Md aware: Qualitatively measuring the impact of longitudinal resiliency curriculum and wellbeing self-assessment tool among medical students [Meeting Abstract]
Background: To bolster medical student wellbeing and combat burnout, the NYU School of Medicine (NYUSOM) implemented a longitudinal resiliency curriculum coupled with a wellbeing self-assessment tool. We qualitatively studied the impact of this curriculum on knowledge, self-awareness, and behaviors related to wellbeing and resiliency.
Method(s): The MD AWARE curriculum was launched in August 2017 for the NYUSOM class of 2020. Six sessions were implemented at critical junctions of their training. Each session includes a short lecture, followed by a small group activity led by trained facilitators. At the start of each session, students complete an anonymous online self-assessment adapted from three validated assessment tools measuring different aspects of wellbeing and burnout. Students immediately receive scores with explanations and benchmarks of each and then debrief in their small group. After each MD AWARE session, students completed a retrospective pre/post evaluation survey. Focus Groups (FG) were held in December 2017 (after Sessions 1& 2) to gain richer insight into the impact of the curriculum and self-assessment tool. A purposeful sampling strategy with maximal variation was employed to recruit participants; 10 students participated in each FG. Qualitative data was gathered through the surveys and the FG. The FG were recorded and transcribed. Each FG had 2 project staff members and post-session debriefing. Member-checking was also used. Responses were subsequently coded and analyzed by two experienced faculty members (a third colleague assisted in theme triangulation). An iterative data analysis strategy was applied. Throughout the analysis, an audit trail, frequent memo writing and a reflexivity journal was maintained.
Result(s): Themes: Community Building: Connecting with another student it was helpful for my wellbeing Skill and Knowledge Acquisition and Application: The main sort of takeaway is you need to be aware of (Burnout) and if you need help there are resources Importance of Faculty Development: I think that a prep session between those who designed the curriculum and those who facilitate the small-groups could go a long way towards creating the environment I imagine was originally intended Value of Refection: The score didn't add much It was more about the act of answering the questions than the number that came out of it NYU Administration Values Medical Student Wellbeing: Just the fact that NYU has this program and is making it part of orientation already speaks volumes about its priorities: that we matter
Conclusion(s): Thematic analysis of the impact of MD AWARE indicated that it provides concrete information on resources available to the students. Additionally, the students value both protected time with their peers and for self-refection. Lastly, although care must to be taken in selecting faculty to facilitate the small groups, the mere existence of the longitudinal curriculum signaled that the NYUSOM administration values medical student wellbeing
Using a group observed standardized clinical experience (GOSE) to teach motivational interviewing [Meeting Abstract]
Needs and Objectives: Didactic training in motivation interviewing (MI) lacks efficacy, because opportunities to practice skills while being directly observed are rare. The goal of our educational innovation was to train interns in the advanced communication skills of motivation interviewing through a group observed standardized clinical experience (GOSCE). Our Learning Objectives were as follows: After an experiential learning session on MI, interns will be able to: 1. Identify opportunities to use MI with patients 2. Recognize "change talk" from a patient as an opportunity to use MI techniques 3. Use MI techniques when discussing behavior change with a patient Setting and Participants: 46 internal medicine interns in an academic internal medicine residency program. Description: Each session began with a 20 minute review of MI for behavior change given by a psychologist trained in Motivational Interviewing. Then, interns participated in a 3 station, one-hour long Group Observed Standardized Clinical Exercise (GOSCE). Interns worked in teams of 3, and for each station, one of the 3 interns was the active physician, while the other 2 observed the encounter. Each intern had an opportunity to be the active physician for a case. Each case was observed by one or two faculty members, one of whom was a psychologist trained in MI. After a 10 minute interaction with the standardized patient, the active physician received feedback on their MI skills and debriefed the encounter with the faculty and their peers. After the 3 cases, the session concluded with a group debrief and summary of the experience. Interns completed a retrospective pre/post survey to assess the impact of the session. Evaluation: Residents reported statistically significant improvement in all domains, including confidence with identifying opportunities to use MI, comfort using reflective and summary statements during MI, and likelihood of using motivational interviewing in future patient encounters. Qualitative comments after the session reflect that residents developed an appreciation for silence as a tool during MI, felt comfortable with tools such as decisional balance, and recognized the value of patient centered-ness during MI. Discussion/Reflection/Lessons Learned: Our interprofessional educational team (psychologists and internists) provided different perspective for both learners and our internal medicine faculty. Our residents appreciated practicing skills and receiving feedback in real time. This academic year (one year after the intern GOSCE), these same learners will participate in an OSCE that includes a case requiring motivational internviewing skills, and we will evaluate the durability of motivation interviewing skills taught during this session. We are interested in expanding opportunities to use GOSCE as a low stakes skills practice and development tool
