Faculty Bibliography

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

INTRODUCTION: Remediating failing medical learners has traditionally been a craft activity responding to individual learner and remediator circumstances. Although there have been moves towards more systematic approaches to remediation (at least at the institutional level), these changes have tended to focus on due process and defensibility rather than on educational principles. As remediation practice evolves, there is a growing need for common theoretical and systems-based perspectives to guide this work. METHODS: This paper steps back from the practicalities of remediation practice to take a critical systems perspective on remediation in contemporary medical education. In doing so, the authors acknowledge the complex interactions between institutional, professional, and societal forces that are both facilitators of and barriers to effective remediation practices. RESULTS: The authors propose a model that situates remediation within the contexts of society as a whole, the medical profession, and medical education institutions. They also outline a number of recommendations to constructively align remediation principles and practices, support a continuum of remediation practices, destigmatize remediation, and develop institutional communities of practice in remediation. DISCUSSION: Medical educators must embrace a responsible and accountable systems-level approach to remediation if they are to meet their obligations to provide a safe and effective physician workforce.

INTRODUCTION: Transitions to residency programs are designed to maximize quality and safety of patient care, as medical students become residents. However, best instructional or readiness assessment practices are not yet established. We sought to study the impact of a screen-based interactive curriculum designed to prepare interns to address common clinical coverage issues (WISE OnCall) on the clinical skills demonstrated in simulation and hypothesize that performance would improve after completing the module. METHODS: Senior medical students were recruited to participate in this single group prestudy/poststudy. Students responded to a call from a standardized nurse (SN) and assessed a standardized patient (SP) with low urine output, interacted with a 45-minute WISE OnCall module on the assessment and management of oliguria, and then evaluated a different SP with low urine output of a different underlying cause. Standardized patients assessed clinical skills with a 37-item, behaviorally anchored checklist measuring clinical skills (intraclass correlation coefficient [ICC], 0.55-0.81). Standardized nurses rated care quality and safety and collaboration and interprofessional communication using a 33-item literature-based, anchored checklist (ICC, 0.47-0.52). Standardized patient and SN ratings of the same student performance were correlated (r, 0.37-0.62; P < 0.01). Physicians assessed clinical reasoning quality based on the students' patient encounter note (ICC, 0.55-0.68), ratings that did not correlate with SP and SN ratings. We compared pre-post clinical skills performance and clinical reasoning. Fifty-two medical students (31%) completed this institutional review board approved study. RESULTS: Performance as measured by the SPs, SNs, and the postencounter note all showed improvement with mostly moderate to large effect sizes (range of Cohen's d, 0.30-1.88; P < 0.05) after completion of the online module. Unexpectedly, professionalism as rated by the SP was poorer after the module (Cohen's d, -0.93; P = 0.000). DISCUSSION: A brief computer-based educational intervention significantly improved graduating medical students' clinical skills needed to be ready for residency.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

BACKGROUND: Safe, high quality outpatient care often depends on the degree to which patients understand their situation and how to follow through on physician recommendations. However, we do not know enough about how often physicians focus on ensuring that their patients have achieved these understandings by the end of the visit and whether such end-of-visit practices are associated with physicians' communication, patient education and activating skills. METHODS: Two Unannounced Standardized Patient cases (highly trained actors who present as real patients) were delivered to 71 internal medicine residents in two clinics: one required the physician to identify a patient's depression and engage him in follow-up care, and the other required the physician to recognize a patient's failure to use her asthma medicine correctly and educate her in using it properly. End-of-visit practices were: reviewing the plan; asking if further questions; giving information about follow-up care and further contact; and helping the patient navigate the system in order to follow through on next steps. Each was assessed by the SP as not done, partly done, or well done. SPs also rated physicians' communication skills, patient activating skills, and case-specific education skills. Summary scores were calculated as% of items well done. RESULTS: Close to three-quarters of the physicians reviewed the plan with the patient and invited further questions in the depression case and slightly more than half did so in the asthma case (56 and 60%). Patients were given complete information about follow-up care and how to navigate the system in just under half of depression visits (49 and 47%) and just over half of asthma visits (58 and 58%). On average, residents were rated as performing 61% of these 8 items well (SD 28%) across both cases. Primary care residents performed significantly better than categorical internal medicine residents (67%vs 47%, p = .004). There were no differences by physician gender. End of visit scores were significantly positively correlated with both general and casespecific clinical skills, and after controlling for the variance contributed by the program (R2 = 12%, p = .004), case-specific education scores explained 10% of the variance in end of visit score (p = .005), patient activating skills 10% of the variance (p = .002) and communication skills 13% of the variance (p = .001). With all variables in the model, only the general communication domain of patient education and counseling was independently associated with end of visit scores (Std Beta = .35, p = .015). CONCLUSIONS: Had these patients been real patients, in one-quarter to onehalf of the visits, the patient would have left not fully understanding the plan or how to follow-through on care. Resident physicians with more effective communication and patient activating skills tended to provide safer end-of-visit care, suggesting that these may reflect an outpatient safety orientation or skillset

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

BACKGROUND: At Bellevue Hospital Center (BHC), we have a robust Unannounced Standardized Patient (USP) program, where trained actors portraying real patients in the clinical setting, incognito, assess the residents' skills following their visit. We sought to determine the relationship between USP ratings of residents' skills and clinical outcomes among the residents' continuity patient panels to define educationally sensitive patient outcomes. METHODS: We assembled a retrospective cohort of PGY 2 internal medicine residents with at least 2 USP visits between 7/1/14-6/30/15 and ambulatory care patient panels at BHC. The two outcome variables were the percentage of hypertensive patients in the residents' panel with blood pressure (BP) <140/90, and the average of the most recent glycosylated hemoglobin (HbA1C) result among the residents' patients with diabetes. The predictor variables included mean USP ratings of residents' clinical skills and mean faculty rating of the residents' clinic notes (scored for quality on a 0 to 3 scale). USPs used a behaviorally anchored checklist (not done, partly done, well done) for the following domains: communication, case specific assessment, patient education, physical examination, professionalism, management plan, patient satisfaction, and patient activation measure. We tested the correlations between USP scores with BP and HbA1C control, and then developed multivariate, linear regression models of USP scores on BP and HbA1C scores, respectively, each controlling for Avg. Chronic health score (ACHS, derived by scoring different clinical conditions by acuity and used to determine if the panel is getting sicker over time) and total number of patients in the panel (TNPP) because these variables were correlated with both the outcome and predictor variables. RESULTS: 29 PGY 2 residents had a mean of 2.5 (SD 1.0) USP visits during the study period. Residents' patient panels size varied (median 124, range 62- 171) and mean patient age was 48 years (SD 1.4). Patient Activation scores were correlated with Average Chronic Health Score (r = .482, p = .008) and Panel Average last A1c (r = -.311, p = .10). Patient activation scores explained 16% variance in the mean panel last HgA1c, (adjusted R2 .137, p = .08). Case specific Assessment & Patient Education skills across USP cases explained 21.5% of the variance and the Average Chart Note Score explained 14.4% of the variance in % of Hypertension controlled (adjusted R2.378, p < .009). CONCLUSIONS: This exploratory study suggests that learnable resident clinical skills are associated with quality of care indicators for HTN and DM control. In particular, being able to activate patients, assess and educate them and write high quality notes are pathways to quality care. Next steps are to confirm these findings in a larger dataset. Doing so will help align medical education with patient safety and care quality and provide guidance for educational and clinical research aimed at improving the health of populations served