Faculty Bibliography

INTRODUCTION/BACKGROUND:COVID-19 forced health systems to rapidly implement telehealth for routine practice, often without sufficient training or standards. We conducted a longitudinal survey of physicians to explore changes in their perceptions of the challenges and benefits of telehealth and identify recommendations for future practice. METHODS:An anonymous online survey was distributed to a cohort of internal medicine physicians in May to June 2020 and March to June 2021. Changes in responses between 2020 and 2021 and by site (private vs. public) were described. These findings, along with those of a thematic analysis of open-ended responses to questions on telehealth experiences, informed a set of recommendations. RESULTS: = 0.027). Physicians' open-ended responses identified recommendations for further improving the design and use of telehealth. DISCUSSION/CONCLUSIONS:Results suggest that physician experience with telehealth improved but opportunities for training and improved integration remain. Longitudinal assessment can deepen understanding of the evolution of telehealth care.

BACKGROUND:The need to engage adults, age 65 and older, in clinical trials of conditions typical in older populations, (e.g. hypertension, diabetes mellitus, Alzheimer's disease and related dementia) is exponentially increasing. Older adults have been markedly underrepresented in clinical trials, often exacerbated by exclusionary study criteria as well as functional dependencies that preclude participation. Such dependencies may further exacerbate communication challenges. Consequently, the evidence of what works in subject recruitment is less generalizable to older populations, even more so for those from racial and ethnic minority and low-income communities. METHODS:To support capacity of research staff, we developed a virtual, three station simulation (Group Objective Structured Clinical Experience-GOSCE) to teach research staff communication skills. This 2-h course included a discussion of challenges in recruiting older adults; skills practice with Standardized Participants (SPs) and faculty observer who provided immediate feedback; and debrief to highlight best practices. Each learner had opportunities for active learning and observational learning. Learners completed a retrospective pre-post survey about the experience. SP completed an 11-item communication checklist evaluating the learner on a series of established behaviorally anchored communication skills (29). RESULTS:In the research staff survey, 92% reported the overall activity taught them something new; 98% reported it provided valuable feedback; 100% said they would like to participate again. In the SP evaluation there was significant variation: the percent well-done of items by case ranged from 25-85%. CONCLUSIONS:Results from this pilot suggest that GOSCEs are a (1) acceptable; (2) low cost; and (3) differentiating mechanism for training and assessing research staff in communication skills and structural competency necessary for participant research recruitment.

OBJECTIVE:Curricula designed to teach and assess the communication skills of pediatric residents variably integrates the parent perspective. We compared pediatric residents' communication skills in an objective structured clinical exam (OSCE) case as assessed by Family Faculty (FF), parents of pediatric patients, versus standardized patients (SP). METHODS:Residents participated in an OSCE case with a SP acting as a patient's parent. We compared resident performance as assessed by FF and SP with a behaviorally-anchored checklist. Items were rated as not done, partly done or well done, with well-done indicating mastery. The residents evaluated the experience. RESULTS:42 residents consented to study participation. FF assessed a lower percentage of residents as demonstrating skill mastery as compared to SP in 19 of the 23 behaviors. There was a significant difference between FF and SP for Total Mastery Score and Mastery of the Competency Scores in three domains (Respect and Value, Information Sharing and Participation in Care and Decision Making). The majority of residents evaluated the experience favorably. CONCLUSION/CONCLUSIONS:Involving parents of pediatric patients in the instructive and assessment components of a communication curriculum for pediatric residents adds a unique perspective and integrates the true stakeholders in parent-physician communication.

Introduction:The known markers of insulin resistance in obese children are well studied. However, they require serial measurements and complicated calculations. The objective is to study IGFBP-1 and its relation with other known risk measures. Materials and Methods:The study included 98 New York City school students of diverse ethnic/racial backgrounds (57 males and 41 females), 11-15 years of age. Subjects were enrolled in a cross-sectional study, and anthropometric measures were collected. They underwent fasting intravenous glucose tolerance tests (IVGTT), and glucose, insulin, lipids, IGFBP-1, adiponectin and inflammatory markers were collected. Results:The subjects were stratified into 3 groups based upon the BMI Z-score. Out of all the subjects, 65.3% were in the group with a BMI Z-score <1 SDS, 16.3% subjects were in the group with a BMI Z-score of 1 to 2 SDS, and 18.4% of the subjects were in the group with a BMI Z-score of more than 2 SDS. The group with a BMI Z-score of more than 2 SDS had increased waist circumference (WC), body fat, increased fasting insulin, and triglycerides (TG). This group had decreased levels of adiponectin and HDL and low IGFBP-1 as compared to the group with BMI <1 SDS. The group with a BMI Z-score of 1 to 2 SDS had a decreased level of IGFBP-1 as compared to the group with a BMI Z-score less than 1 SDS. IGFBP-1 inversely correlated with age, WC, BMI, body fat, TG, and insulin levels. IGFBP-1 positively correlated with adiponectin and HDL levels. Conclusion:IGFBP-1 in children can identify the presence of insulin resistance in the group with BMI 1 to 2 SDS, even before the known markers of insulin resistance such as elevated triglycerides and even before decreased HDL and adiponectin levels are identified.

