Faculty Bibliography

LEARNING OBJECTIVE #1: Recognize the acute neurologic manifestations of non-ketotic hyperglycemia in adults with type 2 diabetes. LEARNING OBJECTIVE #2: Management of chronic disease in non- English speaking patient populations with low health literacy. CASE: 44 year old Mandarin speaking male with a history of hypertension and type 2 diabetes (DM2) presented with five days of intermittent episodes of involuntary right arm movement associated with urinary incontinence. Episodes occurred at least ten times daily and were not associated with alteration of consciousness. Of note, he was diagnosed with DM2 in the past year, but had limited understanding of the disease and was not taking any medications. The patient takes no medication. He has no family history of seizures or other neurological problems. He smokes rarely and does not drink alcohol or use drugs. On presentation he had stable vital signs and physical exam revealed no focal neurological deficits and was otherwise normal. Labs including a blood count, hepatic panel, urine toxicology, and metabolic panel were normal apart from a glucose at 616 mg/dL with a HbA1C at 14.1%. After a normal non-contrast head CT, these episodes were confirmed as focal seizures on EEG and were refractory to 1500mg levetiracetamtwice daily. He was placed on a basal-bolus regimen of insulin, with improvement of his glucose and cessation of his seizures with no further abnormal activity on EEG. Before discharge, the patient was counseled on his diagnosis of DM2 with culturally appropriate, Mandarin based educational materials as well as individual teaching on glucose monitoring and insulin administration using an interpreter. IMPACT/DISCUSSION: Non-ketotic hyperglycemia (NKHG) is a complication of DM2, and often is triggered by metabolic stressors. Classically, this presents as polyuria, polydipsia, lethargy, confusion, and ataxia. Other neurologic findings such as increased motor tone, hemiparesis, or focal seizures are rare. The pathophysiology of focal seizures in NKHG is not fully understood. Hypertonicity is unlikely to be the cause as these seizures are not present in diabetic ketoacidosis, and serum osmolarity is normal during these seizures. A prominent theory is that there may be increased metabolism of the neurotransmitter GABA, decreasing the seizure threshold. Managing these focal seizures is often difficult due to delay in diagnosis and treatment. Focal seizures tend to be refractory to antiepileptic drugs, and phenytoin can worsen these seizures by reducing insulin secretion. Management of focal seizures in NKHG is control of the hyperglycemic state, with insulin and rehydration.
CONCLUSION(S): In our patient, treatment of hyperglycemia was successful in terminating seizure activity, representing a rare case of focal seizures presenting as a symptom NKHG. In addition, usage of culturally and language specific educational materials is vital for the proper management of chronic conditions such as DM2, in order to prevent further complications of chronic disease

LEARNING OBJECTIVE #1: Recognize the presentation of spontaneous coronary artery dissection (SCAD). LEARNING OBJECTIVE #2: Recognize amphetamine use as a potential risk factor for SCAD. CASE: A 33-year-old woman with a history of anxiety and ADHD on dextroamphetamine and amphetamine presented with acute onset sharp, substernal chest pain radiating to her left arm and neck since the morning. It felt similar to a "heartburn" episode a month ago. While in EMS, she felt nauseous, vomited, and described a "sensation of doom." She denied any dyspnea, cough, or lightheadedness. She endorsed a remote history of cocaine use and recent stressors at work causing increased anxiety. Her physical exam was unremarkable. EKG showed 0.5-mm STdepression in leads V4-V6, III and aVF with T-wave inversions in leads V1-V3. She received aspirin 325mg, aluminum-magnesium hydroxidesimethicone, and famotidine 20mg. Initial troponin I was 0.11ng/mL. Ddimer, urine drug screen, chest x-ray, and echocardiogram were normal. Repeat troponin 6 hours later was 11.3 and the EKG remained unchanged. Cardiac catheterization revealed a spontaneous coronary artery dissection (SCAD) in her distal left circumflex artery causing a 95% occlusion. No intervention was performed. She was discharged on aspirin and clopidogrel. Dextroamphetamine and amphetamine was discontinued. IMPACT/DISCUSSION: SCAD is a common cause of nonatherosclerotic coronary artery disease in women under age 50, accounting for 24% of myocardial infarctions [1] and recurrence is common. Young women with anxiety or GERD are often assumed to have noncardiac chest pain and may not be considered for coronary catheterization [2]. This may lead to underdiagnosis of SCAD. Pathophysiology of SCAD is not completely understood, but the proposed mechanism is an intimal tear or bleeding of vasa vasorum, causing a false lumen with an intramural hematoma. Early coronary angiography is critical for diagnosis. Risk factors include connective tissue disease, pregnancy, physical and emotional stress. Our patient was not pregnant and did not have a connective tissue disorder. While cocaine is typically associated with SCAD [3,4], her use was remote and urine test was negative. Interestingly, there are a few case reports showing an association between amphetamine use and risk of SCAD [5,6]. The scarcity of data could be due to rarity of the condition as well as under-diagnosis from lack of awareness that amphetamine use is a risk factor for SCAD. Appreciating amphetamine use as a possible risk factor for SCAD may prompt earlier recognition and treatment. Furthermore, heightening awareness among providers may trigger education of patients on the dangers of misusing or overusing amphetamines.
CONCLUSION(S): Patients with SCAD typically do not have risk factors for coronary artery disease; they are young, healthy and predominantly female. It is critical to maintain a high level of suspicion for SCAD in healthy patients who present with cardiac chest pain and to recognize stimulant medication use as a potential risk factor

