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Sexual Orientation Demographic Data in a Clinical Cohort of Transgender Patients

Dubin, Samuel; Cook, Tiffany E; Radix, Asa; Greene, Richard E
BACKGROUND:There are specific issues regarding sexual orientation (SO) collection and analysis among transgender and nonbinary patients. A limitation to meaningful SO and gender identity (GI) data collection is their consideration as a fixed trait or demographic data point. METHODS:A de-identified patient database from a single electronic health record (EHR) that allows for searching any discrete data point in the EHR was used to query demographic data (sex assigned at birth and current GI) for transgender individuals from January 2011 to March 2020 at a large urban tertiary care academic health center. RESULTS: = 232). CONCLUSION:Current SO categories do not fully capture transgender individuals' identities and experiences, and limit the clinical and epidemiological utility of collecting this data in the current form. Anatomical assumptions based on SO should be seen as a potential shortcoming in over-reliance on SO as an indicator of screening needs and risk factors.
PMID: 33730758
ISSN: 1869-0327
CID: 4836082

Telemedicine Training in the COVID Era: Revamping a Routine OSCE to Prepare Medicine Residents for Virtual Care

Boardman, Davis; Wilhite, Jeffrey A; Adams, Jennifer; Sartori, Daniel; Greene, Richard; Hanley, Kathleen; Zabar, Sondra
Background/UNASSIGNED:During the rapid onset of the pandemic, clinicians transitioned from traditional outpatient practice to virtual modalities for providing routine care to patient panels. Like training programs nationwide, telemedicine training and assessment had not been systematically incorporated into our residency. In response, a scheduled Internal Medicine (IM) Objective Structured Clinical Examination (OSCE) was adapted to a remote modality to become virtual care-focused learning experience for trainees and to provide valuable feedback to educators. Methods/UNASSIGNED:Standardized Patients (SPs) rated residents on their communication (including information gathering, relationship development and patient education), patient activation and satisfaction, and telemedicine skills. Analyses included a comparison of domain scores for residents who participated in both the 2020 remote and 2019 in-person OSCEs, and a review of written resident comments about the virtual OSCE. Results/UNASSIGNED: = .008). Conclusion/UNASSIGNED:Our reformulated OSCE accomplished 3 goals including; (1) physically distancing residents from SPs per COVID regulations, (2) providing residents with the opportunity to practice critical virtual visit skills, and (3) alerting our educators to curricular improvement areas. Our methods are useful for other institutions and have applications to the larger medical education community.
PMID: 34189270
ISSN: 2382-1205
CID: 4950972

Changing hats: Lessons learned integrating coaching into UME and GME [Meeting Abstract]

Zabar, S; Winkel, A; Cocks, P; Tewksbury, L; Buckvar-Keltz, L; Greene, R E; Phillips, D; Gillespie, C
BACKGROUND: The transition from medical school to residency is characterized by an abrupt transition of learning needs and goals. Coaching is a promising intervention to support individual learning and growth trajectories of learners. It is uncommon for medical school faculty to have undergone training as coaches. We explored our faculty's perceptions and skills after instituting a new coaching program.
METHOD(S): Faculty advisors (N=12) and GME (N=16) participated in a coaching development program and in community of practice meetings where challenging coaching scenarios were shared. GME faculty also participated in a Group Objective Structured Clinical Exam (GOSCE) to practice and receive feedback on their skills. Peer-faculty observers and resident raters used behaviorally grounded checklists to assess faculty performance. We conducted 2 focus groups: 1) UME advisors engaged in longitudinal coaching (n=9) and 2) GME faculty participating in the coaching development program (n=8) to better understand how faculty make sense of and put into practice these new coaching roles and skills.
RESULT(S): Simple thematic coding showed that both groups emphasized the blurring of the many roles they serve when interacting with trainees and struggled with recognizing both which hat to wear (role to adopt) and which skills to call upon in specific situations. UME advisors who have dedicated advising/coaching roles reported assuming multiple roles at different times with their same students. Many of the GME coaches serve as Associate Program Directors, and described adopting a coaching frame of reference (mentality) and requiring external reinforcement for coaching skills. Some reported realizing after the fact that coaching would have been a valuable approach. Faculty newer to their role felt more successful in engaging in coaching mindset and coaching. Faculty were curious about how trainees would feel about this approach and anticipated that some would appreciate this more than others. 12 faculty participated in a three station Coaching GOSCE. Both resident raters and faculty peer raters suggested faculty coaches were able to establish trust and engage in authentic listening. Coaches negotiated the tension between empathetic listening with supporting goal-setting. Residents provided slightly lower ratings than peer observers on coaches' ability to ask questions and assume a coachee- focused agenda.
CONCLUSION(S): Medical educators may benefit from obtaining coaching skills, but deliberate training in how these skills complement, and differ, from existing skills requires both didactic and experiential learning. Cultivating a community of practice and offering opportunities for deliberate practice, observation and feedback is essential for medical educators to achieve mastery as coaches. LEARNING OBJECTIVE #1: Identify and perform appropriate learning activities to guide personal and professional development (PBL) LEARNING OBJECTIVE #2: Understand and apply core longitudinal coaching skills (Professionalism)
ISSN: 1525-1497
CID: 4984952