QUALITY ISSUE:The emergence of COVID-19 highlights the necessity of rapidly identifying and isolating potentially infected individuals. Evaluating this preparedness requires an assessment of the full clinical system, from intake to isolation. INITIAL ASSESSMENT:Unannounced Standardized Patients (USPs) present a nimble, sensitive methodology for assessing this readiness. CHOICE OF SOLUTION:Pilot the Unannounced Standardized Patient methodology, which employs an actor trained to present as a standardized, incognito potentially infected patient, to assess clinical readiness for potential COVID-19 patients at an urban, community safety-net clinic. IMPLEMENTATION:The Unannounced Standardized Patient was trained to present at each team's front desk with the complaint of feeling unwell (reporting a fever of 101 degrees Fahrenheit in the past 24 hours) and exposure to a roommate recently returned from Beijing. The Unannounced Standardized Patient was trained to complete a behaviorally-anchored assessment of the care she received from the clinical system. EVALUATION:There was clear variation in care Unannounced Standardized Patients received; some frontline clerical staff followed best practices; others did not. Signage and information on disease spread prevention publicly available was inconsistent. Qualitative comments shared by the Unannounced Standardized Patients and those gathered during group debrief reinforced the experiences of the Unannounced Standardized Patients and hospital leadership. LESSONS LEARNED:Unannounced Standardized Patients revealed significant variation in care practices within a clinical system. Utilization of this assessment methodology can provide just-in-time clinical information about readiness and safety practices, particularly during emerging outbreaks. Unannounced Standardized Patients will prove especially powerful as clinicians and systems return to outpatient visits while remaining vigilant about potentially infected individuals.

LEARNINGOBJECTIVES 1: Interpersonal /Communication Skill: 1) Identify communication skills needed to recruit older adults LEARNING OBJECTIVES 2: 2) Assess feasibility of GOSCEs to enhance recruitment skills in RAs. SETTING AND PARTICIPANTS: Convenience sample of 18 (5 male, 13 female) Research Assistants (RAs) at an urban hospital who recruit older adults for clinical trials. DESCRIPTION: Increasing older adults' participation in clinical trials is urgently needed. We developed a remote, three station simulation (Group Objective Structured Clinical Exam - GOSCE) to teach RAs communication skills. This 2-hour course included a discussion of challenges in recruiting older adults; skills practice with Standardized Participants (SPs); and a debrief to review experiences, highlight best practices. After discussion, RAs rotated (3 per group) through the stations, each with SP and faculty observer who provided immediate feedback. Thus, learners had opportunities for active and observational learning.Scenarios were: 1) an older white woman with hearing impairment; 2) an older white woman and family member together; and 3) an older Black man mistrustful due to history of racism in medical research. SPs completed behaviorally anchored checklists (11 communication skills across all cases, and 5-7 case-specific questions). Learners completed a 36- item survey of self-assessed change in skill after the workshop; insights on recruitment practice; and educational value. EVALUATION: The communication checklist across all cases included: relationship development (5 items, mean of 58% well done (range: 50-75%), patient education (3 items, 44% (42-58%)), patient satisfaction (2 items, 54% (50-58%)), and information gathering (1 item, 92%). Seventeen RAs completed the survey, 100% felt the workshop provided valuable feedback and taught relevant material, 88% would participate again and 52%reported that the workshop improved their recruitment skills. All RAs reported encountering situations similar to hearing impairment and family member cases, and the majority rated the cases as high in educational value. Just 45% reported experiencing a case similar to the Black male case, and 100% rate it as high in educational value. Key points identified by RAs included the value of building a trusting relationship with potential subjects, recognizing possible barriers to communication early on and addressing these directly in a supportive and respectful style. DISCUSSION / REFLECTION / LESSONS LEARNED: Remote GOSCEs are a feasible mechanism for training RAs in subject recruitment focused on the unique needs of older adults. Responses to the RA survey suggest that GOSCEs are feasible for training RAs in simulated clinical scenarios with which participants are familiar and unfamiliar. SP assessment of RAs identified areas for further reinforcement to improve recruitment skills. This innovation is a feasible, high yield strategy for training research staff. It is highly adaptable to the specific recruitment needs and skills of a clinical trials and will add to the literature on educating RAs

