Faculty Bibliography

BACKGROUND:System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP. AIM/OBJECTIVE:To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE. METHODS:For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey. RESULTS:." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice. CONCLUSION/CONCLUSIONS:OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.

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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BACKGROUND: According to the 2017 American College of Gastroenterology (AGA) guidelines, therapeutic drug monitoring (TDM) of drug trough concentrations and anti-drug antibodies is recommended to optimize treatment with anti-tumor necrosis factor (TNF) agents and thiopurines1. Specifically, the AGA conditionally recommends reactive TDM in patients with active symptoms of inflammatory bowel disease (IBD) while on anti-TNF agents, as such testing is crucial for differentiating between mechanistic, non-immune mediated pharmacokinetic and immune-mediated pharmacokinetic drug failure, and allows providers to appropriately tailor treatment regimens. As such algorithms for monitoring therapies in IBD have evolved, it has become incumbent on physicians caring for these patients to develop techniques to engage in patient-centered care using the technique of shared decision making. Gastroenterology (GI) trainees may not be well versed in navigating these complex interpersonal skills. The Observed Structured Clinical Examination (OSCE) is a well-validated method of assessing core competencies of communication and professionalism. While it is traditionally used at the undergraduate medical education level, it has been used at the graduate level to address disease-specific competencies. Here, we discuss the use of an OSCE to assess the performance of GI fellows in engaging in shared decision-making on the topic of TDM for a patient with complex IBD refractory to treatment.
METHOD(S): Eleven second-year gastroenterology fellows from 4 GI fellowship programs participated in a 4 station OSCE. Previously validated OSCE checklists were used to assess the fellows' performance in IBD-specific cases, one of which will be discussed here. In the "Therapeutic Drug Monitoring" case, the objective for the fellows was to discuss the indications for infliximab trough and antibody testing and how results of this testing would impact treatment based on the AGA guidelines. Checklists were scored on a 3 and 5-point Likert Scale by the Standardized Patient (SP), mapped to the appropriate ACGME milestones by a GI medical educator and normalized on a scale from 0 to 9. Post-OSCE, the fellows were surveyed to assess their perspective on their performance as well as the exam's educational value.
RESULT(S): 6 ACGME milestones were assessed in this OSCE. Scores ranged from mean of 5.85 to 7.88. Fellows scored lowest on gathering and synthesizing essential and accurate information to define each patient's clinical problem(s) (PC1, mean score 5.85) with an average score of 5.85. They scored highest for overall clinical knowledge (MK1, mean score 7.88). Overall, 9/10 (90%) of fellows would be recommended for their interpersonal skills, but only 4/10 (40%) were deemed effective in their communication skills. The majority of fellows noted improvement in their understanding of when to use and how to interpret TDM after the exercise. CONCLUSION(S): This OSCE was designed to assess clinical and communication skills for gastroenterology surrounding the complex clinical arena of therapeutic drug monitoring utilizing crucial communication skills. The results suggest weaker performance linked to gathering and synthesizing clinical information, with stronger performance in clinical knowledge, developing management plans and various communication skills. This OSCE feedback and assessment can be used to develop targeted educational interventions to strengthen clinical and communication skills for providers

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.