Evaluatingan innovative VA resident grouppractice model in block scheduling [Meeting Abstract]
Background: The New York University (NYU) internal medicine residency program converted to block schedule in July 2015. Sixty-five NYU residents have their continuity clinic site at New York Harbor VA (VA). Here, we practice in the medical home model (termed PACT), with NYU residents divided into 3 PACT teams. When we implement block scheduling, we also developed team-based group practices within these PACTs. Cohorts of resident providers serve as coverage for their fellow PACT residents when they are busy with inpatient responsibilities. Methods: This study evaluates the impact of a scheduling change and the implementation of group practices among residents at the VA from April 2015-June 2016; we surveyed residents from Bellevue Hospital over the same period for comparison. We estimated the impact of interventions on the following clinical outcomes: hypertension control, diabetes control, smoking cessation rates, influenza vaccination rates, and age-appropriate cancer screening rates for patients empaneled in the VA residents' clinics by comparing FY2014 data to FY2016 data. For each outcome, we estimated changes using linear regression models. We also estimated the impact of the intervention on residents' perceptions of self-efficacy, knowledge, and clinic workload & coordination. These were measured by factor scores generated from confirmatory factor analysis of answers to 23 survey questions administered before and after the intervention. The confirmatory factor model fit the data well according to standard metrics (RMSEA = 0.00; NNFI = 1.0). Results: Influenza vaccination rates and hypertension control increased significantly during the study period. Change in the other outcomes-smoking cessation, mammogram screening, colorectal cancer screening, hypertension control and diabetes control-was in the predicted direction but not significant. In terms of changesin attitudes over the study period, we used linear regression models from three specifications-the full sample with no controls, the full sample with a control for cohort, and the paired sample of pre-and post-tests. We found that the intervention positively impacted residents' perceptions of clinic workload & coordination as well as their perceptions of relevant knowledge. The impact on self-efficacy is less clear, since the difference was only significant among the full sample, but not in the other two specifications. Conclusions: The transition to block scheduling and the creation of group practices within the VA resident clinics has had a positive impact both on resident attitudes towards VA clinic and on clinical outcomes. Specifically, residents' knowledge of clinic functioning and perception of clinic workload & coordination improved. We also saw statistically significant improvements in influenza vaccination rates and hypertension control and no worsening in tobacco cessation rates, diabetes control, or age-appropriate cancer screening rates. Thus, this change improved training and had an impact on health outcomes
Measuring the impact of longitudinal resiliency curriculum and wellbeing self-assessment tool among medical students [Meeting Abstract]
Background: In an effort to bolster medical student wellbeing and mitigate burnout, NYU School of Medicine (NYUSOM) launched a longitudinal resiliency curriculum, coupled with a wellbeing self-assessment tool. We aim to study its impact on the development of knowledge, self-awareness, and practices related to wellbeing and resiliency. Methods: MD AWARE (Medical Students Developing Awareness, Wellbeing, and Resilience) was launched in August 2017 for the incoming NYUSOM class. It involves six interactive sessions implemented at critical junctions over the first three years of medical school. Each session includes a short lecture, followed by a small group activity led by trained facilitators. At the start of each small group session, students are asked to complete an anonymous online survey (results only provided to student). The self-assessment includes 19 items adapted from three validated assessment tools measuring different aspects of wellbeing and burnout. Students immediately receive three scores with explanations of each and the opportunity to debrief in their small group. Thus far, the students have participated in the first two sessions. In the first, students were introduced to research on physician burnout, the protective effects of resilience, and practiced a gratitude exercise. In the second, students were introduced to mindful awareness to identifying cognitive distortions and practiced reframing negative inner dialogue. After each, students completed a retrospective pre/post survey, using a 4-point likert scale, assessing knowledge, self-awareness, and comfort/confidence in activities to promote wellbeing. Comparison between the survey results were calculated using pair t-test. Results: Survey results were available for 106/118 (90%) students participating in the first session and 55/114 (48%) participating in the