Faculty Bibliography

Background: Asthma education should focus on patient self-management support. Objective structured clinical examinations (OSCEs), as measured by standardized patients (SPs), provide a controlled, simulated setting for timed competency assessments while Unannounced Standardized Patients (USPs) measure clinical skills transfer in real world clinical settings. Both enable us to assess skills critical for providing quality care to patients. Learners seeing USPs have added real world stressors such as clinical load. This study describes differences in education and activation skills in two assessment contexts.
Method(s): A cohort of primary care residents (n=20) were assessed during two time points: an OSCE and a USP visit at an urban, safety-net clinic from 2009-2010. Residents consented to use of their de-identified routine educational data for research. The SP and USPs presented with the same case; a female asthmatic patient with limited understanding of illness management and concern over symptom exacerbation. Providers were rated using a behaviorally-anchored checklist upon visit completion. Competency domains assessed included patient education (4 items) and activation (4 items). Within the education domain, items included illness management, while the activation domain items assessed resident communication/counseling style. Responses were scored as not done or well done. Summary scores (mean % well done) were calculated by domain. OSCE vs USP means were compared using a paired samples t-test.
Result(s): Residents were more likely to offer an oral steroid as treatment in the OSCE case (50% vs. 35% for USPs), but performed better with USPs on most other items including domain scores. Residents seeing a USP scored significantly higher on five out of eight individual assessment items (p<.05) including recommending a spacer, helping a patient understand their condition, making patients feel like they can take control of their own health, helping a patient understand illness management, and having a patient leave feeling confident in finding solutions independently. Inhaler technique was assessed rarely in either setting (OSCE: 15%, USP: 5%). Domain summary scores (% well done) from the OSCE (activation: 12%, education: 31%) were lower than USP scores (activation: 84%, education: 37%), with differences in overall activation scores being significant (t(19)=-8.905, p<.001).
Conclusion(s): OSCEs are a widely accepted tool for measuring resident competency in a standardized environment but may be focused primarily on knowledge and technical skills. While SPs are trained to be as objective as possible, rater bias might impact scores. USPs may provide more nuanced assessments of communication skills in a setting with reduced time constraints. Next steps include examining attitudes toward OSCEs vs the clinical setting, looking at impact of provider gender, and examining setting-specific issues that promote or hinder high quality care

Learning Objective #1: Recognize and manage opioid overdose in a community health center setting Learning Objective #2: Improve linkage to effective treatment for opioid use disorder after overdose CASE: A 54 yo man was found unresponsive at the door of our community health center. Rapid Response was called and the patient was found to be unresponsive to sternal rub, with 6 breaths per minute, and pinpoint pupils. One dose of 4mg of intranasal naloxone was administered, and soon the patient was alert and oriented. He declined transfer to the ED but was amenable to observation, stating that he had just purchased his usual 3 bags and used them outside of his primary care clinic. His PMH was notable for 36 years of IV/intranasal heroin use, prior stroke, GERD, glaucoma, hyperlipidemia, lumbar radiculopathy, and tobacco use. He had one overdose in the 1990s, attempted detox several times and tried self-treating himself with methadone and buprenorphine. He lived with his girlfriend and was unemployed. His medications included cyclobenzaprine and ranitidine. The medical assistant from our addiction medicine clinic engaged the patient, who reported that the overdose scared him, and offered medication treatment which he accepted. The addiction clinic nurse and physician saw the patient that day and gave an initial buprenorphine prescription, instructions and follow-up appointment. He is now stable on buprenorphine 8mg daily. IMPACT/DISCUSSION: The overdose described in this case represents one of three overdoses in the past month at our NYC health center. Urban health centers often serve as community hubs and may be seen as a safer place to use opioids. Overdoses at community health centers represent an important point of patient engagement in treatment for OUD. Treatment with opioid agonist therapy after overdose has been shown to reduce all-cause and opioid-related mortality. However, only a small percentage of patients receive medication therapy after overdose. (Larochelle et al. Annals of Internal Medicine. 2018) Initiation of medication treatment for OUD at the time of ED presentation has also been shown to improve engagement in treatment. (DOnofrio et al. JAMA 2015.) Institutional commitment to training all providers and staff to recognize the signs of opioid overdose and administer intranasal naloxone has direct impact on patient outcomes. Our experience with this case has demonstrated the importance of immediate engagement in care at the time of overdose. Having a team available at the time of overdose that cares for patients with addiction enabled us to quickly engage this patient in care and start medication therapy when he felt most receptive to treatment.
Conclusion(s): Our case demonstrates two crucial steps for improving outcomes in opioid overdose: widespread availability of and training for intranasal naloxone use, along with community health sites equipped to treat patients with opioid use disorder at the time of overdose

