPs representing clinical scenarios revealed marked inter-provider variability. Positive associations between rates of excessive, discretionary and indicated ordering suggest tendencies for comprehensiveness over prudence. Over one-fifth of residents completing all 3 cases were high-utilizers, and nearly one in ten were super-utilizers. Awareness of provider-level ordering tendencies can guide education and interventions supporting appropriate diagnostic use

Background: Moral distress occurs when the ethically correct action cannot be taken because of internal or external constraints. High levels of moral distress are associated with burnout in medical providers. A better understanding of factors associated with high moral distress during post-graduate training is crucial to executing interventions to lower rates of burnout during residency.
Method(s): This is a mixed Methods prospective observational cohort study that aims to enroll 90 internal medicine (IM) residents on a rolling basis from one IM residency program (12/2018-12/2019). Data is being collected by a series of 3 surveys over 1 year, using the previously validated Moral Distress Scale, to evaluate frequency and intensity of distress associated with specific situations experienced or witnessed by residents during training. This initial analysis, bivariate and multivariate regression of quantitative data from the first time point (survey #1), investigated associations between moral distress scores and demographic, training-specific, and intrinsic personal factors of participants. Analysis of qualitative open-ended questions further explored causes of moral distress and as well as coping mechanisms employed by residents.
Result(s): 32 IM residents (44% PGY-1, 28% PGY-2 and 28% PGY-3) have been enrolled thus far. 53% of resident participants identify as male, 43% as female (and 3% as other). 66% were " Categorical" residents, 25% " Primary Care (PC)," and 9.4% " Preliminary Year" PGY-1 Interns. Mean and median moral distress scores were: 66.8 (SD 31.0) and 61 (range 16-132). In multivariate linear regression " PC" residents had scores 31 pt. higher compared to " Categorical" residents (p=0.009). Male residents had scores 25pt lower than female residents (p=0.008), and PGY year conferred an incremental score increase of 11 pt. per year (p=0.057). The model was adjusted for covariates: PGY-year, gender, age, and/or program type. Themes regarding causes of moral distress included: lack of resources, situations when patient care is dictated by cost-saving measures, and aggressive futile care. Coping mechanisms included: debriefing with team members or others outside of work, active individual reflection, exercise/yoga/meditation, participating in activities and social events outside of medicine, reflective writing/journaling, and suppression and/or distraction.
Conclusion(s): In this preliminary analysis, residents in the PC track have higher average moral distress scores. It is unclear whether residents prone to more moral distress self select into this track or whether distress is related to differences in training between PC and categorical tracks. Additionally, more senior residents had average higher scores. This supports the theory of residual moral distress; an increasing amount of moral distress is experienced as a provider witnesses/experiences distressing events over time. Most coping strategies involve social connection and reflection

BACKGROUND:Few programs train residents in recognizing and responding to distressed colleagues at risk for suicide. AIM/OBJECTIVE:To assess interns' ability to identify a struggling colleague, describe resources, and recognize that physicians can and should help colleagues in trouble. SETTING/METHODS:Residency programs at an academic medical center. PARTICIPANTS/METHODS:One hundred forty-five interns. PROGRAM DESIGN/UNASSIGNED:An OSCE case was designed to give interns practice and feedback on their skills in recognizing a colleague in distress and recommending the appropriate course of action. Embedded in a patient "sign-out" case, standardized health professionals (SHP) portrayed a resident with depressed mood and an underlying drinking problem. The SHP assessed intern skills in assessing symptoms and directing the resident to seek help. PROGRAM EVALUATION/RESULTS:Interns appreciated the opportunity to practice addressing this situation. Debriefing the case led to productive conversations between faculty and residents on available resources. Interns' skills require further development: while 60% of interns asked about their colleague's emotional state, only one-third screened for depression and just under half explored suicidal ideation. Only 32% directed the colleague to specific resources for his depression (higher among those that checked his emotional state, 54%, or screened for depression, 80%). DISCUSSION/CONCLUSIONS:This OSCE case identified varying intern skill levels for identifying and assessing a struggling colleague while also providing experiential learning and supporting a culture of addressing peer wellness.

