Faculty Bibliography

Background Clinical reasoning (CR) is a core competency in medical education. Few studies have examined efforts to train faculty to teach CR and lead CR curricula in medical schools and residencies. In this report, we describe the development and preliminary evaluation of a faculty development workshop to teach CR grounded in CR theory. Methods Twenty-six medicine faculty (nine hospitalists and 17 subspecialists) participated in a workshop that introduced a framework to teach CR using an interactive, case-based didactic followed by role-play exercises. Faculty participated in pre- and post-Group Observed Structured Teaching Exercises (GOSTE), completed retrospective pre-post assessments (RPPs), and made commitment to change statements (CTCs). Results In the post-GOSTE, participants significantly improved in their use of problem representation and illness scripts to teach CR. RPPs revealed that faculty were more confident in their ability and more likely to teach CR using educational strategies grounded in CR educational theory. At 2-month follow-up, 81% of participants reported partially implementing these teaching techniques. Conclusions After participating in this 3-h workshop, faculty demonstrated increased ability to use these teaching techniques and expressed greater confidence and an increased likelihood to teach CR. The majority of faculty reported implementing these newly learned educational strategies into practice.

Needs and Objectives: The U.S. surgical population is becoming increasingly medically complex, increasing the risk of post-operative complications. Surgeons have traditionally consulted internists and sub-specialists for medical management during inpatient admissions, but this has failed to decrease complications or healthcare costs. To address this issue hospitalists have taken on the role of co-managing patients admitted to surgical services. However, internal medicine residencies don't adequately prepare trainees for this role. Safe and effective modern medical care requires training in medical co-management (MCM), yet there exists no robust theory-and evidence-based curricula to teach these competencies. We designed a curriculum to fill this need. Setting and Participants: Thirteen hospitalists with 0-7 years' clinical experience in an academic medical center in New York, NY. Hospitalists spend 50% of their clinical time on an MCM service covering general surgery, vascular surgery, neurosurgery, general neurology/epilepsy, and orthopedic surgery. Description: We developed a yearlong curriculum based on the Society for Hospital Medicine's guidelines on creating MCM teams and other published frameworks. We applied evidence-based learning theories including: Adult Learning Theory, Cognitivism, Constructivism, and Ericsson's Theory of Expertise. We developed a conceptual framework incorporating key stakeholders in MCM (medical attending, surgical attending, PCP, mid-levels, and patients/families) and 6 core content topics (Roles & Responsibilities, Communication Strategies, Trust & Respect, Common Complications, Transitions of Care, and Deliberate Practice). The curriculum includes two parts: a week-long intensive orientation with Objective Structured Clinical Examinations (OSCEs) and workshops in the main content areas, and a series of monthly continuing professional development (CPD) sessions to facilitate deliberate practice and improve skills needed to manage niche patients on surgical services. These CPD skills are based upon needs identified by the hospitalists and surgical teams. Evaluation: Effectiveness will be measured at the program and hospitalist level. The program will be assessed by patient quality metrics (eg, LOS and readmission rates) and satisfaction by the surgical teams yearly. We will evaluate the impact on hospitalists using retrospective pre-post surveys to measure changes in clinical knowledge, confidence and engagement. Assessments will be collected using Qualtrics survey software. Discussion/Reflection/Lessons Learned: In the early stages of this curriculum, 79% of participants found the CPD sessions "very or extremely helpful." Participants have shown increasing engagement in the curriculum as evidenced by proposals of future session topics and attendance. Data collection is ongoing

