Faculty Bibliography

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): Can user-centered design (UCD) facilitate the development of novel and effective training tools for the virtual ambulatory learning environment LEARNING OBJECTIVES 1: To identify the needs, preferences, and concerns of resident trainees and attending preceptors regarding the current virtual ambulatory care learning environment. LEARNING OBJECTIVES 2: To apply user-centered design (UCD) strategies to the development of effective tools to enhance the virtual learning experience of trainees and preceptors. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The COVID-19 pandemic spurred a rapid transition to virtual learning environments, the design of which may impact learning experiences and competency development for trainees. User-centered design (UCD) offers a framework to iteratively and collaboratively incorporate needs, preferences, and concerns of users (e.g. trainees and preceptors) in the development of acceptable and effective educational tools. This study applied UCD strategies of empathize, define, ideate, prototype, and test among Internal Medicine residents and outpatient attending preceptors to develop innovations for the virtual ambulatory care learning environment. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICHWILL BEUSEDTOEVALUATE PROGRAM/INTERVENTION): Using the UCD framework, we identified: 1) needs, preferences, and concerns of residents and preceptors in current virtual precepting practices (empathize) 2) key problem areas and pain points (define) 3) potential solutions (ideate) 4) specific products to develop (prototype), deploy, and evaluate (test) in practice FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): Qualitative needs-assessment interviews were conducted among 8 residents and 10 preceptors, which identified key areas of learner need: technical and workflow competency; the virtual precepting experience; patient rapport-building and communication; and documentation requirements. Subsequently, a Design Thinking Workshop focusing on virtual precepting was developed, and 3 workshops were conducted with 12 participants (residents and attendings). Using a three-phase interactive sequence of explore, ideate, and create, participants were divided into 2-or 3-person virtual breakout groups and asked to 1) identify a key problem in current virtual precepting, 2) brainstorm possible solutions, and 3) design and present a low-fidelity prototype of one solution. Key problems identified included: management of technical issues, goal setting for precepting sessions, clinic-specific information dissemination practices, and the loss of shared learning space with colleagues. Potential solutions included: a digital shared-learning plan for residents, a real-time virtual clinical bulletin board, an integrated virtual team huddle, and just-in-time digital chalk talks. Two prototypes are being developed for testing in the live precepting environment. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY): User-centered design can be deployed as an effective strategy to engage learners and preceptors in the design and development of educational innovations for the virtual training environment. We recommend collaborating with residents, preceptors, and other stakeholders in the iterative design of virtual learning tools

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): In the transition away from traditional doctors' offices, how can we optimize shared multi-use clinical spaces to serve clinicians' needs LEARNING OBJECTIVES 1: Identify ways in which a practice that relies upon shared clinical spaces can remain familiar and effective for clinical work. LEARNING OBJECTIVES 2: Determine how might technology help clinicians develop a sense of belonging, professional pride, and patient rapport in multi-use spaces by allowing them to display personal information and patient education materials related to their practice. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The traditional doctor's office is being rapidly replaced by multi-use clinical environments that combine exam rooms with shared touchdown spaces, promoting efficient use of space & team-based care approach while utilizing network technologies. While potentially efficient & lower-cost, there's a need to assess the impact of these configurations on clinician workflows, professional identity & explore opportunities to improve their build and aesthetics. We conducted need assessment interviews with 9 clinicians, health technologists, 2 operational leaders, shadowed 3 clinicians & conducted 4 site visits across various clinical practices. We then issued a 10-question survey and conducted 2 HCD workshops with 12 clinicians to understand the new conditions of clinical work, their impact on clinicians' professional & personal identity, practice habits, to identify areas for potential optimization to improve clinical workflow & experience. Workshops were divided in three phases: explore, ideate and create. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICHWILL BE USEDTOEVALUATE PROGRAM/INTERVENTION): We report qualitative success metrics used to evaluate the results of the HCD workshops: 1. Understanding of what shared multi-use work spaces mean to participating clinicians. 2. Identified needs, potential concerns and pain points of clinicians and stakeholders. 3. Group generation of potential solutions without bias towards feasibility. 4. Described solutions using quick prototyping tools. FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): Clinicians identified the lack of customization and capability for sharing information about their areas of expertise and tailored patient education materials as the most significant problem, and had privacy concerns about sharing personal information on a digital display. Potential solutions include customizable content display controlled by patients that fosters engagement, exploring education materials, patient testimonials, information about the care team and wait time as well as patient-specific information, such as labs and imaging. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY): The use of the HCD principles helped us better understand the challenges of multi-use spaces for clinicians, and identify potential technology solutions for data sharing, patient education, personalization, and efficiencies. It is crucial to design these spaces and choose appropriate technology solutions that will help reduce patients' anxiety by ensuring privacy, comfort, thorough understanding of care plans and boost collaborative care decision making between clinicians and patients

