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Complexity of resident-identified challengies during training [Meeting Abstract]

Altshuler, L; Abraham, M; Boardman, D; Tannenbaum, J; Park, A; Lipkin, M
BACKGROUND: On the road to becoming competent, compassionate and ethical physicians, trainees need to reflect on their experiences, understand the clinical and social contexts, and integrate cognitive and affective reactions in ways that build resilience and a coherent professional identity. Using a qualitative approach, this study seeks to identify medical residents' stressors and challenges, and to understand their experience of the internal and external factors of such situations. Such information can guide educators to develop curricula that better meet residents' needs.
METHOD(S): Primary Care residents at NYU School of Med have ongoing Psychosocial Rounds (PSR) throughout their 3 years, facilitated by a faculty member and Chief Resident, where residents present challenging cases or situations, framed by a specific question. Semi-structured notes taken by facilitators, including question, case description, process of discussion and teaching points were compiled into a deidentified database of 119 cases spanning 2010-2019. These notes were coded by three coders using iterative thematic analysis.
RESULT(S): Seventy four of the 119 cases have been coded to date. Four general themes emerged, with each comprised of 2 to 4 main codes. These themes were 1) Self (S): including management of medical uncertainty, emotional reactions, roles and responsibilities, self-care; 2) Teams (T): including relationship with peers, supervisors, other health professionals; 3) Understanding Patient and Families (PF): including social and cultural context, mental health issues, patient/ family and provider disagreements; and 4) Hospital, Healthcare and Societal issues (HHS). There was a high co- occurrence of themes within cases, 60% had 2 themes present, 24% had 3, and only 16% had one theme. Cases with 3 themes most often included S, T and PF.
CONCLUSION(S): This analysis of PSR cases identifies issues for which residents seek help and support in a safe, case-oriented problem-solving discussion group, and allows for in-depth reflection and exploration. The cooccurrences of themes indicate the complexity of issues faced, and the importance of integrating multiple domains when beginning to understand these issues. LEARNING OBJECTIVE #1: Professionalism: Coping with challenges of becoming resilient physician with emotional and cognitive capacity to deal with complex situations LEARNING OBJECTIVE #2: Interpersonal and Communication Skills: Develop awareness and skills to negotiate interpersonal situations
ISSN: 1525-1497
CID: 4986602


Boardman, Davis; Tanenbaum, Jessica; Altshuler, Lisa; Lipkin, Mack
ISSN: 0884-8734
CID: 4799192

Training Primary Care Physicians to Serve Underserved Communities: Follow-up Survey of Primary Care Graduates [Letter]

Altshuler, Lisa; Fisher, Harriet; Hanley, Kathleen; Ross, Jasmine; Zabar, Sondra; Adams, Jennifer; Lipkin, Mack
PMID: 31342328
ISSN: 1525-1497
CID: 3988152

Resource intensive care transitions program impact on 90-day hospital readmissions [Meeting Abstract]

