Faculty Bibliography

LEARNING OBJECTIVES 1: Describe a longitudinal curriculum to train internal medicine (IM) residents in point-of-care ultrasound (POCUS). LEARNING OBJECTIVES 2: Recognize the impact of decreased patient contact on residents' retention of POCUS skills. SETTINGAND PARTICIPANTS:Despite thewell-documented benefits of POCUS, internal medicine residents receive little formal training. We implemented a curriculumin the 2019 academic year to train 55 PGY-2 IMresidents in POCUS across four urban teaching hospitals and a method to evaluate its efficacy. As the COVID pandemic hit, we additionally sought to understand the impact of COVID on the efficacy of our curriculum and to ascertain from IM residents their barriers to using POCUS during the COVID pandemic. DESCRIPTION: The curriculum was composed of three workshops, consisting of lectures and hands-on practice covering lung, cardiac, abdominal, and lower extremity vascular views. Following the workshops, we sought to consolidate learners' knowledge with a subsequent year-long skill building phase. The skill-building phase was truncated due to the pandemic.A hands-on assessment was performed prior to the course and not repeated at course conclusion due to social distancing concerns. An online knowledge test was administered before the course, immediately following the course, and at one year. A survey assessing attitudes and barriers to POCUS was administered before the course and at one year. EVALUATION: No resident passed the pre-course hands-on assessment. Prior to the course, the average resident score was 54% on the online knowledge quiz; directly after the workshop series, the average rose to 78%. At one year, the average score on the online knowledge quiz was 74%, a statistically significant decrease (p=0.04). Ninety-one percent of residents reported performing POCUS at least once/month prior to the pandemic. During the pandemic, scanning activity decreased; 67% residents reported they scanned rarely or never. DISCUSSION/ REFLECTION / LESSONS LEARNED: Our course led to significant improvement of knowledge regarding ultrasound technology and image interpretation, however this decayed at one year, likely due to lack of skill reinforcement. Though POCUS was widely used prior to the pandemic, usage dropped at the pandemic's peak, despite its utility as both a diagnostic and therapeutic tool. The most commonly cited reason for lack of use was concern regarding contamination and infectious exposure. While the COVID pandemic disrupted our curriculum, it also highlighted opportunities to incorporate POCUS into clinical practice and reinforced the importance of continued longitudinal practice to retain learned skills

LEARNING OBJECTIVE #1: Know the possible drug interactions of HMG CoA reductase inhibitor (statin) and commonly used antiplatelet agents LEARNING OBJECTIVE #2: Understand options for statin therapy in people with statin induced myopathy CASE: A 75-year-old man presented to his primary care physician (PCP) with two weeks of progressively worsening bilateral anterior thigh pain causing difficulty with ambulation. One month prior to presentation, he had been hospitalized for non-ST elevation myocardial infarction and in-stent thrombosis after he self-discontinued aspirin therapy. Upon discharge, he was switched to ticagrelor after he was found to be a non-responder to clopidogrel on platelet function tests. One day prior to admission his PCP discovered AST and ALT elevations to over 400 U/L (normal ranges 11-39 U/L and 11-35 U/L) and instructed the patient to present to the emergency room for further workup. In the emergency room (ED), the patient reported his symptoms started after he started taking ticagrelor, and he denied alcohol use. Past medical history includes hypertension and coronary artery disease treated with five drug eluting stents. He reported adherence medication regimen, which consisted of aspirin, ticagrelor, atorvastatin, amlodipine, hydrochlorothiazide, losartan, and metoprolol. He denied shortness of breath, dyspnea on exertion, abdominal pain, and leg edema. Vital signs were normal. Physical exam was most notable for tenderness to palpation of the thighs bilaterally. AST and ALT were 228 U/L and 158 U/L respectively, and CK was 4600 U/L (normal range: 45-245 U/L). Urinalysis revealed small blood with 0-4 red blood cells; urine culture produced no growth. Liver ultrasound found a normal liver and biliary tree. Hepatitis B and C serologies were negative. Troponin I was 0.07 ng/mL (normal range: <0.06 ng/mL), though there were no EKG changes from his prior admission. Once admitted to the floor, his atorvastatin was discontinued. The next day his AST and ALT decreased to 57 U/L and 121 U/L, and his CK fell to 715 U/L. IMPACT/DISCUSSION: Both myopathy and hepatitis occurred in this patient after initiation of ticagrelor, which is a known inhibitor of CYP P450 3A4. The levels of atorvastatin, which is metabolized by CYP P450 3A4, likely increased and caused a dose dependent toxicity, causing the patient's symptoms and lab abnormalities. He was subsequently discharged with improvement of thigh pain.
CONCLUSION(S): The drug-drug interaction of atorvastatin and ticagrelor has been established. This submission focuses on increasing knowledge of this common interaction. In this case, atorvastatin was discontinued and rosuvastatin was started as it is not metabolized by CYP P450 3A4. This combination is often better tolerated when combined with ticagrelor. The patient returned for outpatient follow-up and was started on rosuvastatin 5 mg with repeat liver function tests ordered with plans titrate as tolerated