Needs and Objectives: Point-of-care ultrasound (POCUS), when integrated with a physical examination, increases accuracy of diagnosis and decreases procedural complications. However, most hospitalists have not been trained to use this new technology. We developed a year-long curriculum, the Integrated Sonographic Competency at NYU (I-ScaN), to train hospitalists in POCUS. Setting and Participants: Twenty-three hospitalists from across the 4 hospitals affiliated with NYU Langone Health participated. Sixteen of the participants (72%) reported prior ultrasound training, with a range of 2-80 hours (median = 4 hours); 3 reported more than 5 hours of prior training. Three reported active clinical use of POCUS though none of them had more than 5 hours of prior training. The group averaged 4.5 years of clinical practice (range = 1-13 years). Description: The program began with an intensive 2-day course consisting of lectures and hands-on training on human models covering views of the heart, lungs/pleura, abdomen, and leg vasculature. We developed the remainder of the year-long program with the goal of helping participants retain and improve upon the skills acquired during the initial course. Our program included hands-on teaching sessions held at each institution by local experts, presentations at monthly conferences with the course director (HS), and online feedback on uploaded ultrasound images. To facilitate this final item, each participant was given access to portable ultrasound devices with the ability to upload ultrasound clips to a HIPAA-compliant website. Participants provided a clinical interpretation and assessment of image quality for each of their clips. The clips were then reviewed by an expert who provided feedback on both of these domains. Participants could then use these clips to create personal portfolios in accordance with national standards set by the Society of Hospital Medicine. Evaluation: Participants rated the 2-day intensive program as very useful and satisfaction with the individual components of the program ranged from useful to very useful. Participants reported statistically significant increases in their confidence in acquiring images, interpreting images, and performing a clinical evaluation using POCUS for all domains except in performing paracentesis. Knowledge scores increased from a baseline of 58% to 83%; p< 0.001. At 6 months into the program, 2 hospitalists had uploaded > 400 clips each and 7 had uploaded fewer than 20 clips each. Discussion/Reflection/Lessons Learned: I-ScaN is a highly rated and effective program to train hospitalists in core POCUS competencies. The 2-day intensive program significantly improves confidence and knowledge. Monitoring of progress and scanning activity was difficult because few hospitalists uploaded clips regularly. Our focus now is on identifying barriers to using POCUS for new trainees. Future analysis will include frequency of scanning, retention of knowledge and skill, and generation of learning curves for each view

Background: Faculty development programs (FDP) in medical education can increase clinician educators' (CE) confidence in teaching and improve their teaching skills. The impact of FDP on faculty's role as educators and sense of an educator community is less well understood. Identification with a community of educators (COE) can enhance teaching in the workplace along with personal and professional growth. We evaluated the impact of participation in the Education for Educators program (E4E) on these issues. E4E is a yearlong FDP designed to enhance teaching confidence and skill in a variety of venues; improve ability to assess learners; promote an environment of academic inquiry with trainees at different levels; and create a COE.
Method(s): An annual needs assessment of key stakeholders including medical school deans, program directors, and participants forms the basis for the E4E curriculum. The program begins with a Group Observed Structured Teaching Experience (GOSTE) followed by three 3-hour workshops which pair a clinical and teaching topic. After each workshop, participants complete " commitment to change" statements and take part in peer-to-peer (P2P) observations wherein participants observe each other teaching in their usual teaching environment. The program concludes with structured debriefs and an assessment of participants' perception of their role as educators and their sense of an educator community. Participants reported how participation in E4E impacted their teaching and what new skills they implemented. Structured phone conversations assessed the same information one-year after completing the program.
Result(s): Fifty-one CEs completed the program in two cohorts (2016-17 and 2017-18), 60% of whom were women. Participants included 20 hospitalists and 31 subspecialists, averaging 8 years in practice (range 1-28) and spending an average of 63% of their time in patient care (range 10-100%). Thirty-eight participants (75%) completed the immediate post-program debrief sessions. Participants reported a renewed identification with their role as an educator. They cited a change in perspective to become more reflective and focused on teaching and recognized that their teaching skills can in fact be improved. Many reported time constraints as a barrier to teaching. They noted an increased identification with their COE, stating that they now had peers and mentors with whom to discuss teaching challenges. To date, phone interviews have been completed with three participants at one-year of follow-up. The preliminary Results show a sustained impact on educators' roles and belonging to a COE. They also reported ongoing use of specific skills including resilience strategies, and planning teaching sessions.
Conclusion(s): Longitudinal FDP in medical education for CE can lead to a greater appreciation for the role of an educator, and identification with a COE. Investment in longitudinal FDP may have lasting impact on the clinical learning environment and the identity of faculty as an educator

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)

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