BACKGROUND: Virtual Urgent Care (VUC) is a now a common modality for providing real-time assessment and treatment of common medical problems. However, most providers have not had formal telemedicine training or clinical experience. Faculty have little experience with this new modality of healthcare delivery. We created an experiential onboarding program in which standardized patients (SPs) are deployed into a VUC platform to assess and deliver feedback to physicians in an effort to provide individual- level quality assurance and identify programlevel areas for improvement.
METHOD(S): We simulated a synchronous urgent care evaluation of a 25- year-old man with lingering upper respiratory tract symptoms refractory to over-the-counter medications. The SP was trained to strongly request an antibiotic prescription. A mock entry in the electronic medical record, available to providers during the visit, provided demographic, prior medical, pharmacy and allergy information. The encounter was scheduled into a regular 30-minute appointment slot during a routine 8-hour shift. We developed a behaviorally- anchored assessment tool to evaluate core communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' SPs provided post-encounter verbal feedback to urgent care providers (UCPs), who received a summary report and had an opportunity provide structured feedback regarding the case. A single SP performed 20 / 21 visits.
RESULT(S): Twenty-one UCPs, with 2 to 23 years of clinical experience, participated in an announced scheduled visit. UCPs performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. All UCPs provided appropriate management plans and did not give antibiotics. In contrast, Education and Counseling skills were less strong (32% 'well done'). Within this domain, few received 'well done' for checking understanding (14%); conveying small bits of information and summarizing to ensure clarity (9%). Most (71% well done) collaborated with the SP in discussing next steps. Specific telemedicine skills were infrequently used: only 19% performed a virtual physical exam, 24% utilized the audio/video interface to augment information gathering, 14% optimized technical aspects by assessing sound, video or ensuring a backup plan should video fail. A subset of UCPs (n=9) provided structured feedback regarding the case. 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improved telehealth skills.
CONCLUSION(S): This experiential virtual urgent care onboarding program utilizing standardized announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. These findings form the basis for dedicated training for virtual urgent care providers to assure quality across the program

LEARNING OBJECTIVE #1: Recognize need for early diagnostic fluid study for patients presenting with new ascites or effusion and constitutional symptoms, despite history of CHF LEARNING OBJECTIVE #2: Diagnose and manage HIV-unrelated, HHV-8-associated PEL in patients presenting with unusual clinical presentation CASE: 70-year-old HIV-negative male with advanced heart failure presented with altered mental status and mild hypotension. Physical exam was remarkable for increased abdominal girth concerning for new ascites and lab work was remarkable for mild leukocytosis, hypercalcemia and supratherapeutic INR. With no history of liver cirrhosis, ascites was thought to be secondary to heart failure and congestive hepatopathy and paracentesis was delayed due to elevated INR. Patient remained lethargic despite negative stroke work up, and was treated for aspiration pneumonia. Patient was eventually transferred to ICU for worsening delirium, hypotension, atrial fibrillation with RVR, and new fever of 103 F. Paracentesis with cytology confirmed a new diagnosis of primary effusion lymphoma. Patient tested negative for HIV and Epstein-Barr Encoding region (EBER), but was positive for Human Herpesvirus Type 8 (HHV8). Clinical course was complicated by aspiration pneumonia, C. difficile infection, and persistent hypotension, making him a poor candidate for chemotherapy treatment. IMPACT/DISCUSSION: Primary effusion lymphoma (PEL) is a rare, high-grade non-Hodgkin's lymphoma (NHL) that typically develops in immunocompromised patients, with HIV or following organ transplant, and often associated with HHV8 or Ebstein-Barr virus. Patients often present with constitutional symptoms and effusions in body cavities with no defining mass or overt sign of malignancy. Our patient presented with new ascites but diagnosis was delayed due to elevated INR and attribution to acute decompensated heart failure with congestive hepatopathy. Recognition of unexplained hypercalcemia and constitutional symptoms followed by early diagnostic paracentesis may have expedited the diagnosis and affected patient's clinical course.
CONCLUSION(S): Primary effusion lymphoma is a very rare disease that almost exclusively occurs in HIV positive or immunocompromised patients, representing only 4% of NHL cases associated with HIV and only 0.1% to 1% of all lymphomas in patients with other types of immunodeficiency. This case highlights HIV- negative/EBV-negative/HHV-8-positive PEL in a patient presenting unusually as acute decompensated heart failure and altered mental status treated for aspiration pneumonia. It is imperative that patients presenting with new ascites or pleural effusion get an early diagnostic fluid study with a high suspicion of malignancy especially with other constitutional symptoms and metabolic encephalopathy with unexplained hypercalcemia and negative infectious workup. Early recognition in patients particularly with underlying CHF may lead to timely treatment initiation and further reduce complications