second. Results of both pre/post surveys showed significant improvement (p=<.01) on every item. Notably, after the first session, students reported a substantial increase in their comfort acknowledging stressors (31.1% very comfortable pre-vs 61.1% post-) and seeking help when in need (18.1% very comfortable pre-vs 45.2% post-). After the second session, students reported increased comfort practicing mindful awareness (65.5% comfortable/very comfortable pre-vs 90.9% post-), increased confidence both identifying cognitive distortions (59.2% comfortable/very comfortable pre-vs 96.3% post-) and reframing negative responses (47.2% comfortable/very comfortable pre-vs 81.8% post-). Conclusions: While many schools have looked at ways to foster wellbeing in their medical students, our curriculum is unique in its longitudinal nature and use of repeated wellbeing self-assessments. Preliminary assessment demonstrates a positive impact on medical students' knowledge, self-awareness, and practices around wellbeing and resilience. Thus, our novel curriculum is a promising way to bolster resiliency skills and mitigate burnout in this vulnerable population
Patient experience: Comparison of primary care patients' and unannounced standardized patients' perceptions of care [Meeting Abstract]
BACKGROUND: Patient experience is an important quality indicator, and healthcare organizations spend considerable resources assessing patient satisfaction. Yet a view of patient experience gleaned from patient satisfaction measures tends to show high levels of reported satisfaction, with little variation. Unannounced standardized patients (USPs) have been used to assess providers' clinical skills, but can also provide other information about the healthcare encounter. This study examined the concordance between USP and patient reports of care at the same site. METHODS: Data was gathered at Bellevue Hospital Primary Care Clinic, a city safety-net hospital. USPs assess internal medicine residents training there, and complete a behaviorally anchored checklist of resident skills and interactions with other staff, wait times, ease of clinic navigation, and perceptions of team functioning. Data from 155 USP visits from July 2015-Oct 2016 was used in this study. Independently, as part of team-training efforts in the Primary Care Clinic, patient satisfaction surveys were collected, addressing similar issues. At the end of a clinic visit, research assistants unrelated to patient care asked patients to complete a 30-item survey. 118 surveys were completed between July-November 2016. 11 items appeared on both scales (though worded slightly different) and were used in this comparison. These included questions about clerical (CA) and patient care associates (PCA), and providers (MDs, NPs, PAs), provision of information, team functioning and clinic environment. Of the 11 items, 4 had the same response choices. 7 had differing numbers of responses (eg 4 vs 3 point Likert scales), evenly distributed across patient and USP scales. For each of these items, we collapsed items so to maximize positive ratings (eg. on a 4 point scale from poor to excellent, "good" and "excellent" were combined rather than "good" and "fair"). Chi-square analyses were computed to examine group differences. RESULTS: On chi-square analyses, 9 of the 11 items significantly differed between the USP and patient groups, with patients more likely to have positive ratings. These included rating PCAs as friendlier (x2 = 8.67(1,206), p = .003) and providers better at answering questions (x2 = 11.75 (2,265), p = .003); reporting that they received sufficient/clear instructions about medication refills and follow-up (x2 = 29.5(2,264), p = .0001); finding the clinic atmosphere calmer than did USPs (x2 = 10.5 (2,265), p=.005) and noting that the team functioned better (x2 = 7.31(2,268), p = .026). There were no significant differences in willingness to recommend the clinic or on clarity of CAs' communication. CONCLUSIONS: Results of this study document the differing perspectives of patients and USPs. Consistent with previous work, patients in our study tended to rate most items higher than did the USPs. USPs provide a different, and likely a more critical look at the clinical setting and this information can enhance efforts to improve patient experience. (Table Presented)
Creating a sustainable interprofessional ambulatory care team training: All hands on deck [Meeting Abstract]
NEEDS AND OBJECTIVES: Team-based primary care (PC) is seen as the best way to provide proactive, patient-centered quality care. However, developing these team-based skills is difficult in the ever-shifting, stressful healthcare environment. We sought to develop effective training to enhance team functioning at an urban safety-net hospital, with the goal of clinical transformation (e.g. improving clinic flow, enhancing care for patients with diabetes). SETTING AND PARTICIPANTS: Team training intervention at Bellevue Hospital's Adult Ambulatory Care Center, flagship of the NYC Health & Hospitals (H +H), serving poor, diverse patients with complex medical and social needs. There are 4 adult PC teams, each with 8 attending physicians, 20 residents, 1-2 physician assistants, 2 nurses, 5 patient care associates (PCA), and 2 clerical associates (CA), all caring for a panel of ~7,500 patients. To date, we have completed a training cycle for one team, with 26 members: 10 providers (7 MDs, 2 PAs, and 1 NP), 4 RNs, 5 PCAs, 3 CAs, and 4 residents participating. We are scheduled to complete training of a second team in February 2017, with the other 2 to follow. DESCRIPTION: We