Background: Low-value tests, defined as inappropriate for a given clinical scenario, are ordered in one in five clinic visits. Residents tend to over-order diagnostic tests to "minimize uncertainty" of presenting cases, even though these tests are not useful according to Bayesian statistics; a pursuit deemed the "Ulysses syndrome". Simultaneously, evidence suggests residents misuse preventive tests in half of relevant clinical scenarios. We sought to quantify ordering behaviors in urban primary care clinics across three unannounced standardized cases.
Method(s): Unannounced standardized patients (USPs) were trained for standardized simulation of three clinical scenarios: a "Well" visit, a chief complaint of "Fatigue," and a diagnosis of "Asthma." USPs were introduced into medicine residents' clinics in an urban, safety-net hospital. All electronic orders were extracted via chart review. Scenario-specific appropriateness of diagnostic testing was determined by referencing United States Preventive Services Task Force (USPSTF) and society clinical practice guidelines (CPGs). "Preventive" tests (such as lipid panels or hemoglobin A1C) were derived from USPSTF guidelines whereas "Diagnostic" tests (such as pulmonary function testing for Asthma or heterophile antibodies for Fatigue) were from CPGs. "Excessive" tests were those not explicitly indicated for a given scenario in either USPSTF or CPGs (versus "indicated" tests).
Result(s): Indicated tests were ordered in 29% of Well (124 encounters), 16% of Fatigue (148 encounters), and 12% of Asthma (170 encounters) cases. One or more excessive tests were ordered in 44%, 22%, and 17% of Well, Fatigue, and Asthma encounters respectively. The distribution of indicated and excessive tests for preventive versus diagnostic purposes varied by case: In Well visits, the majority (71%) of excessive testing was in pursuit of a diagnosis, while three-quarters of indicated testing was for preventive purposes. In Fatigue and Asthma visits, the reverse patterns were true: the majority of indicated tests ordered were diagnostic (81% and 68%, respectively) while the majority of excessive tests were preventive (78% and 63%, respectively).
Conclusion(s): Introducing USPs to resident clinics revealed that, for patients presenting without a chief complaint (Well visit), residents successfully ordered less than one-third of indicated tests, and over 75% of inappropriately ordered tests pursued a diagnosis. For patients presenting with chief complaints (Fatigue and Asthma), rates of appropriate ordering were even lower (16% and 12%), and tended to overlook preventive care. In these cases, inappropriate tests tended to be ordered for preventive purposes. Awareness of resident mis-utilization of preventive and diagnostic testing in distinct clinical circumstances can guide educational efforts towards evidence-based care and resource stewardship

Statement of Problem Or Question (One Sentence): Does actionable feedback on patient safety indicators and responses to disclosed social determinants of health (SDOH) impact clinical behavior? Objectives of Program/Intervention (No More Than Three Objectives): (1) Develop/disseminate quarterly audit-feedback reports on SDoH practice behavior, focusing on elicitation of patient information. (2) Enhance our understanding of factors related to disparities in safety/quality of care. (3) Increase rates of SDoH documentation and referral. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We sent Unannounced Standardized Patients (USPs) with SDoH-related needs to care teams in two urban, safety-net clinics. Data collected on practice behaviors were used for cycles of audit and feedback on the quality of electronic health record (EHR) documentation, team level information sharing, and appropriate service referral. Reports contained an evolving educational component (e.g. how to recognize, refer, and document SDoH). We disseminated reports to teams (doctors, nurses, physician's assistants, medical assistants, and staff) at routine meetings and via email. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): Three audit feedback reports have been distributed to date. Survey data was collected at two time points, 2017 (n=77) and 2018 (n=81), to assess provider attitude changes and integration of feedback into clinical practice. Measures included change in team knowledge and attitudes towards SDoH, and response to/documentation of presented SDoH (measured via post-visit checklist and EMR). Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Preliminary data shows no change or improvement in documentation of SDoH and limited variation between firm-level responses. (1) Only 7% of providers reported feeling strongly confident in knowing how to make referrals for social needs in 2018; no improvement since 2017. (2) Despite regular report distribution, 58% of providers reported having received no formalized feedback on responding to SDoH. 24% reported maybe or not sure. (3) 86% of 2018 survey participants self-reported having referred a patient to appropriate services when a social need was identified. Our referral data says otherwise, referrals occur for less than 30% of visits with SDoH-related needs. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Results suggest disconnect between team data and individual reporting: most report they refer but data suggests few do. Deeper integration of reports into team processes, attachment of feedback to curricula, and increased frequency of regular feedback may be needed for accountability. These preliminary Results help refine audit feedback methodology but research is needed to understand motivation and systems barriers to referral and documentation. Future research will look at provider attitudes toward referral processes

