Faculty Bibliography

Background /UNASSIGNED:Physicians across specialties need to be skilled at diagnosing and treating depression, yet studies show underrecognition and inadequate treatment. Understanding the reasons requires specifying the influence of patient presentation, screening, and physician competence. Objective /UNASSIGNED:We deployed an unannounced standardized patient (SP) case to assess clinic screening and internal medicine (IM) residents' practices in identifying, documenting, and treating depression. Methods /UNASSIGNED:The SP represented a new patient presenting to the outpatient clinic, complaining of fatigue, with positive Patient Health Questionnaire (PHQ) items 2 and 9 and a family history of depression. The SPs assessed clinic screening and IM resident practices; appropriate treatment was assessed through chart review and defined as the resident doing at least 1 of the following: prescribing a selective serotonin reuptake inhibitor (SSRI), making a referral, or scheduling a 2-week follow-up. Results /UNASSIGNED:< .001). Conclusions /UNASSIGNED:The use of unannounced SPs helps identify targets for training residents to provide evidence-based treatment of depression.

Background: Conflicting data exists on the relationship between outpatient visits and emergency department (ED) visit and admission rates. While some have shown outpatient access prevents ED visits and admissions, others show that factors such as continuity are more important. A mental health diagnosis is consistently cited as a factor associated with increased inpatient utilization. There is little published data about resident-run outpatient clinics and their outcomes, including how these ambulatory contacts affect ED visit and admission rates. Methods: The medical record was used to collect data for all patients seen at least once in the primary care resident clinic at a large, public New York City hospital over the course of 1 academic year. We counted the number of outpatient visits per patient, regardless of type, including both primary care visits and clinic visits for all medical and surgical subspecialties. We controlled for the level of health of each patient using locally developed scores. Our primary outcomes were total number of ED visits and total number of inpatient admissions; secondary outcomes were inpatient length of stay (LOS) and admissions for ambulatory care sensitive conditions (ACSC). We conducted bivariate analyses, using T-Tests and ANOVA, and multivariate analysis, using ordinary least of squares regression, to determine whether increased contact with outpatient clinics was associated with ED visit and admission rates. A separate analysis was conducted for patients with a mental health diagnosis. Results: Our sample consisted of 2,988 patients, seen at least once in the resident-run primary care clinic, averaging 7 outpatient visits across all sub-specialties. There were 2,544 ED visits (1317 unique patients), 571 inpatient admissions (368 unique patients), and 126 ACSC admissions (97 unique patients). Patients who were hospitalized averaged 2 admissions; average LOS was 9.5 days. Multivariate analysis, controlling for sociodemographic and health factors, found more ambulatory care visits were associated with more ED visits and more inpatient admissions (p < 0.01). There was no statistically significant association between ambulatory care visits and LOS or ACSC admissions. A mental health diagnosis was associated with increased ambulatory care visits, and increased ED visits and inpatient admissions, and a 4 day longer LOS. Conclusions: Among patients seen in the resident internal medicine clinic, we were surprised to find that more outpatient visits were positively associated with more ED visits and admissions when controlling for all sociodemographic factors and health status. Our study adds to the body of literature, as there has been little previously published about resident clinic outcomes. Further studies are needed on how to improve these resident run clinics in order to help prevent ED visits and admission. Our study also showed that a mental health diagnosis was positively associated with ambulatory care visits, consistent with the previous literature

Objective: To present clinical and radiographic descriptions of conditions that may feature corticospinal tract abnormalities observed on magnetic resonance imaging (MRI). Background: Corticospinal tract lesions have a broad differential diagnosis, including neurodegenerative diseases, toxic/metabolic derangements, malignancies, autoimmune diseases, infectious diseases, and neurogenetic conditions. Design/Methods: Review of clinical presentations and brain MRIs. Results: Conditions that have been associated with corticospinal tract hyperintensities on brain MRI include: amyotrophic lateral sclerosis, primary lateral sclerosis, heroin leukoencephalopathy, brainstem glioma, neuroBehcets, HIV infection, neuromyelitis optica, Krabbe A disease, adult polyglucosan body disorder, Xlinked Charcot-Marie-Tooth disease, Behr syndrome, Whipple disease, and sequela of liver transplantation. We present representative images and discuss clinical and radiographic features that distinguishing these conditions. Conclusions: Corticospinal tract lesions have a heterogenous etiology, with widely different treatments and prognoses. An understanding of these potential etiologies will assist neurologists confronted with this imaging finding