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: The core Entrustable Professional Activities medical school graduates should be able to perform on day 1 of residency provides a framework for readiness for residency. Communication skills are an essential foundation for these core EPAs and yet there have been few studies that describe communication competence across the UME-GME continuum. We report on our OSCE-based assessment of communication skills from the first few weeks of medical school to the first year of medicine residency.
Method(s): Assessment of communication is consistent in our OSCE program across UME and GME. Domains include Information Gathering (5 items), Relationship Development (6 items), and Patient Education (3 items) and these are assessed via a behaviorally anchored checklist (scores=% well done) that has strong reliability and validity evidence. In this study, we report on 3 multi-station OSCEs: the Introductory Clinical Experience (ICE) OSCE that occurs within the first weeks of medical school; the high-stakes, pass/fail Comprehensive Clinical Skills Examination (CCSE) OSCE that is fielded after clerkship year; and the Medicine Residency Program's PGY 1 OSCE. Across 3 classes of medical school (2014-2016) we have complete data for the 24 students who continued on in our Medicine Residency (and who provided consent to include their educational data in an IRB-approved registry). Analyses focus on differences in communication skills over time and between cohorts and the relationship between communication skills measured in medical school and those assessed in residency.
Result(s): Communication scores show significant improvement through medical school (but not into residency) in Information gathering (ICE mean=56%; CCSE mean=76%; PGY1 mean=77%) (F=11.54, p<.001, ICE< CCSE) and in relationship development (ICE=59%; CCSE=78%; PGY1= 74% (F=10.68, p<.001, ICE < CCSE). Mean patient education skills, however, increase significantly across all 3 time points (32% to 50% to 65%; F=31.00, p<.001). Patterns are similar across cohorts except that the Class of 2016 means increase from CCSE to PGY1. Regression analyses show that CCSE information gathering scores are more strongly associated with PGY performance than ICE scores (Std Beta=.32 vs.06), while for relationship development, it is the ICE scores that are more strongly associated (Std Beta=.40 vs.24). ICE and CCSE patient education skills have associations with PGY1 skill of similar size (Std Beta=.30 and.28).
Conclusion(s): Findings, despite the small sample, suggest a clear developmental trajectory for communication skills development and that information gathering and patient education skills may be more influenced by medical school than relationship development. That communication skills seem to level out in PGY1 highlights need for re-consolidation as clinical complexity increases. Results can inform theory development on how communication skills develop and point to transitions where skills practice/feedback may be particularly important

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: To bolster medical student wellbeing and combat burnout, the NYU School of Medicine (NYUSOM) implemented a longitudinal resiliency curriculum coupled with a wellbeing self-assessment tool. We qualitatively studied the impact of this curriculum on knowledge, self-awareness, and behaviors related to wellbeing and resiliency.
Method(s): The MD AWARE curriculum was launched in August 2017 for the NYUSOM class of 2020. Six sessions were implemented at critical junctions of their training. Each session includes a short lecture, followed by a small group activity led by trained facilitators. At the start of each session, students complete an anonymous online self-assessment adapted from three validated assessment tools measuring different aspects of wellbeing and burnout. Students immediately receive scores with explanations and benchmarks of each and then debrief in their small group. After each MD AWARE session, students completed a retrospective pre/post evaluation survey. Focus Groups (FG) were held in December 2017 (after Sessions 1& 2) to gain richer insight into the impact of the curriculum and self-assessment tool. A purposeful sampling strategy with maximal variation was employed to recruit participants; 10 students participated in each FG. Qualitative data was gathered through the surveys and the FG. The FG were recorded and transcribed. Each FG had 2 project staff members and post-session debriefing. Member-checking was also used. Responses were subsequently coded and analyzed by two experienced faculty members (a third colleague assisted in theme triangulation). An iterative data analysis strategy was applied. Throughout the analysis, an audit trail, frequent memo writing and a reflexivity journal was maintained.
Result(s): Themes: Community Building: Connecting with another student it was helpful for my wellbeing Skill and Knowledge Acquisition and Application: The main sort of takeaway is you need to be aware of (Burnout) and if you need help there are resources Importance of Faculty Development: I think that a prep session between those who designed the curriculum and those who facilitate the small-groups could go a long way towards creating the environment I imagine was originally intended Value of Refection: The score didn't add much It was more about the act of answering the questions than the number that came out of it NYU Administration Values Medical Student Wellbeing: Just the fact that NYU has this program and is making it part of orientation already speaks volumes about its priorities: that we matter
Conclusion(s): Thematic analysis of the impact of MD AWARE indicated that it provides concrete information on resources available to the students. Additionally, the students value both protected time with their peers and for self-refection. Lastly, although care must to be taken in selecting faculty to facilitate the small groups, the mere existence of the longitudinal curriculum signaled that the NYUSOM administration values medical student wellbeing