Background: It is well documented that few ordered tests are " high value" a significant percentage of those ordered are " low-value." Residency offers an opportunity to teach high-value care and educational interventions to do so have been effective. However, the relationship between high-value care and residents' ability to communicate effectively with patients has not been explored. Ability to establish rapport, gather information effectively, and be patient-centered may impact residents' use of tests. We hypothesize that residents with poor skills in these areas may order tests less efficiently.
Method(s): Unannounced Standardized Patients (USPs) were introduced into residents' primary care clinics in a large urban, safety net hospital to portray 3 clinical scenarios: a well visit, a chief complaint of fatigue, and a diagnosis of asthma. Orders were extracted via chart review. Appropriateness of orders was determined by reference to United States Preventive Services Task Force (USPSTF) and clinical practice guidelines. Excessive tests were defined as not explicitly indicated for the scenario-indicated tests were the converse. Number of excessive and % of indicated tests were calculated across the 3 visits for 48 residents. Communication skills in information gathering (5 items) and developing a relationship (6 items) and a patient-centeredness score (4 items: took a personal interest, answered all my questions) were computed as % of behaviorally anchored items rated as " well done" and included in regression models predicting test utilization.
Result(s): On average, residents ordered 15% of indicated tests (SD 9%, 0-38%) across the 3 visits and a mean of 1.3 unnecessary tests (SD 1.7, 0-6). In the regression model, the 3 skills explained 16% of variation in unnecessary tests (p=.047). Information gathering explained the greatest share (8%, p=.041). With all 3 variables in the model, patient-centeredness was positively associated with unnecessary tests (Std Be-ta=.42, p=.016) and information gathering was negatively associated with unnecessary tests (Std Beta=-.34, p=.041). Mirroring these Results, superutilizers (10 residents ordering > =3 excessive tests) had lower information gathering and relationship development scores than other residents (66% vs 75% and 72% vs 76%) but higher patient centeredness scores (80% vs 74%)-although differences were not significant.
Conclusion(s): Our findings suggest that information gathering skills may have a small influence on residents' ordering of excessive tests. Further research with larger samples (adequate power) will help clarify the effect sizes. If our Results stand, interventions for high-value care should include information gathering skills and residency programs should continue to reinforce core communication skills training. In addition, our finding that patient centeredness was associated with ordering unnecessary tests suggests that residency programs could caution residents about conflating ordering of tests with patient-centeredness