BACKGROUND: To justify nonprofit hospital organizations' tax exemption, the Affordable Care Act (ACA) requires these organizations to report on efforts to identify and invest in local health needs via Community Health Needs Assessments (CHNAs), Implementation Strategies (ISs), and Schedule H (990H) tax forms. However, there is no requirement that 990H spending aligns with topics raised on CHNAs or ISs, and recent reports have questioned whether 990H reporting categories adequately measure investments in social determinants of health. To assess the utility of ACA-mandated reporting for tracking spending on social health needs, this cross-sectional study aimed to describe how often a need identified in CHNAs is reflected in plans noted in ISs and in spending reported in 990Hs. Using housing as an example of a social health need, we focused on communities with the most homelessness to study organizations most likely to address housing.
METHOD(S): We identified nonprofit hospital organizations with facilities in the 5 metropolitan areas with highest per-capita homelessness using Department of Housing & Urban Development data and the Community Benefit Insight (CBI) database. We reviewed organizations' public reporting documents, obtained via internet search and from CBI, to determine whether they ever addressed housing on CHNAs, ISs, and 990Hs from 2015-2017. We excluded 3 organizations for which we could not obtain all 3 documents.
RESULT(S): Of 47 organizations sampled (representing 57 facilities in Washington, DC; Santa Cruz County; Boston; New York City; and San Francisco), housing was noted in 55% (n=26) of CHNAs, 36% (n=17) of ISs, and 26% (n=12) of 990Hs. Among the 26 organizations that recognized housing needs in CHNAs, 10 noted housing-related plans in ISs, and 7 reported spending on housing in 990Hs.
CONCLUSION(S): Although many nonprofit hospital organizations in areas with high homelessness recognize housing as a health need, public reporting documents provide limited evidence that an identified community need for housing was translated into related plans and spending. Further investigation should explore whether discrepancies among documented needs, strategies, and spending reflect inadequacy of the 990H for capturing housing-related spending versus hospitals' uncertainty in whether or how to invest in housing after identifying it as a health need. Regulatory reform to increase guidance for social investments and require greater concordance among CHNAs, ISs, and 990Hs could promote accountability and transparency in organizations' efforts to address housing and other health-related social needs. LEARNING OBJECTIVE #1: Quantify use of public reporting documents by nonprofit hospitals in communities with high rates of homelessness to show how they identify and invest in housing as a community health need (Patient Care) LEARNING OBJECTIVE #2: Appraise policy opportunities to enhance Affordable Care Act-mandated reporting requirements to hold nonprofit hospital organizations accountable to improving community health (SystemsBased Practice)

Background/UNASSIGNED:Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana's Upper East Region. Objective/UNASSIGNED:This study sought to identify non-physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana's current primary health care structure. Methods/UNASSIGNED:Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants. Findings/UNASSIGNED:Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies. Conclusions/UNASSIGNED:Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.

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)

Introduction:Students desire instruction in skill development to address both their own implicit biases and bias perceived in the learning environment. Curricula to date achieve strategy identification through reflection and discussion but do not provide opportunity for personally relevant skill development and practice in implicit bias recognition and management. To address this gap, we developed and evaluated a skills-based elective in implicit bias recognition and management focused on learners' own interpersonal interactions, including patient encounters, and perceived bias in the learning environment. Method:Fifteen first-year medical students completed the nine-session elective over three annual offerings. Each session lasted 1.5 hours. Curriculum development was informed by published frameworks and transformative learning theory. Direct observation of student performances in role-plays and other active learning exercises constituted the formative assessment. Program evaluation focused on the impact of instruction through pre- and posttests, along with analysis of notes taken by the investigative team, including notes on formative assessments. Results:Students engaged with all aspects of instruction, including role-plays. Pretest/posttest results demonstrated increased self-reported knowledge and comfort in addressing perceived bias. Formative assessment demonstrated students' skill development in safely and respectfully addressing perceived bias in the learning environment without endangering their relationships with supervisors. Discussion:Skills developed-addressing bias in interpersonal encounters and perceived bias in clinical and teaching encounters-are relevant to learners throughout their careers. This course is relevant to medical students and trainees at various experience levels and could serve as a template for novel, skills-based curricula across health professions.