Faculty Bibliography

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: 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

NEEDS AND OBJECTIVES: Standardized Patients (SPs) are integral to health care professions (HCPs) training. We must understand this workforce, make effective use of SPs' skills, and ensure they accurately portray cases and rate learners. To be authentic, simulation should reflect the demographics of the population served, while providing exposure to less commonly seen patients. We created an SP database to facilitate our work with SPs; review their demographic characteristics; and align information on SP performance -to better serve our educational mission. SETTING AND PARTICIPANTS: NYSIM (Simulation Center for NYU Langone and the City University of NY) serves hundreds of HCP training programs for learners at all levels. While sharing common resources, many programs independently recruit and train SPs. DESCRIPTION: We fielded a web-based survey for SPs and staff to populate the database. Survey items were iteratively reviewed by staff and SPs to ensure items elicited key information. Questions included basic demographics; SP experience/training; other professional background; and relevant physical findings (eg scars, cardiac findings). SPs also uploaded a headshot and resume. Staff separately input information about SPs' work on cases and programs; information about case portrayals; types of cases for which the SP is best suited, and other relevant information. EVALUATION: To date, we have 232 SP surveys, representing the majority of SPs at NYSIM. Demographics included gender (43% male, 56% female, 1% transgender), age range (x = 34.9 years, range teen to 75+) and selfidentified race (71% Caucasian, 17% African-American, 25.6% Asian/South Asian, 3.5% Middle Eastern, 3% Native American/Pacific Islander and 9% other). 22%are bilingual, with over 20 languages represented. SPs had a broad range of SP experience (x = 2.8 years, S.D. = 1.8, range 0-20 years). Almost all SPs were trained in basic case portrayal, with others being trained in aspects of the physical exam, emotional issues, giving feedback, and high stakes rating. SPs bring other skills to their work, including teaching (75%) or healthcare (12%). Survey information helps educators recruit SPs and identify (re)training needs. SPs who perform high stakes exams or are Unannounced Standardized Patients are shielded from general recruitment in order to maintain their anonymity. DISCUSSION/REFLECTION/LESSONS LEARNED: An SP database is useful for a high volume simulation center. Information in a searchable SP data base allows programs to understand the potential pool and expertise of SPs, and to track learners' exposure to specific SPs (this is relevant as our internal data reveal that SPs with more experience tend rate towards the middle of the scale). The demographic characteristics of our SPs broadly match the profile of our healthcare systems, and tracking the data allows us to maintain a good fit between SPs and our environment

NEEDS AND OBJECTIVES: To address the need for sustainable, efficient interprofessional education and practice (IPEP) at the graduate level health professions education (GHPE), the NYU School of Medicine (SoM) and NYU RoryMeyers College of Nursing (NYUMeyers) designed IPEP, a mobile learning solution. We aimed to: * Provide learners with applicable interprofessional (IP) practice skills * Encourage reflection on IP care planning * Develop an accessible and sustainable IP geriatric education curriculum for GHPE * Collect residents' reflection on IP practice for future curriculum design SETTING AND PARTICIPANTS: IPEP was housed on the NYU SOM learning management system. Since 2014, about 3500 learners from Health Professions schools across the U.S. have completed the 6 I.E. modules. DESCRIPTION: Approach/Methods To overcome barriers (e.g. limited learning space, lack of faculty, heterogeneous curricula) NYU SoM and NYU Meyers developed a series of 10-min e-learning materials including didactic modules and virtual geriatric primary care patient (VP) cases. These are based on the undergraduate online IP modules, NYU3T: Teaching, Technology, and Teamwork. The modules address: * IP teams/responsibility * Effective healthcare teams * Teamwork skills * Communication skills Conflict resolution * IP care planning 4 VP cases include IP assessment and management of older adults with chronic conditions. Reflective questions are integrated into modules and VP cases to stimulate critical thinking and attitude shift. In order to facilitate use, online modules and VP cases are designed in bite-size 10-min modules without heavy multimedia components. Thus, residents, nurse practitioners, and other graduate level providers can complete the modules via phone, tablets, or computers. EVALUATION: Users rated modules very positively (4.2 out of 5). More than 80% of users responded the length of the modules were "just right"; about 90% agreed to "recommend the modules to others". About 500 learners completed four VP cases this last year. According to the validated questionnaire measuring attitudes toward IP teams, there was a significant change toward team value (p = .006) but no significant changes around team efficiency or physician's shared role on team. DISCUSSION/REFLECTION/LESSONS LEARNED: Scheduling of IP activities, with joint clinical experiences and OSCEs, takes time, effort, and coordination of multiple schedules. The IPEP e-modules help smoother dissemination of IPE knowledge and skills to busy trainees. IP learners have found these a valuable resource. More VP cases for different populations may increase the application of IPE skills

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: 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: Interprofessional collaboration (IPC) is essential for quality care. Understanding residents' level of competence is a critical first step to designing targeted curricula and workplace learning activities. In this needs assessment, we measured residents' IPC competence using specifically designed Objective Structured Clinical Exam (OSCE) cases and surveyed residents regarding training needs. METHODS: We developed three cases to capture IPC competence in the context of physician-nurse collaboration. A trained actor played the role of the nurse (Standardized Nurse - SN). The Interprofessional Education Collaborative (IPEC) framework was used to create a ten-item behaviorally anchored IPC performance checklist (scored on a three-point scale: done, partially done, well done) measuring four generic domains: values/ethics; roles/responsibilities; interprofessional communication; and teamwork. Specific skills required for each scenario were also assessed, including teamwork communication (SBAR and CUS) and patient-care-focused tasks. In addition to evaluating IPC skills, the SN assessed communication, history-taking and physical exam skills. IPC scores were computed as percent of items rated well done in each domain (Cronbach's alpha > 0.77). Analyses include item frequencies, comparison of mean domain scores, correlation between IPC and other skills, and content analysis of SN comments and resident training needs. RESULTS: One hundred and seventy-eight residents (of 199 total) completed an IPC case and results are reported for the 162 who participated in our medical education research registry. IPC domain scores were: Roles/responsibilities mean = 37 % well done (SD 37 %); Values/ethics mean = 49 % (SD 40 %); Interprofessional communication mean = 27 % (SD 36 %); Teamwork mean = 47 % (SD 29 %). IPC was not significantly correlated with other core clinical skills. SNs' comments focused on respect and IPC as a distinct skill set. Residents described needs for greater clarification of roles and more workplace-based opportunities structured to support interprofessional education/learning. CONCLUSIONS: The IPC cases and competence checklist are a practical method for conducting needs assessments and evaluating IPC training/curriculum that provides rich and actionable data at both the individual and program levels.