Telemedicine training in the covid era: Adapting a routine osce and identifying new core skills for training [Meeting Abstract]

Boardman, D; Wilhite, J; Adams, J; Sartori, D; Greene, R E; Hanley, K; Zabar, S
BACKGROUND: During the rapid onset of the pandemic, clinicians transitioned from traditional outpatient practice to telemedicine for triaging COVID-19 patients and providing routine care to patient panels. Telemedicine training and assessment had not been systematically incorporated into most residencies. In response, a scheduled Internal Medicine (IM) Objective Structured Clinical Examination (OSCE) was adapted to a telemedicineemphasized, virtual modality to become a just-in- time learning experience for trainees.
METHOD(S): Remote cases deployed on common web-based video conference platform included; (1) a potential COVID-19 triage, (2) educating on buprenorphine maintenance, (2) counselling on mammogram screening, and (3) addressing frustration with electronic health record documentation. Simulated Patients (SPs) rated residents on communication skills, patient activation and satisfaction, and case-specific telemedicine items. Analyses included a comparison of domain scores (mean % well done) for residents who participated in both the 2020 remote and 2019 in-person OSCEs, and a review of written resident feedback.
RESULT(S): Fewer than half (46%) of 2020's residents (n=23) performed well on the COVID-19 case's telemedicine skill domain. Residents excelled in using nonverbal communication to enrich on-camera communication (100%), but struggled with virtual physical exams (13%), gathering information (4%), and optimizing technology (4%). Residents expressed interest in more opportunity to practice telemedicine skills going forward. Residents' overall COVID-19 knowledge was fair (54% of items were rated as 'well done'). Fewer than half (45%) advised the SP that testing was not available at the time, but that he should call the city hotline for information, and about half (55%) provided quarantine/ home care instructions. In comparing 2020 (virtual) to 2019 (in-person) OSCE scores, residents who participated in both assessments (n=9) performed similarly on communication skills including information gathering (84% vs. 83%), and relationship development (93% vs. 92%), patient satisfaction (72% vs. 80%) and activation (65% vs. 66%). Patient education scores were significantly lower during the virtual OSCE (40% vs. 76%, P=.008).
CONCLUSION(S): Our reformulated OSCE accomplished three goals: (1) physically distancing residents from SPs, (2) providing residents the opportunity to practice critical telemedicine skills, and (3) alerting our educators to curricular improvement areas in virtual physical exam, patient education, gathering information and optimizing technology. Our methods are scalable at other institutions and have applications to the larger medical and clinical education community. LEARNING OBJECTIVE #1: Describe challenges and barriers to effective communication and clinical skill utilization during televisits. LEARNING OBJECTIVE #2: Understand resident physician practice patterns and communication regarding infectious disease
ISSN: 1525-1497
CID: 4985002

Human Papillomavirus Prevalence, Genotype Diversity, and Risk Factors Among Transgender Women and Nonbinary Participants in the P18 Cohort Study

LoSchiavo, Caleb; Greene, Richard E; Halkitis, Perry N
PMID: 33207125
ISSN: 1557-7449
CID: 4730502

How Do OSCE Cases Activate Learners About Transgender Health?

Greene, Richard E; Blasdel, Gaines; Cook, Tiffany E; Gillespie, Colleen
PURPOSE:To describe the effect of transgender health-related objective structured clinical examination (THOSCE) case exposure on learner activation regarding gender-affirming care. METHOD:A modified grounded theory approach was applied to identify the educational value of THOSCE cases. Focus groups with current and former primary care internal medicine residents who participated in THOSCE cases were conducted in 2018-2019. Transcripts were analyzed and coded until saturation to identify themes. RESULTS:Eighteen (72%) eligible learners participated in the focus groups. Themes were identified relating to gender-affirming care, and modified grounded theory analysis was used as a framework to organize the themes into 4 stages of learner activation: (1) believing the learner role is important, (2) having the confidence and knowledge necessary to take action, (3) taking action to maintain and improve one's skills, and (4) staying the course even under stress. CONCLUSIONS:Residents were grateful for the opportunity to practice the skills involved in transgender health in a simulation. Many felt unprepared and were concerned about how they were perceived by the standardized patient and faculty. Residents identified feeling more comfortable with gender-affirming language in the inpatient setting, which may provide an opportunity for learning in the future. Residents identified the psychosocial skills of gender-affirming care as more directly relevant while biomedical aspects of gender-affirming care seemed less accessible to residents, given the lack of outpatient experience. The authors propose a staged approach to teaching the skills of gender-affirming care using simulation to address learners of all levels.
PMID: 32889930
ISSN: 1938-808x
CID: 4734402