Trivedi, S P; Trawick, E; Diuguid-Gerber, J; Fagan, I; Lipkin, M; Schwartz, M D
Statement of Problem Or Question (One Sentence): Is enrollment in a Care Transitions Program (CTP) associated with decrease in 90-day hospital admissions compared to standard discharge care for high utilizers in a large safety-net city hospital? Objectives of Program/Intervention (No More Than Three Objectives): 1. Implement a team to follow high-utilizers for 30 days post-discharge; 2. Assess patient needs with a home visit or other face-to-face visit and coordinate care based on needs, and 3. Decrease hospital admissions of high utilizers Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): In a large safety-net hospital, high utilizers were Medicaid-insured or uninsured patients who had four or more admissions in the prior year. Inpatient medical teams made referrals to CTP. In CTP, a multidisciplinary team of a social worker, nurse, community liaison and, at times, a medicine resident followed the patient for 30 days post-discharge. Interventions included medication reconciliation, weekly phone calls, and either a home visit or face-to-face visit at a preferred location for the patient. Eligible high utilizers not referred to CTP received standard discharge follow-up and served as controls in this quasi-experimental study. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We identified all admissions of high-utilizers eligible for CTP enrollment between 4/1/17 and 9/30/17. Patients were categorized as enrolled in CTP, with or without a home or face-to-face visit, or not enrolled in CTP. Changes in 90-day admission rates before and after the eligible admission were compared in the CTP and control groups, with the eligible admission included in the pre-intervention period. Subgroup comparisons were also performed. The decrease in 90-day admission rates across groups were compared using ANOVA. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Of the 358 admissions of eligible high-utilizers, 31% (112) were enrolled in CTP. Of those in CTP, 54% had either a home visit (28) or a face-to-face visit (32). Within control patients, 90-day admission rates fell from 2.90 to 1.26, a decrease of 50.6% (95% CI 39.0%-62.3%). Within CTP patients, admission rates fell from 2.53 to 1.02, a decrease of 54.6% (95% CI 41.0%-67.6%). The difference in 90-day admission reductions between CTP and control groups, 3.7% (95% CI-22.8%-30.2%), was not significant. Per-protocol analysis of the CTP subgroups who had either a home visit or a face-to-face visit showed decreases in 90-day admissions of 68.7% (95% CI 51.2%-86.2%) and 64.0% (95% CI 46.9%-81.1%) respectively. The differences in 90-day admission reductions between CTP patients with home or face-to-face visit vs. controls, 18% (95% CI-13%-49%, p=0.59) and 13.3% (95% CI-17.8%-44.5%, p=0.84) respectively, were not significant. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): The trend towards greater decrease in 90-day admissions for high utilizers that had a home or face-to-face visit suggests that assessing high utilizers in their community environment may improve care for these patients. Given the small sample size and non-randomized allocation, interpretation of the Results is preliminary, and subsequent, randomized, adequately powered study with criteria-based high-utilizer referral to these high-intensity resources is warranted
ISSN: 1525-1497
CID: 4052642

Learners who struggle in medical education: Common presentations [Meeting Abstract]

Celdir, M G; Steeves-Fuentes, A; Schoenthaler, A; Yellin, P B; Lipkin, M
Needs and Objectives: It is common for students to struggle in the challenging academic and social environments of medical education. We posit that some who struggle are not simply the edge of a Gaussian distribution of success but present definable syndromes which are recognizable, testable, and remediable. In this first heuristic look at our hypothesis, we aimed to identify prominent learning profiles and early signs of struggle among medical students with poor academic performance and measurable factors that correlate with their struggles. Setting and Participants: Ninety medical students with academic struggles were referred to a learning assessment center between 2006 and 2018. Reports of the assessment process were constructed to provide remediation strategies for students and educators. Description: We evaluated reports of the comprehensive neurodevelopmental evaluations. Reports documented referral concerns, students' self-assessments of their competencies, academic history, neuropsycho-logical evaluations and interviews in the assessment process to establish learning profiles of strengths and challenges of each student and recommended remediation strategies. We applied grounded theory Methods to identify common patterns in students' comprehensive evaluations. Evaluation: Students who displayed signs of struggle earlier in medical school commonly presented after poor performance on standardized assessments (63%, 50/80). They had historically excelled in academic areas rewarding intuitive ways of learning and chosen academic degrees that played to their strengths. In medical school, rote memorization and passive study Methods such as transcribing lectures, without active information processing led to inefficient learning, requiring more time for their studies. They lacked strategies to plan their studies and exams, regulate their attention, filter and systematically store information of salient details. Students experienced high rates of anxiety and depression (41%, 37/90) and some received psycho/pharmacotherapy (27%, 24/90). Social isolation and feelings of inadequacy further exacerbated their struggles. Discussion/Reflection/Lessons Learned: Lack of learning and test-taking strategies appropriate for the unique and standardized medical school curriculum, combined with psychosocial stress in a competitive learning environment, expose challenges which may have been unnoticed by students in prior academic pursuits. Their patterns of presentation might alert instructors and students to seek evaluation and assistance early, receive guidance and remediation of specific learning challenges and avoid distressing, diminished academic performance
ISSN: 1525-1497
CID: 4052832