Background: Low-value tests, defined as inappropriate for a given clinical scenario, are ordered in one in five clinic visits. Residents tend to over-order diagnostic tests to "minimize uncertainty" of presenting cases, even though these tests are not useful according to Bayesian statistics; a pursuit deemed the "Ulysses syndrome". Simultaneously, evidence suggests residents misuse preventive tests in half of relevant clinical scenarios. We sought to quantify ordering behaviors in urban primary care clinics across three unannounced standardized cases.
Method(s): Unannounced standardized patients (USPs) were trained for standardized simulation of three clinical scenarios: a "Well" visit, a chief complaint of "Fatigue," and a diagnosis of "Asthma." USPs were introduced into medicine residents' clinics in an urban, safety-net hospital. All electronic orders were extracted via chart review. Scenario-specific appropriateness of diagnostic testing was determined by referencing United States Preventive Services Task Force (USPSTF) and society clinical practice guidelines (CPGs). "Preventive" tests (such as lipid panels or hemoglobin A1C) were derived from USPSTF guidelines whereas "Diagnostic" tests (such as pulmonary function testing for Asthma or heterophile antibodies for Fatigue) were from CPGs. "Excessive" tests were those not explicitly indicated for a given scenario in either USPSTF or CPGs (versus "indicated" tests).
Result(s): Indicated tests were ordered in 29% of Well (124 encounters), 16% of Fatigue (148 encounters), and 12% of Asthma (170 encounters) cases. One or more excessive tests were ordered in 44%, 22%, and 17% of Well, Fatigue, and Asthma encounters respectively. The distribution of indicated and excessive tests for preventive versus diagnostic purposes varied by case: In Well visits, the majority (71%) of excessive testing was in pursuit of a diagnosis, while three-quarters of indicated testing was for preventive purposes. In Fatigue and Asthma visits, the reverse patterns were true: the majority of indicated tests ordered were diagnostic (81% and 68%, respectively) while the majority of excessive tests were preventive (78% and 63%, respectively).
Conclusion(s): Introducing USPs to resident clinics revealed that, for patients presenting without a chief complaint (Well visit), residents successfully ordered less than one-third of indicated tests, and over 75% of inappropriately ordered tests pursued a diagnosis. For patients presenting with chief complaints (Fatigue and Asthma), rates of appropriate ordering were even lower (16% and 12%), and tended to overlook preventive care. In these cases, inappropriate tests tended to be ordered for preventive purposes. Awareness of resident mis-utilization of preventive and diagnostic testing in distinct clinical circumstances can guide educational efforts towards evidence-based care and resource stewardship

Background: For quality care, physicians must be skilled in diagnosing and treating chronic pain. Some studies have shown gender differences in how providers manage pain. And more broadly, female providers provide more patient-centered communication which in turn has been linked to patient activation and satisfaction with care. We explore, using Unannounced Standardized Patients (USPs), whether resident physician gender is associated with the core underlying skills needed to effectively diagnose and management chronic pain: communication, patient centeredness, and patient activation.
Method(s): We designed two USP cases and sent these undercover patients into primary care clinics at two urban, safety-net clinics. The USP cases were similar: a 30-35 y.o. male, presented as a new patient to the clinic with either shoulder pain induced by heavy lifting or knee pain due to a recreational sports injury. USPs completed a post-visit checklist that assessed patient satisfaction (4 items), patient activation (3 items), and communication skills (13 items) using a behaviorally-anchored scale (not done or partly done vs. well done). Summary scores were calculated for each of the three domains. Residents provided consent for their educational data to be used for research as part of an IRB-approved medical education registry.
Result(s): A total of 135 USP visits (80 female providers, 55 male) occurred between 2012 and 2018. Female providers saw 41 shoulder pain and 39 knee pain cases while male providers saw 21 shoulder and 34 knee cases. ANOVA was used to assess differences in summary scores by provider gender (male vs female) and by case portrayed (knee vs shoulder). Skills did not differ significantly by whether knee or shoulder pain case. Gender effects were not seen for patient centeredness or for patient activation; however female providers performed significantly better at relationship development (83% vs males 72% shoulder pain; 70% vs 66% knee pain case; p<.001) and information gathering (86% vs. males 72% shoulder pain; 79% vs66% in knee case; p<.016). Male providers, however, performed slightly better in patient education and counseling (65% vs 63% for shoulder and 38% vs 33% for knee cases; p<.001).
Conclusion(s): Developing a relationship and gathering information are critical to pain management and female residents performed better than male residents in these areas. Male providers performed slightly better than women in patient education and provider gender was not associated with any differences in patient centeredness or activation. In the future, we plan to link these underlying skills to pain management decisions, documentation and ultimately to patient outcomes. We suspect that patient activation may best be measured at follow-up, something not possible with our current USP methodology. Gender differences could be viewed as striking in the context of our relatively homogeneous sample (medicine residency program) and shared clinical environment/healthcare system