Building Telemedicine Capacity for Trainees During the Novel Coronavirus Outbreak: a Case Study and Lessons Learned

Lawrence, Katharine; Hanley, Kathleen; Adams, Jennifer; Sartori, Daniel J; Greene, Richard; Zabar, Sondra
INTRODUCTION/BACKGROUND:Hospital and ambulatory care systems are rapidly building their virtual care capacity in response to the novel coronavirus (COVID-19) pandemic. The use of resident trainees in telemedicine is one area of potential development and expansion. To date, however, training opportunities in this field have been limited, and residents may not be adequately prepared to provide high-quality telemedicine care. AIM/OBJECTIVE:This study evaluates the impact of an adapted telemedicine Objective Structured Clinical Examination (OSCE) on telemedicine-specific training competencies of residents. SETTING/METHODS:Primary Care Internal Medicine residents at a large urban academic hospital. PROGRAM DESCRIPTION/METHODS:In March 2020, the New York University Grossman School of Medicine Primary Care program adapted its annual comprehensive OSCE to a telemedicine-based platform, to comply with distance learning and social distancing policies during the COVID-19 pandemic. A previously deployed in-person OSCE on the subject of a medical error was adapted to a telemedicine environment and deployed to 23 primary care residents. Both case-specific and core learning competencies were assessed, and additional observations were conducted on the impact of the telemedicine context on the encounter. PROGRAM EVALUATION/RESULTS:Three areas of telemedicine competency need were identified in the OSCE case: technical proficiency; virtual information gathering, including history, collateral information collection, and physical exam; and interpersonal communication skills, both verbal and nonverbal. Residents expressed enthusiasm for telemedicine training, but had concerns about their preparedness for telemedicine practice and the need for further competency and curricular development. DISCUSSION/CONCLUSIONS:Programs interested in building capacity among residents to perform telemedicine, particularly during the COVID-19 pandemic, can make significant impact in their trainees' comfort and preparedness by addressing key issues in technical proficiency, history and exam skills, and communication. Further research and curricular development in digital professionalism and digital empathy for trainees may also be beneficial.
PMID: 32642929
ISSN: 1525-1497
CID: 4518942

Interrupting Microaggressions in Health Care Settings: A Guide for Teaching Medical Students

Acholonu, Rhonda Graves; Cook, Tiffany E; Roswell, Robert O; Greene, Richard E
Introduction/UNASSIGNED:Microaggressions are connected to broader conceptualizations of the impact of implicit bias and systems of inequity. The body of evidence supporting the need for more-open discussions in medical education about race, racism, and their impact on health disparities continues to grow. Some have advocated for the importance of bringing anti-racist pedagogy into medical education curricula, which involves explicitly attempting to move beyond people's comfort zones and acknowledging that discomfort can be a catalyst for growth. To discuss the intent and impact of microaggressions in health care settings and how we might go about responding to them, we developed a workshop for third-year undergraduate medical students within a longitudinal undergraduate medical education diversity and inclusion curriculum. Methods/UNASSIGNED:= 154). Prior to the workshop, the students were asked to anonymously submit critical incident reports on any microaggressions experienced or witnessed to develop case studies for problem-based learning. Teaching modalities included lecture, problem-based learning with case studies, pair and share, and facilitated small- and large-group debriefs. Results/UNASSIGNED:The session was evaluated using a 4-point Likert scale to assess students' comfort in learning about the information presented. Ninety-eight percent felt confident in identifying microaggressions, and 85% felt confident in interrupting microaggressions when they occur. Discussion/UNASSIGNED:This personalized workshop exposes students to microaggressions personally experienced by colleagues with an attempt to interrupt them using empathy, awareness, and communication techniques.
PMID: 32754633
ISSN: 2374-8265
CID: 4554022

Understanding clinician attitudes toward screening for social determinants of health in a primary care safety-net clinic [Meeting Abstract]

