Faculty Bibliography

Needs and Objectives: In the changing landscape of healthcare, physicians must be adaptive, visionary and evidence-based in their approach to care Medical education must be adjusted to allow learners to gain skills that prepare them to function effectively in this new paradigm. In order to meet these needs, we developed a community based curriculum with emphasis on transitions of care, population health and innovation of care. Setting and Participants: Curriculum was developed as part of a new NYU Internal Medicine Residency Community Health Track, housed at NYU Langone Hospital-Brooklyn, a community based, academic teaching hospital. Ambulatory training is based at the Family Health Centers at NYU Langone, a network of FQHCs. Both the hospital and FQHCs serve a vulnerable, diverse community in south Brooklyn. To date we have recruited one class of 10 interns. As of July 2020 we anticipate having a full track consisting of 30 residents. Description: Our first year curriculum aims to develop a framework for thinking about community health introducing key concepts such as population-based care, novel delivery of care, and interdisciplinary collaboration. Early in their training, residents completed a community assessment using observational data, interviews and census track data. These assessments paired with collaboration with CHW and community organizations gave them first hand exposure to our area's specific challenges and gaps in care. The residents began to develop skills in home care by working with an interdisciplinary team of doctors, nurses and CHWs. Additionally, they participated in a transitions of care workshop, examining their own hospital patients who had been readmitted and identifying best practices for hospital discharge. Evaluation: A multi-method evaluation plan is essential as we evaluate and strengthen the curriculum. Qualitative feedback is gathered at regular intervals throughout the year along with surveys of trainees. Initial Results suggest that curricula is well-received by residents. Aggregated longitudinal educational data including resident self-report, 360^oevaluations and performance-based assessment, (OSCEs, USP visits) will contribute to program evaluation. The most important outcome will be how these trainees practice once they have graduated. We plan to use postgraduate surveys to judge the impact of the curriculum. Discussion/Reflection/Lessons Learned: We adapted curriculum to focus on our particular community and created innovative programs to improve the population's health. Essential to these accomplishments was our partnership with learners and our reliance on their feedback to guide curriculum development. Allowing trainees to explore their interests has lead to visionary projects. We have learned that by being flexible and adapting to the learners' needs and interests we can serve our community in deeper ways than we had initially anticipated. However, structural limitations of the clinic coupled with institutional changes resulted in a slower time frame for clinical adaptations

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: 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

Objective/UNASSIGNED:To determine the efficacy of a 4-month school-based health, nutrition and exercise intervention on body fatness and examine possible effects of demographic and anthropometric covariates. Methods/UNASSIGNED: = 469) received a 12-session classroom-based health and nutrition educational programme with an optional exercise intervention. Results/UNASSIGNED: = 0.005). Conclusion/UNASSIGNED:A 4-month school-based health intervention was effective in decreasing measures of adiposity in middle school students, particularly in men, participants who were obese and South Asians.

BACKGROUND: Unprofessional behaviour can interfere with patient care. Empowering trainees to address each other's unprofessional behaviour can help address a larger number of incidents that may not be witnessed by supervisors, as well as promote a culture of professionalism in a teaching programme. The goal of the study was to teach trainees to effectively address observed unprofessional behaviour and to assess the impact of this exercise on the percentage of cases directly addressed, reported or ignored 6-12 months after the initial training. METHODS: Eighty-four trainees participated in objective structured clinical examination (OSCE) cases designed to address a colleague's inappropriate behaviour. Baseline and follow-up surveys performed 6-12 months after the OSCE were completed detailing the number of incidents witnessed in colleagues and the method employed to address those incidents: personally address (with level of satisfaction), report or ignore. RESULTS: There was a significant increase in the number of unprofessional incidents identified after the OSCE (pre-OSCE, 1.12 per resident; post-OSCE, 1.69 per resident; t = 2.27, p = 0.029). Of the 72 incidents at baseline, 43 per cent were addressed directly and 43 per cent of those had a satisfactory resolution. Of the 71 incidents described 6-12 months later, 61 per cent were addressed directly and 79 per cent of those had a satisfactory resolution. Trainees were more likely to address rather than to report unprofessional behaviour chi2 (2, 58) = 13, p = 0.001. Empowering trainees to address each other's unprofessional behaviour can help promote a culture of professionalism DISCUSSION: The intervention had a significant impact on the percentage of trainees that addressed any observed unprofessional behaviour, and the rate of satisfaction after doing so. It did not change the percentage of cases that were neither addressed nor reported.

Introduction/UNASSIGNED:Research staff are critical to productive translational research teams, yet their professional development is rarely formally addressed. Methods/UNASSIGNED:We created Strategic Teamwork for Effective Practice Mentor Development Program (STEP-MDP) to promote skills development and build a community of practice. We ran and evaluated the STEP-MDP for 32 participants, which consisted of workshops focusing on team communication and mentorship/coaching skills. Results/UNASSIGNED:We found that STEP-MDP had a long-term positive impact on participants and their teams. Conclusion/UNASSIGNED:This program facilitated the professional development of research staff.

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.