INTRODUCTION/BACKGROUND:Data regarding underpinning and implications of ethical challenges faced by humanitarian workers and their organisations in humanitarian operations are limited. METHODS:We conducted comprehensive, semistructured interviews with 44 experienced humanitarian aid workers, from the field to headquarters, to evaluate and describe ethical conditions in humanitarian situations. RESULTS:61% were female; average age was 41.8 years; 500 collective years of humanitarian experience (11.8 average) working with diverse major international non-governmental organisations. Important themes included; allocation schemes and integrity of the humanitarian industry, including resource allocation and fair access to and use of services; staff or organisational competencies and aid quality; humanitarian process and unintended consequences; corruption, diversion, complicity and competing interests, and intentions versus outcomes; professionalism and interpersonal and institutional responses; and exposure to extreme inequities and emotional and moral distress. Related concepts included broader industry context and allocations; decision-making, values, roles and sustainability; resource misuse at programme, government and international agency levels; aid effectiveness and utility versus futility, and negative consequences. Multiple contributing, confounding and contradictory factors were identified, including context complexity and multiple decision-making levels; limited input from beneficiaries of aid; different or competing social constructs, values or sociocultural differences; and shortcomings, impracticality, or competing philosophical theories or ethical frameworks. CONCLUSIONS:Ethical situations are overarching and often present themselves outside the exclusive scope of moral reasoning, philosophical views, professional codes, ethical or legal frameworks, humanitarian principles or social constructivism. This study helped identify a common instinct to uphold fairness and justice as an underlying drive to maintain humanity through proximity, solidarity, transparency and accountability.

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.

The coronavirus disease 2019 (COVID-19) pandemic has accelerated the drive of health-care delivery towards virtual-care platforms. While the potential of virtual care is significant, there are challenges to the implementation and scalability of virtual care as a platform, and health-care organisations are at risk of building and deploying non-strategic, costly or unsustainable virtual-health systems. In this article, we share the NYU Langone Health enterprise approach to building and scaling an integrated virtual-health platform prior to and during the COVID-19 pandemic, and offer lessons learned and recommendations for health systems that need to undertake or are currently undertaking the transition to virtual-care delivery.

BACKGROUND: Moral distress is defined as a situation in which an individual believes they know the ethically appropriate action to take but are unable to take that action. The concept of moral distress is increasingly recognized as an important mediator of occupational stress and burnout in medicine, particularly in the nursing profession. However, there is a dearth of literature on moral distress among physician trainees, with the majority focused on dilemmas in end-of-life care. This study explores the phenomenon of moral distress among internal medicine trainees, with particular focus on drivers, situational contexts, and adaptive strategies such as coping mechanisms.
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants, and was identified across four major domains: personal values and morals, professional competency and training challenges, interpersonal relationships and conflicts, and systems/structural issues. Participants identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, as well as between private, public, and government- run hospital facilities. Participants described a number of adaptive mechanisms for managing moral distress, including social support and connectivity, humor, and disassociation.
CONCLUSION(S): Physician trainees experience considerable moral distress across multiple domains during the course of their training. They also develop unique adaptive strategies and copingmechanisms tomanage and learn from distressing experiences. This improved understanding ofmoral distress among physician trainees, particularly drivers and protective factors, has important implications for the training of physicians, and may have a role in promoting wellness and resilience among physicians across the training and professional pipeline

BACKGROUND: Moral distress is defined as a situation in which an individual believes they know the ethically appropriate action to take but are unable to take that action. The concept ofmoral distress is increasingly recognized as an important mediator of occupational stress and burnout in healthcare, particularly in the nursing literature. However, there is a dearth of literature focusing on moral distress among physician trainees, particularly as regards the clinical training environment. This study explores the phenomenon of moral distress among internal medicine trainees, with an emphasis on the contexts of clinical training and professional role development.
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants. Trainees identified several drivers of moral distress that were unique to their professional development as clinicians and their role as trainees/ learners within clinical teams, including: feelings of inadequacy in clinical or procedural skills, being asked to performduties outside of their scope of practice, discomfort with the idea of 'practicing' skills on patients, poor team communication, disagreements with senior team members, experiences of disempowerment as junior team members, and overwhelming or inappropriate administrative or non-clinical burdens. Participants also identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, aswell as between private, public, and government-run hospital facilities.
CONCLUSION(S): Physician trainees experience considerable moral distress in the context of their professional development, with unique drivers of moral distress identified in the training and clinical team context. This improved understanding of factors unique to the trainees' experience has implications for tailoring educational experiences as professional development activities, as well as potential wellness- and resilience-building among physician trainees. It may also inform the training of physician leaders and seniors clinicians who engage with trainees in learning and clinical environments

OBJECTIVE: To explore the characteristics, motivations, ideologies, experience and perspectives of experienced medical humanitarian workers. DESIGN: We applied a qualitative descriptive approach and conducted in-depth semistructured interviews, containing open-ended questions with directing probes, with 44 experienced international medical aid workers from a wide range of humanitarian organisations. Interviews were coded and analysed, and themes were developed. SETTING: International non-governmental organisations (INGOs) and United Nations (UN). RESULTS: 61% of participants were female; mean age was 41.8 years with an average of 11.8 years of humanitarian work experience with diverse major INGOs. Significant core themes included: population's rights to assistance, altruism and solidarity as motives; self-identification with the mission and directives of INGOs; shared personal and professional morals fostering collegiality; accountability towards beneficiaries in areas of programme planning and funding; burnout and emotional burdens; uncertainties in job safety and security; and uneasiness over changing humanitarian principles with increasing professionalisation of aid and shrinking humanitarian access. While dissatisfied with overall aid operations, participants were generally satisfied with their work and believed that they were well-received by, and had strong relationships with, intended beneficiaries. CONCLUSIONS: Despite regular use of language and ideology of rights, solidarity and concepts of accountability, tension exists between the philosophy and practical incorporation of accountability into operations. To maintain a humanitarian corps and improve aid worker retention, strategies are needed regarding management of psychosocial stresses, proactively addressing militarisation and neo-humanitarianism, and nurturing individuals' and organisations' growth with emphasis on humanitarian principles and ethical practices, and a culture of internal debate, reflection and reform.