BACKGROUND: All physicians need to be skilled at diagnosing, treating, and managing depression. We designed an unannounced standard patient (USP) case to assess residents' clinical skills in addressing depression and explored how those skills are associated with residents' general clinical skills in order to design targeted curriculum on depression. METHODS: The USP was a 26 y.o. male presenting as a new patient to a clinic complaining of fatigue and problems sleeping. Goals of the case were to diagnose a common presentation of depression and make a treatment/follow-up plan. The USP was trained to have a positive PHQ 2 &PHQ 9, family history of depression, and be willing to engage in medication and/or therapy if offered. A post-visit checklist was used by the SPs to assess communication, patient education, and assessment skills using behaviorally anchored items rated as not done, partly done, or well done. A systematic chart review was conducted to examine treatment, quality of documentation, and referrals. Case fidelity was checked by audiotape and confirmed by PHQ 9 score in the EHR. Evidence based treatment was defined as prescribing an SSRI and/or providing a psychiatric referral; if neither of those, scheduling follow-up for within 2 weeks. RESULTS: 122 residents saw the USP case from 2009-2015. Mean visit length = 45 min, SD 25 (14 to 183 min). The patient was screened for depression with a PHQ 2 in 93% of visits; 82% also had a PHQ 9. Overall, 77 residents (63%) provided appropriate treatment: 8% prescribed an SRRI, 23% provided a referral, 19% did both, 7% prescribed a sleep aid and <2 week follow-up, and 43% provided a combination of these treatments. 45 residents (37%) did not provide appropriate treatment: 27 (60%) prescribed a sleep aid and follow-up >2 weeks and 18 (40%) provided no treatment/referral and follow-up >2 weeks. There were no differences in exploration of medical history or substance use, but 83% of residents who treated appropriately had a PHQ 9 compared to 62% of residents who did not treat appropriately. 71% also included depression on the problem list compared to 13%of residents who did not treat appropriately. Residents who treated appropriately had significantly better clinical skills assessed by the USP including: overall communication (71% vs. 54%, p = 0.00), information gathering (72% vs. 55%, p = 0.01), relationship development (75% vs. 60%, p = 0.03), patient education (55% vs. 21%, p = 0.00), and patient activation skills (33% vs. 13%, p = 0.01). CONCLUSIONS: Although almost all residents obtained the relevant information, only about 50% of residents diagnosed depression. PHQ 9 appears to be associated with providing more effective treatment, supporting the importance of health system screening protocols. Residents' communication and depression-specific patient education and activation skills seem to be related to how they identify and manage depression, suggesting that interventions to build these skills may lead to higher quality care