Background: There is an increased awareness among healthcare professionals to discuss social determinant of health (SDOH) information with patients. However, the awareness does not necessarily translate into effective response to the situation. In order to better understand the nuances in such conversations between patients and providers, we reviewed qualitative responses from Unannounced Standardized Patient (USP) portraying patients with SDOH concerns who were seen as part of a study to investigate healthcare teams' management of SDOH information.
Method(s): USPs, representing six different clinical cases, were seen by residents at an urban safety-net hospital. Each case had SDOH issues (financial and housing insecurity, social isolation), and USPs were trained to provide such information in a systematic fashion in response to provider questioning. After the encounter, USPs completed a behaviorally-anchored, standardized checklist, and also entered their impressions of the encounter in free text. The focus of this study was to evaluate these comments using a qualitative approach, focusing only on those that addressed SDOH. 258 visits occurred from 2017-present, and 209 relevant comments were analyzed.
Result(s): Three general themes emerged: residents' openness to discussion of SDOH, their understanding of how these issues related to presenting concerns, and how they responded to those concerns. Some providers did not explore SDOH prompts, e.g. " I don't think she cut me off, but she quickly moved on to her next question without further delving deeper", while others were more responsive and supportive e.g., the provider " is very open to hearing my situation, I was able to fully explain my situation clearly." Such provider behavior impacted trust and connection, e.g., " Doctor X had good communication skills, but I felt like he didn't really hear my full story" There were variations in how well providers related SDOH to medical symptoms, e.g. " he completely ignored my concerns about mold at home" [asthma case] vs. " His questions centered around possible anxiety this (housing issue) might be causing me." After acknowledgement, fewer providers provided specific information or referrals to address the problem. This lack of follow-up seemed to leave USPs feeling uncomfortable. Both empathic comments and suggestions for actions influenced their sense of activation to manage their health post-visit.
Conclusion(s): Data from the USP visits indicate that there is a range of attention to and follow up on patient presentation of SDOH needs by trainees in clinical settings. Issues of both general communication skills, awareness of connection between SDOH and health, and awareness of local resources impacted provider behavior, which then had an effect on relationship with patients. The complex issues involved in addressing SDOH highlights the diverse training needs for learners

