Faculty Bibliography

OBJECTIVE:Medical student knowledge about brain death determination is limited. We describe an educational initiative to improve medical student awareness about brain death and assess the impact of this initiative. SUBJECTS AND METHODS/METHODS:Beginning in July 2016, students at our medical school were required to attend a 90-min brain death didactic and simulation session during their neurology clerkship. Students completed a test immediately before and after participating in the initiative. RESULTS:Of the 145 students who participated in this educational initiative between July 2016 and June 2017, 124 (86%) consented to have their data used for research purposes as part of a medical education registry. Students correctly answered a median of 53% of questions (IQR 47-58%) on the pretest and 86% of questions (IQR 78-89%) on the posttest (p < .001). Comfort with both performing a brain death evaluation and talking to a family about brain death improved significantly after this initiative (18% of students were comfortable performing a brain death evaluation before the initiative and 86% were comfortable doing so after the initiative, p < .001; 18% were comfortable talking to a family about brain death before the initiative and 76% were comfortable doing so after the initiative, p < .001). CONCLUSIONS:Incorporation of simulation in undergraduate medical education is high-yield. At our medical school, knowledge about brain death and comfort performing a brain death exam or talking to a family about brain death was limited prior to development of this initiative, but awareness and comfort dealing with brain death improved significantly after this initiative.

Introduction: Veterans with mental health disorders smoke at high rates, but encounter low rates of tobacco treatment. We sought to understand barriers and facilitators to treating tobacco use in VA mental health clinics. Methods: This qualitative study was part of a trial evaluating a telephone care coordination program for smokers using mental health services at 6 VA facilities. We conducted semi-structured interviews with 14 staff: 12 mental health clinic staff working at the parent study's intervention sites (n=6 psychiatrists, 3 psychologists, 2 social workers, 1 NP), as well as one psychiatrist and one psychologist on the VA's national tobacco advisory committee. Interviews were transcribed and inductively coded to identify themes. Results: Five "barriers" themes emerged: 1) competing priorities, 2) patient challenges/resistance, 3) complex staffing/challenging cross-discipline coordination, 4) mixed perceptions about whether tobacco is a mental health care responsibility, and 5) limited staff training/comfort in treating tobacco. Five "facilitators" themes emerged: 1) reminding mental health staff about tobacco, 2) staff belief in the importance of addressing tobacco, 3) designating a cessation medication prescriber, 4) linking tobacco to mental health outcomes and norms, and 5) limiting mental health staff burden. Conclusions: VA mental health staff struggle with knowing that tobacco use is important, but they face competing priorities, encounter patient resistance, are conflicted on their role in addressing tobacco, and lack tobacco training. They suggested strategies at multiple levels that would help overcome those barriers that can be used to design interventions that improve tobacco treatment delivery for mental health patients. IMPLICATIONS: This study builds upon the existing literature on the high rates of smoking, but low rates of treatment, in people with mental health diagnoses. This study is one of the few qualitative evaluations of mental health clinic staff perceptions of barriers and facilitators to treating tobacco. The study results provide a multi-level framework for developing strategies to improve the implementation of tobacco treatment programs in mental health clinics.

Introduction Physicians often struggle with the intricacies of brain death determination and communication about end-of-life care. In an effort to remedy this situation, we introduced an educational initiative at our medical school to improve student comprehension and comfort dealing with brain death. Methods Beginning in July 2017, students at our medical school were required to attend a 90-minute brain death didactic and simulation session during their neurology clerkship. Students completed a test immediately before and after participating in the initiative. Results Of the 145 students who participated in this educational initiative between July 2016 and June 2017, 124 (86%) consented to have their data used for research purposes. Students correctly answered a median of 53% of questions (IQR 47-58%) on the pretest and 86% of questions (IQR 78-89%) on the posttest (p<0.001). Comfort with both performing a brain death evaluation and talking to a family about brain death improved significantly after this initiative (18% of students were comfortable performing a brain death evaluation before the initiative and 86% were comfortable doing so after the initiative, p<0.001; 18% were comfortable talking to a family about brain death before the initiative and 76% were comfortable doing so after the initiative, p<0.001). Conclusions Incorporation of simulation in undergraduate medical education is high-yield. At our medical school, knowledge about brain death and comfort performing a brain death exam or talking to a family about brain death was poor prior to development of this initiative, but awareness and comfort dealing with brain death improved significantly after this initiative. This initiative was clearly a success and can serve as a model for brain death education at other medical schools