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

BACKGROUND: The importance of addressing patients' social determinants of health (SDoH) is widely recognized, but less is known about how physicians specifically elicit, respond to, and document these determinants. We sought to describe resident practices when caring for a patient whose SDoH is integral to accurate diagnosis and treatment using Unannounced Standardized Patients (USPs).
METHOD(S): USPs were used (n=68) to assess how medicine residents responded to the consistent portrayal of a patient with asthma exacerbation and concern that her living situation (moldy, dilapidated housing) might be contributing to her symptoms. USPs, or "secret shoppers", were sent to two of New York's safety-net hospitals. Resident practices were assessed by the USP during a post-visit behaviorally-anchored checklist (7 items) and through a systematic chart review (3 items). Checklist items included whether or not a provider explored and fully elicited the USPs concerns, how they responded once shared, and what the provider actually did in response. Chart review items included whether or not a provider documented their patient's housing concerns in the history of present illness (HPI), problem list, or through use of a billingrelated Z-code.
RESULT(S): 68/79 consented residents participated: 11 PGY1 (16%), 31 PGY2 (46%), and 26 PGY3 (38%). 65% (44/68) of residents elicited the patient's housing SDoH and of those, 75% (33/44) responded by acknowledging/exploring and providing notes/practical support. 30% (10/33) connected the patient to informative resources or direct referral. Less than half (14/33; 42%) of those who acknowledge/explored documented appropriately in the EMR. No residents documented housing in the problem list or with a housing-related ICD10 Z-code. Of the 14 high performers, 6 successfully elicited, acknowledged, and documented housing concerns for one of our other five SDoH cases. More than half (55%) of the residents who elicited housing information connected the mold to the asthma exacerbation as a possible trigger, either during clinical interaction or in documentation. All but one (93%) of those who el icited, acknowledged, and documented made this connection.
CONCLUSION(S): Using USPs to directly observe resident practice behaviors in gathering information about, documenting and taking action on a consistently portrayed SDoH case closely linked to clinical symptoms is the first piece of the puzzle needed to better understand education and training that prepares physicians to address SDoH. Our study identifies practice gaps at all stages - adequately collecting information, understanding the clinical/ treatment consequences of, effectively responding to needs, and in documentation of SDoH. Future research should explore the influence of the clinical microsystem (e.g., SDoH screening tools, available resources and referrals, and workflows) on physician SDoH-related practices

BACKGROUND: Unannounced Standardized Patients (USPs) provide opportunity to measure residents' clinical skills in actual practice. USPs, or secret shoppers, are trained to ensure accurate case portrayal across encounters, making them optimal for tracking changes in skills longitudinally. At present, little is known about how residents handle USP visits with repeat cases. This study examines variation in resident communication and global domain scores when visited by the sameUSPcase at two separate time points during residency training.
METHOD(S): Primary care residents (n=46) were assessed twice by one of six standardized cases (asthma, fatigue, Hepatitis B concern, back pain, shoulder pain, or well visit) during the course of their residency, typically during their first and third training year. Upon visit completion, residents were rated using a behaviorally-anchored checklist. Communication domains assessed included info gathering (4 items), relationship development (5 items), and patient education (4 items). Other domains included patient activation (4 items) and satisfaction (4 items). Responses were scored as not done, partly done, or well done. Summary scores (mean % well done) were calculated by domain. All cases were combined to create composite scores, due to small sample sizes per case. First and second visit domain scores were compared using a t-test. Finally, we grouped high performers (80% or higher on communication scores during their first visit) because this measure demonstrated competency.
RESULT(S): With cases combined, there were no significant differences based on time of assessment and changes in score between first and second visit were small. 14/46 (30%) learners who performed well on composite overall communication scores (80% or higher) during their first visit outperformed poorer communicators in patient satisfaction (93% vs 61%, P<.001) and activation (48% vs 18%, P<.001). In subsequent visits, these high performers performed at a similar level to their fellow residents, with no significant differences noted. Further, when looking at individual trajectories, individual learner scores in the communication domain increased between visits for 21 learners (46%), decreased for 19 (41%), and stayed same for 7 (15%).
CONCLUSION(S): Results suggest that a learning curve occurs between assessments during the first year in residency and subsequent assessments. This could be due to an increased capacity to engage with a patient occurring training progression, or due to a better understanding of addressing common chief complaints presented with our USP cases. Understanding causes of individual-level score decreases will enable tailoring of educational interventions suitable for specific learner trajectories, as will a deeper dive into the impact of the clinical microsystem on performance. We predict a more nuanced understanding of these mediating factors through our plan of increasing our repeat visit sample size