Background: It is well documented that few ordered tests are " high value" a significant percentage of those ordered are " low-value." Residency offers an opportunity to teach high-value care and educational interventions to do so have been effective. However, the relationship between high-value care and residents' ability to communicate effectively with patients has not been explored. Ability to establish rapport, gather information effectively, and be patient-centered may impact residents' use of tests. We hypothesize that residents with poor skills in these areas may order tests less efficiently.
Method(s): Unannounced Standardized Patients (USPs) were introduced into residents' primary care clinics in a large urban, safety net hospital to portray 3 clinical scenarios: a well visit, a chief complaint of fatigue, and a diagnosis of asthma. Orders were extracted via chart review. Appropriateness of orders was determined by reference to United States Preventive Services Task Force (USPSTF) and clinical practice guidelines. Excessive tests were defined as not explicitly indicated for the scenario-indicated tests were the converse. Number of excessive and % of indicated tests were calculated across the 3 visits for 48 residents. Communication skills in information gathering (5 items) and developing a relationship (6 items) and a patient-centeredness score (4 items: took a personal interest, answered all my questions) were computed as % of behaviorally anchored items rated as " well done" and included in regression models predicting test utilization.
Result(s): On average, residents ordered 15% of indicated tests (SD 9%, 0-38%) across the 3 visits and a mean of 1.3 unnecessary tests (SD 1.7, 0-6). In the regression model, the 3 skills explained 16% of variation in unnecessary tests (p=.047). Information gathering explained the greatest share (8%, p=.041). With all 3 variables in the model, patient-centeredness was positively associated with unnecessary tests (Std Be-ta=.42, p=.016) and information gathering was negatively associated with unnecessary tests (Std Beta=-.34, p=.041). Mirroring these Results, superutilizers (10 residents ordering > =3 excessive tests) had lower information gathering and relationship development scores than other residents (66% vs 75% and 72% vs 76%) but higher patient centeredness scores (80% vs 74%)-although differences were not significant.
Conclusion(s): Our findings suggest that information gathering skills may have a small influence on residents' ordering of excessive tests. Further research with larger samples (adequate power) will help clarify the effect sizes. If our Results stand, interventions for high-value care should include information gathering skills and residency programs should continue to reinforce core communication skills training. In addition, our finding that patient centeredness was associated with ordering unnecessary tests suggests that residency programs could caution residents about conflating ordering of tests with patient-centeredness

Background: Diagnostic tests account directly for 5% of healthcare costs, but influence decisions constituting 70% of health spending. Only 5% of ordered labs are actually " high value," depending on clinical circumstances. Low-value tests, defined as not appropriate for a given clinical scenario, are ordered in one in five clinic visits. Up to $ 750 billion is spent on these low-value tests, contributing to the estimated one-quarter to one-third of healthcare spending is on wasteful services. We sought to quantify test-specific low-value ordering behaviors in urban outpatient clinics across three standardized patient cases.
Method(s): Unannounced standardized patients (USPs-highly trained actors portraying patients with standardized case presentations) were introduced into medicine residents' primary care clinics in a large urban, safety net hospital over the past five years. The USPs simulated three common outpatient clinical scenarios: a " Well" visit, a visit with a chief complaint of " Fatigue," and a visit with a diagnosis of " Asthma." Diagnostic orders were extracted via retrospective chart review for these standardized visits. For each scenario, appropriateness of diagnostic testing was determined by reference to United States Preventative Services Task Force (USPSTF) and relevant specialty society clinical practice guidelines (CPGs). " Wasteful" (over-ordered) tests were defined as those not explicitly indicated for the given scenario. Costs were derived from GoodRx.com according to local ZIP codes.
Result(s): The most commonly wasteful tests for the Asthma case were CBC (8% of 170 visits) and Chem-7 (6%), though the relative risk of over-ordering TSH was 3.8x that of other scenarios. The most commonly over-ordered tests for the Fatigue case were LFTs (14% of 148 visits) and HBV (5%), with LFTs ordered up to 15-fold more frequently than in other scenarios. The most commonly over-ordered tests for the Well case were BMP (35% of 124 visits), CBC (15%), LFTs (15%), and HBV (11%) ordered at rates up to 6.3x, 2.0x, 14.2x, and 7.4x higher than other scenarios. Finally, the average per patient excess costs were $ 8.27 (+/-$ 1.76), $ 6.79 (+/-$ 4.5), and $ 23.5 (+/-$ 9.34) for Asthma, Fatigue, and Well cases respectively.
Conclusion(s): Inappropriateness in test ordering patterns were observed through USP simulated cases. Certain tests (CBC, BMP, LFTs, and HBV) were more likely used wastefully across cases. Between cases, specific tests were ordered in an inappropriate manner (such as TSH for Asthma, LFTs for Fatigue, and BMP for Well visits). The per patient direct cost of low value testing rose above $ 20 per visit for the Well visit, though the Fatigue case exhibited the most variation. Notably, this excludes downstream (indirect) costs inestimatable from standardized encounters alone. Knowledge of wasteful utilization patterns associated with specific clinical scenarios can guide interventions targeting appropriate use of testing