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): In order to describe quality improvement (QI) methods for health systems, we report on 10-years of using Unannounced Standardized Patient (USP) visits as the core of a program of education, training, and improvement in a system serving vulnerable patients in partnership with an academic medical center. LEARNING OBJECTIVES 1: Consider methods for supporting learning healthcare systems LEARNING OBJECTIVES 2: Identify performance data to improve care DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The IOM defines a Learning Healthcare System (LHCS) as one in which science, informatics, incentives and culture are aligned for continuous improvement and innovation and where best practices are seamlessly embedded in the delivery process and new knowledge is captured as an integral by-product of the delivery experience. As essential as electronic health records are to LHCS, such data fail to capture all actionable information needed to sustain learning within complex systems. USPs are trained actors who present to clinics, incognito, to portray standardized chief complaints, histories, and characteristics. We designed and delivered USP visits to two urban, safety net clinics, focusing on assessing physician, team, and clinical micro system functioning. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICHWILL BE USEDTOEVALUATE PROGRAM/INTERVENTION): Behaviorally anchored assessments are used to assess core clinical skills (e.g., communication, information gathering, patient education, adherence to guidelines, patient centeredness, and patient activation). Team functioning assessments include professionalism and coordination. Micro system assessment focuses on safety issues like identity confirmation, hand washing, and navigation. Data from these visits has been provided to the residency, primary care teams, and to leadership and have been used to drive education, team training, and QI. FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): 1111 visits have been sent to internal medicine and primary care residents and their teams/clinics. At the resident level, needs for additional education and training in depression management, opioid prescribing, smoking cessation, and patient activation were identified and informed education. Chart reviews found substantial variation in ordering of labs and tests. At the team level, USPs uncovered needs for staff training, enhanced communication, and better processes for eliciting and documenting Social Determinants of Health (SDoH). Audit/feedback reports on provider responses to embedded SDoH combined with targeted education/resources, were associated with increased rates of eliciting and effectively responding to SDoH. In the early COVID wave, USPs tested clinic response to a potentially infectious patient. Currently, USPs are being deployed to understand variability in patients' experience of telemedicine given the rapid transformation to this modality. Finally, generalizable questions about underlying principles of medical education and quality improvement are being asked & answered using USP data to foster deeper understanding of levers for change. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY): A comprehensive USP program can provide unique insights for driving QI and innovation and help sustain a LHCS

BACKGROUND: NYU uses the same 14-item checklist for assessing medical student communication skills across our curriculum, which includes highquality Objective Structured Clinical Skills Exams throughout the first three years of medical school: a 3-station Introductory Clinical Experience OSCE (ICE), a 3-station end-of-clinical skills OSCE (Practice of Medicine; POM); and an 8-station, high- stakes OSCE (Comprehensive Clinical Skills Exam; CCSE) after core clerkship. We describe how skills change throughout school and explore how patterns vary by cohort (class) in ways that could be explained by admissions criteria, measurement quality, and/or curriculum changes.
METHOD(S): Three domains are assessed: Info gathering (6 items), relationship development (5 items); and patient education & counseling (3 items). Checklist items use a 3-point scale (not done, partly, well done) with behavioral anchors. Internal consistency (Cronbach's alpha) exceeds .75 for all subdomains and across all years. Domains are supported by Confirmatory Factor Analysis. Mean average % well done was calculated across cases and individuals for each subdomain in an OSCE and compared over the OSCEs and between 8 classes of medical school students entering from 2009 to 2016 (graduating 2013 to 2020) (n=1569).
RESULT(S): Cohorts showed similar patterns communication skills trajectories - improvement over time. Despite changes in admissions criteria and processes, cohorts did not differ in terms of demographics, undergraduate GPA, or MCAT scores. Variability in scores decreased in all cohorts over time while communication improved. Patient education & counseling was significantly and substantially lower than other domains. In terms of cohort effects, communication scores for the entering class of 2013 at the start of medical school (ICE OSCE) were significantly higher than the previous 4. At the end of MS2, scores were similar for cohorts for info gathering and relationship development domains (and high, mean range=77-87% well done) but patient education & counseling varied: Improvement from the 1st to 3rd cohort and then decline for the last 5 cohorts. Within the CCSE (8-station pass/fail, MS3), communication scores increased steadily across entering classes, especially from cohort 4 on. These changes over time and between cohorts were mapped onto a priori descriptions of curricular, measurement and admission changes.
CONCLUSION(S): Our cohort data showed interesting and complex patterns. This study reinforces some limitations of linking curriculum to performance (e.g., no direct measures of the curriculum in terms of content, process and intensity over time, limited data on what makes cohorts different, variable measurement over time, and being unable to control for broader trends likely to influence both cohort and time effects) while also demonstrating the promise of longitudinal perspectives on the development of core competencies. LEARNING OBJECTIVE #1: Understand cohort performance in relation to curricular trends. LEARNING OBJECTIVE #2: Describe variation in performance