Altshuler, L; Fisher, H; Mari, A; Wilhite, J; Hardowar, K; Schwartz, M D; Holmes, I; Smith, R; Wallach, A; Greene, R E; Dembitzer, A; Hanley, K; Gillespie, C; Zabar, S R
BACKGROUND: Social determinants of health (SDoH) play a significant role in health outcomes, but little is known about care teams' attitudes about addressing SDoH. Our safety-net clinic has begun to implement SDoH screening and referral systems, but efforts to increase clinical responses to SDoH necessitates an understanding of how providers and clinical teams see their roles in responding to particular SDoH concerns.
METHOD(S): An annual survey was administered (anonymously) to clinical care teams in an urban safety-net clinic from 2017-2019, asking about ten SDoH conditions (mental health, health insurance, food, housing, transportation, finances, employment, child care, education and legal Aid). For each, respondents rated with a 4-point Likert-scale whether they agreed that health systems should address it (not at all, a little, somewhat, a great deal). They also indicated their agreement (using strongly disagree, somewhat disagree, somewhat agree, strongly agree) with two statements 1) resources are available for SDoH and 2) I can make appropriate referrals.
RESULT(S): 232 surveys were collected (103 residents, 125 faculty and staff (F/S), 5 unknown) over three years. Of note, mental health (84%) and health insurance (79%) were seen as very important for health systems to address, with other SDoH items seen as very important by fewer respondents. They reported little confidence that the health system had adequate resources (51%) and were unsure how to connect patients with services (39%). When these results were broken out by year, we found the following: In 2017 (n=77), approximately 35% of respondents thought the issues of employment, childcare, legal aid, and adult education should be addressed "a little," but in 2018 (n=81) and 2019 (n=74) respondents found the health system should be more responsible, with over 35% of respondents stating that these four issues should be addressed "somewhat" by health systems. In addition, half of respondents in 2019 felt that financial problems should be addressed "a great deal," up from 31% in 2017. Across all years, food, housing, mental health, and health insurance were seen as SDoH that should be addressed "a great deal". It is of note that respondents across all years reported limited understanding of referral methods and options available to their patients.
CONCLUSION(S): Many of the SDoH conditions were seen by respondents as outside the purview of health systems. However, over the three years, more members increased the number of SDoH conditions that should be addressed a "great deal." Responses also indicated that many of the team members do not feel prepared to deal with "unmet social needs". Additional examination of clinic SDoH coding, referral rates, resources, and team member perspectives will deepen our understanding of how we can cultivate a culture that enables team members to respond to SDoH in a way that is sensitive to their needs and patient needs
ISSN: 1525-1497
CID: 4803172

Implicit bias: Trends in evaluation [Meeting Abstract]

Cannell, E; Cook, T E; Wilhite, J; Altshuler, L; Greene, R E
BACKGROUND: Academic medical centers have identified a need to train faculty about implicit bias. Prior to interview season, NYU held implicit bias workshops with departments, in which participants were asked to evaluate applicants for positions in their departments. Participants rated applicants on a scale from 1-10 and listed 2 positive and 2 negative adjectives about them. The resumes were identical except for gender and race. Individual assessment forms were collected without data to identify the participants or the departments in which they worked.
METHOD(S): The adjectives were categorized into 10 types of positive adjectives and 7 types of negative adjectives in order to analyze any systematic differences in which types of adjectives were using based on demographics. For example, the most common positive categories of adjectives related to education/experience, work ethic, and intelligence, and the most popular negative categories were related to dishonesty, social difficulty, and assertiveness. Chi-square tests were performed on positive adjectives and negative adjectives testing differences between two genders (Woman, Man) and three racial groups (Black, Caucasian, Latinx).
RESULT(S): N=153 applicant evaluations were reviewed. There was no significant difference in the final rating scores for the different applicants. The gender data showed a significant difference in how men and women were describedwith the second of the two positive adjectives ascribed (p = 0.012, chi=21.063). For negative adjectives, the category of the first adjective written was significantly different between men and women (p = 0.043*, chi = 13.018). The most noteworthy distributions of adjectives were that "bright" was used for only females in the intelligence category, "assertive" was more often used positively for men and negatively for women. Evasiveness wasmore often attributed to men than women, while distractibility by familial issues was more often applied to women. Regarding race and ethnicity, there were no significant differences among race in the positive adjectives given. However, the second positive adjective given by race/ethnicity showed some statistically significant difference by category (p =0.007*, chi=35.96). With regard to the negative adjectives given, the first was statistically significant, describing Caucasians as difficult to get along with. The most noteworthy distributions of adjectives were that "hardworking" was used mostly for Latinx and intelligence categories were less likely to be used for Black applicants.
CONCLUSION(S): Even during activities that are part of implicit bias workshops, differences in perceptions of race/ethnicity and gender persist with identical descriptions of hypothetical candidates. These data also suggest that workshop participants were more likely to ascribe similar adjectives by gender or race/ethnicity as their first instinct but when assigning a second adjective, they may have leaned more on bias or stereotype
ISSN: 1525-1497
CID: 4803232