When Suicide Happens in the Medical Community

Lipkin, Mack
When suicide happens close to doctors, students, and faculty, to our families, friends, colleagues, students, residents, fellows and patients, it challenges us as individuals and as members of institutions that seek to provide safety and support. The US suicide rate has increased and suicide remains difficult to predict or to prevent despite its association with depression and addiction. It is less common in medical students and residents than in the general, age-matched population but generates troubling, complex aftershocks for us. Individuals react according to their history and style, through stages, psychological defenses, and difficult affects. Grief, shock, anger, denial, and guilt are prevalent. People responding to a close suicide seek information, asking "why", "what if" and "if only", despite the speculative nature of attempting to understand what happened and why. Nearby suicide may be more challenging for us in the medical profession because the helplessness it evokes undermines our sense of omniscience and omnipotence. Thus, we engage in retrospection and a search for preventive interventions that may or may not be evidence based, salutary, or healing.
PMID: 30426344
ISSN: 1525-1497
CID: 3458632


Trivedi, Shreya P.; Fagan, Ian; Zabar, Sondra; Lipkin, Mack
ISSN: 0884-8734
CID: 4449862

Retaining residents in primary care for the underserved: Primary caring, rigor, and community [Meeting Abstract]

Ross, J A; Rastogi, N; Altshuler, L; Adams, J; Hanley, K; Greene, R E; Chuang, L; Zabar, S; Lipkin, M
BACKGROUND: As healthcare increases demands, primary care physicians need evidenced-based, patient-centered care coordination, effective use of information technology, interdisciplinary team functioning and shared decision-making skills more so in underserved areas. In 2008, we documented 20 years of the NYU/Bellevue Primary Care Internal Medicine Residency Program (NYUBPC) on readiness for practice1. In light of the recent primary care changes we assessed our recent training of Primary Care Residents in high quality, person-centered, systems-savvy, team-based care for the underserved. Specifically we aimed to: 1. Assess the NYUBPCP impact on graduate career choices, values and style 2. Elicit reflections that illustrate complexities in educating primary care physicians METHODS: We surveyed 56 graduates of the NYUBPCP from 2007-2014. The 44 question survey included 12 open-ended questions about career path, current practice, preparedness for practice and specifics about how aspects of training provided necessary skills and knowledge. Responses were unidentified. We received 37 responses, (66%). RESULTS: 36 respondents currently provide clinical care, with about 40% of their time spent in a primary care setting (S.D. 32%). On a 4- point scale 85% either agreed or strongly agreed with Primary Care as a career choice. 74% felt prepared for the challenges of a primary care practice, rating clinical experiences with underserved communities, and the psychosocial, clinical epidemiology and health policy focus as essential aspects of training. All but 4 provide care to medically underserved populations. They valued the community of peers and colleagues that the NYUBPCP provided. While 53% rated their clinical site as hectic/chaotic (4 or 5 on a 5 point scale), only 6% reported persistently feeling burnout. 19% reported at least one symptom of burnout. Qualitative analyses revealed overlapping themes in alumni perceptions of how residency influenced current practice, aspects of training that were difficult to implement and expectations for the future directions of primary care. Responses demonstrated a mismatch between the "purity" of primary care practice graduates strove to achieve after residency and the actuality of a practice influenced by external factors (e.g. time pressures, reimbursement issues and metric achievements). Some found it difficult to be involved with research or advocacy while in full-time clinical practice. Graduates believed the future of primary care lies in a team-based approach. CONCLUSIONS: A training program emphasizing rigorous curriculum, committed role modeling, care of the underserved, and strong residency community for support continues to document high rates of retention in primary care. They are well adapted entering physicians with the skills and attitudes necessary to succeed in primary care and become educators of the next generation
ISSN: 0884-8734
CID: 2554302


Hanley, Kathleen; Gillespie, Colleen; Naidu, Mrudula; Nudelman, Irina; Adams, Jennifer; Lipkin, Mack; Zabar, Sondra
ISSN: 1525-1497
CID: 1730082


Augustine, Matthew R; Appelblatt, Rachel; Lipkin, Mack; Hanley, Kathleen
ISSN: 1525-1497
CID: 1730322