BACKGROUND: Opioid analgesics are effective and appropriate therapy for many types of acute pain. Epidemiologic evidence supports a direct relationship between increased opioid prescribing and increases in opioid use disorders and overdoses. OBJECTIVE: To tailor our residency curriculum, we designed and fielded an unannounced standardized patient (USP) case involving a patient with acute back pain who is requesting Vicodin (5/325 mg). We describe residents' case management and examine whether their management decisions, including opioid prescribing, were related to their core clinical skills. METHODS: Results are based on 50 (USP) visits with residents in 2 urban primary care clinics. Highly trained USPs portrayed a patient with acute lower back pain who was taking leftover Vicodin with effective pain relief but was running out. We describe how residents managed this case, using both USP report and chart review data, and compare summary clinical skills scores between those who prescribed Vicodin and those who did not. RESULTS: Of the 50 residents, 18 prescribed Vicodin (10-60 pills). Among those who did not prescribe (32/50), most (50%) prescribed ibuprofen. Eighty-three percent of the prescribers and 72% of nonprescribers ordered physical therapy (nonsignificant). Of the 18 prescribers, 13 documented checking the prescription monitoring database. Prescribers had significantly better communication scores than nonprescribers (relationship development: 80% vs. 58% well done, P = .029; patient education: 59% vs. 31% well done, P = .018). Assessment summary scores were also higher (60% vs. 46%) but not significantly (P = .060). Patient satisfaction and activation scores were higher in the prescribers than nonprescribers (71% vs. 39%, P = .004 and 48% vs. 26%, P = .034, respectively). CONCLUSIONS: Most Vicodin prescribers did not follow prescribing guidelines, and they demonstrated better communication and assessment skills than the nonprescribers. Results suggest the need to guide residents in using a systematic approach to prescribing opioids safely and to develop an acceptable alternative pain management plan when they decide against prescribing.

AIM: To assess first-year gastroenterology fellows' ability to address difficult interpersonal situations in the workplace using objective structured clinical examinations (OSCE). METHODS: Two OSCEs ("distracted care team" and "frazzled intern") were created to assess response to disruptive behavior. In case 1, a fellow used a colonoscopy simulator while interacting with a standardized patient (SP), nurse, and attending physician all played by actors. The nurse and attending were instructed to display specific disruptive behavior and disregard the fellow unless requested to stop the disruptive behavior and focus on the patient and procedure. In case 2, the fellow was to calm an intern managing a patient with massive gastrointestinal bleeding. The objective in both scenarios was to assess the fellows' ability to perform their duties while managing the disruptive behavior displayed by the actor. The SPs used checklists to rate fellows' performances. The fellows completed a self-assessment survey. RESULTS: Twelve fellows from four gastrointestinal fellowship training programs participated in the OSCE. In the "distracted care team" case, one-third of the fellows interrupted the conflict and refocused attention to the patient. Half of the fellows were able to display professionalism despite the heated discussion nearby. Fellows scored lowest in the interprofessionalism portion of post-OSCE surveys, measuring their ability to handle the conflict. In the "frazzled intern" case, 68% of fellows were able to establish a calm and professional relationship with the SP. Despite this success, only half of the fellows were successfully communicate a plan to the SP and only a third scored "well done" in a domain that focused on allowing the intern to think through the case with the fellow's guidance. CONCLUSION: Fellows must receive training on how to approach disruptive behavior. OSCEs are a tool that can assess fellow skills and set a culture for open discussion.