partnered with a parallel NYC H + H effort, enabling a seamless NYU-HRSA/NYC H + H program with increased time allotted. This includes 4 three-hour workshops co-led by NYC H + H and NYU-HRSA faculty. Each workshop blends activating, team-building exercises for teams; mini-lectures on topics like roles and responsibilities, communication skills, huddles, and experiential activities using the team's patient data. This is reinforced with seven, 30-min biweekly meetings to follow up on teamidentified topics and facilitate team members' quality improvement projects. EVALUATION: A 31-item (each item rated 0-3), retrospective pre/post survey was administered to trainees after training, addressing individual skills and attitudes (16 items) and team functioning (15 items)14 of 26 participants (54%) in team 1 completed the survey, and Team 2 participants will complete the survey in Feb. 2017. Training resulted in increased rating of individual skills t = 4.86, p < .0001) and team functioning (t = 4.02, p = .003). Additional metrics, including tracking teams' QI efforts and assessing patient experience (e.g. Unannounced Standardized Patient reports) and administrative and panel level data, are ongoing. DISCUSSION/REFLECTION/LESSONS LEARNED: Implementation of successful team training in an under-resourced, urban primary care setting is challenging. It demands flexibility, tailoring to participants' concerns; and responding to changing clinical and administrative circumstances. Essential to success was partnering with team members to guide the training
Unmet needs among people reported with hepatitis C, New York City
OBJECTIVE: This project sought to describe unmet needs among patients reported with hepatitis C in New York City. DESIGN: From the New York City Health Department's hepatitis C surveillance database, we randomly selected patients whose positive hepatitis C test was in April or May 2005. In 2006, we interviewed patients by telephone and collected information from their clinicians or by medical record review. SETTING: New York City. PARTICIPANTS: We interviewed 180 of the 387 eligible patients and collected information from clinicians for 145 of the 180 patients. MAIN OUTCOME MEASURES: These included whether patients had understood their clinicians' explanation of their hepatitis C diagnosis, if they had been counseled about not drinking alcohol, information about support group attendance, vaccination against hepatitis A and B, health status, treatment, and other factors. RESULTS: Of the 180 patients, 7% stated that they had not understood their clinicians' explanation of their hepatitis C diagnosis, and 26% said that they had not been counseled about avoiding alcohol. Among the 90% of patients who had not attended a hepatitis support group, 31% were interested in attending. Among the 145 patients with information from clinicians, at least 28% were susceptible to hepatitis A and 18% to hepatitis B. CONCLUSIONS: This hepatitis C surveillance project, with information from patients and clinicians, illustrates a valuable use of a chronic hepatitis C surveillance system. The patients described here had several unmet needs, including hepatitis A and B vaccination, basic information about the virus, support groups, and counseling about preventing further liver damage and preventing transmission to others. Relatively simple and affordable health department activities can address these needs, improving quality of life and decreasing the likelihood of liver disease progression.
Different endovascular referral patterns are being learned in medical and surgical residency training programs
Physicians in residency training will be the referring physicians of tomorrow. We sought to determine the current surgical and medical trainees' perception of vascular surgery's endovascular qualifications and capabilities. An anonymous survey was sent to all general surgery and internal medicine residents at a single academic institution. Respondents answered the question 'Which specialty is the most qualified to perform (1) inferior vena cava (IVC) filter insertion; (2) angiograms, angioplasty, and stenting of the carotid arteries; (3) renal arteries; (4) aorta; and (5) lower extremity arteries?' For each question, respondents chose one response, either vascular surgery, interventional radiology, interventional cardiology, or do not know. One hundred respondents completed the survey (general surgery, n=50; internal medicine, n=50). There was a significant difference in the attitudes of surgery and medicine residents when choosing the most qualified endovascular specialist (p<0.05). Surgery residents chose vascular surgery as the most qualified specialty for each listed procedure: carotid (80%, n=40), IVC (56%, n=28), aorta (100%, n=50), extremity (86%, n=43), renal (78%, n=39). Medicine residents chose vascular surgery as the most qualified specialty less frequently: carotid (66%, n=33), IVC (6%, n=3), aorta (88%, n=44), extremity (72%, n=36), renal (16%, n=8). There was no significant difference in specialty selection based on postgraduate year. There is a large discrepancy between surgical and medical trainees' perception of vascular surgery's endovascular abilities, particularly regarding IVC placement and renal artery interventions. If our own institution mirrors the nation, each passing year a significant portion of the 21,722 graduating internal medicine residents go into practice viewing vascular surgeons as second-tier endovascular providers. A concerted campaign should be undertaken to educate medical residents regarding the skills and capabilities of vascular surgeons