BACKGROUND: Training residents to effectively practice value-based care is challenging. We hypothesized that residents with better communication skills would order fewer unnecessary tests and prescribe more appropriate care. We used a USP case of a patient with uncontrolled asthma to examine the relationship between value-based care and communication skills. METHODS: A 25 year-old female USP presented as a new patient to a medicine resident's clinic, reporting asthma since childhood with worsening symptoms over the past few months. At the time of the visit, she was using her albuterol inhaler multiple times daily, without any additional asthma treatment, and was unsure whether she was using it properly. Data was collected using two forms of assessment: a post-visit USP checklist and a systematic review of the corresponding clinic note to examine treatment recommendations including referrals and quality of documentation. The USP checklist measured communication, patient education, and assessment skills. Each response option included descriptive behavioral anchors and was rated as not done, partly done, or well done. Domain scores were calculated as percent items rated well done. RESULTS: 141 USP visits were made from 2009 to 2016 with a mean visit length = 88 min, SD= 28 min (range: 40 to 180 min). Almost all residents (92%) evaluated the patient's asthma with a pulmonary examination. The most common treatment prescribed was albuterol and an inhaled steroid, with or without a spacer (79%). The majority of residents (53%) did not order any additional studies; 21% ordered one study, and 26% ordered two or more studies. Study orders fell into one of three categories: gold (appropriate/recommended: PFTs, flu shot, HIV), grey (pulmonary consult, HCG), or inappropriate (TSH, A1C). Across the 141 visits, 129 studies were ordered; 46% were gold, 5% were grey, and 49% were inappropriate. The most common study ordered was a PFT (31%). 87% of single study orders were gold, but 92% of multiple orders included at least one inappropriate study. Residents who did not order any studies had significantly higher patient education and counseling skills than residents who ordered one or more studies (54% vs 34%, p = 0.00) and were more likely to explain how to correctly use an inhaler than residents who ordered one or more studies (48% vs 27%, p = 0.01). These residents also had significantly higher management and treatment skills (61% vs 39%, p = 0.00) and overall communication skills (68% vs 55%, p = 0.01). There were no significant differences between groups in medications prescribed or in quality of documentation. CONCLUSIONS: Effective communication skills may contribute to valuebased care through appropriate patient education and ordering of fewer inappropriate studies. Rigorous curricula and assessment of resident's patient education skills should be in place to help both patients and health care system achieve value-based care

BACKGROUND: Effective smoking cessation counseling improves smokers' health and quality of life. As part of our assessment program, an Unannounced Standardized Patient (USP) case was developed to measure residents' performance in a routine visit with a smoker. METHODS: The USP was a 40 year-old male new patient presenting with heartburn. He began smoking up to two packs/day at 22 years old; at the time of the visit, he reports having cut down to one pack/day and quitting cold turkey twice in the past only to return to smoking. If the resident engages him, he discusses his relationship with smoking and the possibility of quitting. TheUSP received 6 hours of character and checklist training to ensure standardized portrayal and evaluation. Data was collected using 2 forms of assessment: a post-visit USP checklist and a systematic review of the EMR (lab orders, prescriptions, and referrals). The 170- item USP checklist measured communication, patient education, assessment skills, and case-specific items. Each response option included descriptive behavioral anchors and was rated as not done, partly done, or well done. RESULTS: Data was examined from 73 USP visits from 2009-2015. Mean visit length = 37 min, SD = 15 min (range: 15 to 95 min). Overall communication scores ranged from 17 to 100% with an average of 62% (Cronbach's alpha = 0.75). All residents documented History of Tobacco Use or Tobacco Use Disorder in the EMR, and the majority (82%) prescribed smoking cessation medication. There was variation in the sophistication of smoking cessation-counseling approach. Whilemost residents (78%) discussed the risks of smoking and/or the benefits to quitting, significantly fewer (48%) explored the patient's view of the pros and cons of his smoking (p = 0.00). Residents who prescribed smoking cessation medication and discussed risks/benefits to smoking/quitting (N = 31) were compared to residents who did the same but also invited the patient to discuss his personal pros and cons of smoking (N = 29). Groups were not significantly different by PGY or gender. Patients who were asked to discuss their pros/cons rated the resident higher on patient activation questions (0-2 point scale), including "Helped you understand the importance of quitting smoking" (1.38 vs 0.90, p = 0.00), "Made you want to change your smoking" (1.10 vs 0.52, p = 0.00), and "Made you feel like you would be able to quit smoking" (1.07 vs 0.35, p = 0.00). There were no significant differences in labs ordered, referrals to a smoking cessation program, or quality of documentation. CONCLUSIONS: While all residents ask about tobacco use and most appropriately prescribe medication, fewer than half demonstrate the skills known to motivate patients to quit smoking. Curricula needs to reinforce the importance of a patient discussing their personal relationship with smoking in order to feel activated and willing to engage in cessation