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

BACKGROUND: Entrustable Professional Activities (EPAs) and milestones are expert judgments made based on many formative assessments. Their validity is dependent on the number of assessments but attention is increasingly being paid to having a "fair" sample of observations equally distributed across residents and contexts. OSCEs provide such a consistent, fair sample of behavior assessed under controlled conditions but have mostly used been used to provide granular skills feedback. We explore how faculty judge the "entrustability" of residents based on observing OSCE cases and then how these entrustments relate to OSCE skills performance. METHODS: In an 11-case OSCE for primary care residents (n = 25; PGY1-3), SPs rated skills in communication (information gathering, relationship development, education/counseling), assessment, patient education (case-specific), physical exam, professionalism, treatment plan, patient satisfaction and patient activation. Summary scores were calculated as%items rated well done (vs not or partly done; internal consistency > .72). Faculty observers then judged how much supervision the resident would need in actual practice to handle the case: 1-requires direct supervision, 2-requires indirect supervision, 3-ready for unsupervised practice, or 4- can supervise others. Mean entrustment rating across cases was correlated with clinical skills. RESULTS: Mean entrustment =2.46 (SD .37), falling between requires indirect supervision and ready for unsupervised practice. On average, residents were judged to need direct supervision in .40 cases (SD .65), indirect supervision in 4.76 (SD 2.03), ready for unsupervised practice in 2.92 (SD 1.80), and able to supervise others in 1.07 cases (SD 1.15) with PGY1 residents needing direct and indirect supervision in more cases than PGY2 and 3 (p = .037). Associations between OSCE performance and faculty entrustment ranged from essentially zero (communication sub-domains of information gathering and education/counseling; case-specific patient education; patient satisfaction) to negative (communication sub-domain of relationship development r = -.25, p = .16; professionalism r = -.21, p = .22) to positive (case-specific assessment, r = .35, p = .07; physical exam r = .30, p = .13; treatment plan r = .40, p = .04; patient activation r = .51, p = .008). Associations between skills performance and entrustment ratings varied by case. CONCLUSIONS: OSCEs provide a valuable opportunity for faculty to make entrustment judgments based on observing the same, complete encounter across many trainees. Entrustment judgments appear to be capturing elements of competence related to but different from SP assessments of performance, including especially "bottom line" aspects of practice such as assessment, physical exam, treatment plans and patient activation. Interestingly, we consider patient activation skills to be an "educationally sensitive patient outcome" i because both teachable and associated with patient outcomes and our results support the importance of this skill set

BACKGROUND: It is critically important for medical schools to understand how well prepared their graduates are for residency and yet we do not have a full understanding of how well competencies, assessed in medical school, transfer to residency. This study explores how communication skills measured in a high-stakes, rigorous, comprehensive OSCE in the 3rd year of medical school are related to performance in a similar OSCE in residency and to Residency Program Directors' ratings of intern competence. METHODS: We analyzed communication skills from three time points in a longitudinal cohort of NYU graduates who entered our Internal Medicine Residency (n = 42). 39 provided consent for their GME-UME data to be compiled into a longitudinal, de-identified educational research database through an IRB-approved Registry. Communication skills were measured using a behaviorally anchored 15-item checklist across the 8-station, pass/fail, MS3 OSCE and then midway through PGY2 of residency in a 6- station OSCE (score =% of items rated well done). SPs also provided an overall rating of communication skills (not recommend, with reservations, recommend, highly recommend). In between, at the end of intern year, residents were also rated by their Program Directors on communication skills (and other competencies) using a 4-pt scale. RESULTS: OSCE communication performance assessed in medical school was modestly associated with performance in residency (r = .26, p = .07) but not with Program Directors' ratings of residents' communication skills as interns (r = .11, p = .28). Number of cases in which medical students were "not recommended" for their communication skills was negatively associated with residency OSCE communication scores (r = -.33, p = .05) and positively associated with number of "not recommends" (r = .46, p = .01) but not with Directors' ratings of interns (r = -.08, p = .49). Number of not recommends independently explained more variance in subsequent residency communication scores than did medical school performance (9% vs. 5%). While average OSCE communication scores improved from medical school to residency (65 to 71%), those with 2 or more "not recommends" improved significantly more than those with 1 or no not recommends. Overall, most learners' (21/39) communication scores improved substantially; less than a quarter (7) decreased; and about a quarter (11) were stable. CONCLUSIONS: While communication scores from medical school are associated with similarly measured scores in residency, SPs' decisions to "not recommend" students appear to serve as an independent indicator of future skill deficits. Patterns of change, however, are not necessarily straightforward: students with the most "not recommends" improved the most. The ability to track competency assessments longitudinally is essential for understanding the transition from medical school to residency and future research will benefit from larger sample sizes and the inclusion of learner characteristics that may explain developmental patterns

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