Faculty Bibliography

Background: Te Accreditation Council for Graduate Medical Education (ACGME) has identifed six core competencies in which trainees are expected to demonstrate profciency. Milestones have been developed to provide a framework for evaluating trainee performance within these competencies. We used an objective structured clinical examination (OSCE) focused on inflammatory bowel disease (IBD) to assess the milestones in gastroenterology (GI) fellows. METHODS: Ten second-year fellows from six GI fellowship programs participated in a four case OSCE. In the "Transition of CareTM case the fellow was to assess a patient's readiness on the planned transition from child-centered to adult-centered care. In the "Shared Decision MakingTM case the fellow was to evaluate a patient with Crohn's disease who would beneft from combination therapy. In the "ER FlareTM case the fellow was to triage and suggest management of a flaring ulcerative colitis patient. In the "IBS in IBDTM case the fellow was asked to discuss irritable bowel syndrome in the context of quiescent IBD. Previously validated OSCE checklists were used to assess the GI fellows' performance using a 3-and 5-point behaviorally-anchored Likert Scale. Checklists were scored by the standardized patient. Checklist items were mapped to appropriate ACGME milestones by a GI medical educator. Scores within each milestone were normalized on a scale from 0-9 as utilized by the ACGME in the Next Accreditation System milestone initiative. Fellows were provided feedback on their performance. RESULTS: Te majority of fellows scored between 6 and 9 in the milestones assessing patient care (PC), medical knowledge (MK), interpersonal and communication skills (ICS), professionalism (Prof), and systems-based practice (SBP). Composite average scores for all participants were as follows: PC1 7. 7, PC2 6. 9, MK1 6. 9, MK2 7. 0, ICS1 7. 4, Prof1 7. 6, Prof3 6. 9, and SBP4 6. 4. Fellows scored highest in the "Shared Decision MakingTM case and scored lowest in the "Transitions of CareTM case. CONCLUSION(S): In this OSCE GI fellows performed well in the majority of milestones evaluated, however areas of less optimal performance were identifed, providing areas for future focus in fellow training. Te OSCE is a well-validated standardized tool for evaluating trainees, and with appropriate mapping of checklists to ACGME milestones, it can serve as an objective method to assess GI fellows' progress in the core competencies

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: 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: 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: 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