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health (SDoH), less is known about how physicians elicit, respond to, and act upon their patients' SDoH information. We report on the results of a study that 1) sent Unannounced Standardized Patients (USPs) with programmed SDoH into clinics to assess whether providers uncovered, explored and acted upon the SDoH, 2) provided audit/feedback reports with educational components to clinical teams, and 3) tracked the impact of that intervention on provider response to SDoH.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well-visit), each with specific housing (overcrowding, late rent, and mold) and social isolation (shyness, recent break up, and anxiety) concerns that they shared if asked broadly about. USPs assessed team and provider SDoH practices (eliciting, acknowledging/exploring, and providing resources and/or referrals). 383 USP visits were made to residents in 5 primary care teams in 2 urban, safety- net clinics. 123 visits were fielded during baseline period (Feb 2017-Jan 2018); 185 visits during intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed; and 75 follow-up phase visits were fielded (Apr-Dec 2019). Analyses compared rates of eliciting and responding to SDoH across the 3 periods (chi- square, z-scores). One team, by design, did not receive the intervention and serves as a comparison group.
RESULT(S): Among the intervention teams, the rate of eliciting the housing SDoH increased from 46% at baseline to 59% during the intervention period (p=.045) and also increased, but not significantly, for the social issue (40% to 52%, p=.077). There was a significant increase from baseline to intervention in providing resources/referrals for housing (from 7% to 24%, p=.001) and for social isolation (from 13% to 24%, p=.042) (mostly resources, very few referrals were made). The comparison team's rates followed a different pattern: eliciting the housing issue and the social isolation issue decreased from baseline to the intervention period (housing: 61% to 45%; social isolation: 39% to 33% of visits) and the rate of providing resources/referrals stayed steady at 13% for both. In the cases where SDoH were most clinically relevant, baseline rates of identifying the SDoH were high (>70%) but rates of acting on the SDoH increased significantly from baseline to intervention. Increases seen in the intervention period were not sustained in the follow-up period.
CONCLUSION(S): Giving providers SDoH data along with targeted education was associated with increased but unsustained rates of eliciting and responding to housing and social issues. The USP methodology was an effective means of presenting controlled SDoH and providing audit/feedback data. Ongoing education and feedback may be needed

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health, less is known about how members of the care team respond to patient-volunteered SDoH - especially when the determinant is related to financial insecurity. With increasing calls for universal screening for SDoH - what do teams do when a patient shares a financial concern? We report on the use of Unannounced Standardized Patients (USP) to assess how primary care teams respond to volunteered information about financial insecurity and whether an audit/ feedback intervention (with targeted education included) improved that response.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six common scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well visit). USPs volunteered a financial concern (fear of losing job, challenges with financially supporting parent, trouble meeting rent) to the medical assistant (MA) and then again to their provider and assessed the response of both the MA (did they acknowledge and/ or forward the information to the provider?) and the provider (did they acknowledge/ explore and/or provide resources/referrals?). A total of 383 USP visits were delivered to 5 care teams in 2 safety-net clinics. Providers were medicine residents. 123 visits were fielded during the baseline period (Feb 2017-Jan 2018); 185 visits during the intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed. 75 follow-up phase visits were fielded (Apr- Dec 2019). Analyses compared rates of MA and provider response to the volunteered financial insecurity issue across the 3 periods (chi-square, z-scores).
RESULT(S): The baseline rate of responding in some way to the volunteered information was high for both the MA (86% acknowledged) and the providers (100% responded). These overall rates of response did not change substantially or significantly across the three time periods (MA: Intervention period = 87%, Follow- Up period=90%; Provider: Intervention period=98%; Follow-Up period=98%). Rates of acting upon the volunteered information also remained quite consistent across the time periods: from 29 to 35% of MA forwarded the information to the provider across the 3 time periods and from 22 to 28% of providers in each intervention period gave the patient resources or a referral (mostly resources).
CONCLUSION(S): Our findings highlight the importance of patients directly telling team members about a financial concern. Future research should explore whether screening tools are effective in instigating a response. Audit/feedback reports with targeted educational components did not appear to influence the teams' response unlike what we found for housing and social concerns that had to be elicited. Whether this is due to differences in volunteered vs. elicited SDoH or to the nature of the SDoH (financial vs housing/social) warrants further investigation

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