Background: There is an increased awareness among healthcare professionals to discuss social determinant of health (SDOH) information with patients. However, the awareness does not necessarily translate into effective response to the situation. In order to better understand the nuances in such conversations between patients and providers, we reviewed qualitative responses from Unannounced Standardized Patient (USP) portraying patients with SDOH concerns who were seen as part of a study to investigate healthcare teams' management of SDOH information.
Method(s): USPs, representing six different clinical cases, were seen by residents at an urban safety-net hospital. Each case had SDOH issues (financial and housing insecurity, social isolation), and USPs were trained to provide such information in a systematic fashion in response to provider questioning. After the encounter, USPs completed a behaviorally-anchored, standardized checklist, and also entered their impressions of the encounter in free text. The focus of this study was to evaluate these comments using a qualitative approach, focusing only on those that addressed SDOH. 258 visits occurred from 2017-present, and 209 relevant comments were analyzed.
Result(s): Three general themes emerged: residents' openness to discussion of SDOH, their understanding of how these issues related to presenting concerns, and how they responded to those concerns. Some providers did not explore SDOH prompts, e.g. " I don't think she cut me off, but she quickly moved on to her next question without further delving deeper", while others were more responsive and supportive e.g., the provider " is very open to hearing my situation, I was able to fully explain my situation clearly." Such provider behavior impacted trust and connection, e.g., " Doctor X had good communication skills, but I felt like he didn't really hear my full story" There were variations in how well providers related SDOH to medical symptoms, e.g. " he completely ignored my concerns about mold at home" [asthma case] vs. " His questions centered around possible anxiety this (housing issue) might be causing me." After acknowledgement, fewer providers provided specific information or referrals to address the problem. This lack of follow-up seemed to leave USPs feeling uncomfortable. Both empathic comments and suggestions for actions influenced their sense of activation to manage their health post-visit.
Conclusion(s): Data from the USP visits indicate that there is a range of attention to and follow up on patient presentation of SDOH needs by trainees in clinical settings. Issues of both general communication skills, awareness of connection between SDOH and health, and awareness of local resources impacted provider behavior, which then had an effect on relationship with patients. The complex issues involved in addressing SDOH highlights the diverse training needs for learners

Needs and Objectives: There is an increasing need for resident education on substance use disorders (SUDs). The purpose of our curriculum was to improve residents' knowledge, skills, and attitudes on treating patients with SUDs. Setting and Participants: First and second year residents from NYU's Primary Care, Internal Medicine program participated in the Block of Addiction Medicine (BAM!) curriculum. Clinical settings included buprenorphine/methadone clinics and outpatient treatment programs in a large, urban safety net hospital system. Description: BAMis an intensive two week curriculum focused on SUDs. To improve residents' knowledge, we included didactic sessions on substances, including alcohol, opiates, and tobacco. Sessions covered epidemiology, biology, and treatment, including pharmacologic options, with all residents receiving buprenorphine prescribing waiver training. BAMwas delivered by an interdisciplinary faculty that included addiction medicine specialists, department of health officials, and general practitioners, nurses, and social workers who have worked extensively with patients with SUDs. Workshops built skills including screening, brief interventions, and referral to treatment (SBIRT) and motivational interviewing. Residents attended buprenorphine/methadone clinics, outpatient treatment programs, and 12-step (AA/NA) meetings. Residents shared lunch in a non-clinical setting with patients in recovery to understand their perspectives on living with addiction. Evaluation: Residents' attitudes and self-perceived efficacy in treating SUDs were surveyed. Pre and post data was obtained on 15 of 16 participants. Using the medical condition regard scale (MCRS), an 11 item questionnaire on biases/emotions/expectations for treating patients with SUD, we found a statistically significant improvement in the composite score, from 44.46 to 47.0 (p=0.026). Of 15 residents, 11 reported improved ability to effectively screen for SUD, 10 reported improved comfort in screening patients for SUD, 12 reported improved knowledge in using medically assisted treatment (MAT), and 14 reported improved ability to effectively treat patients with MAT (all p<.001 in Wilcoxon signed rank test). Qualitative feedback showed residents felt this curriculum was an essential part of their education; one participant commented: "this is a course that should be offered to every medical care provider." Discussion/Reflection/Lessons Learned: BAMincluded a varied curriculum delivered by inter-professional faculty. Residents reported improved comfort in treating patients with SUDs and demonstrated a significant improvement on the MCRS in their already positive attitudes towards treating this patient population. Qualitative feedback indicated that residents enjoyed BAMand found it important to their training. Given the increasing need for providers who are able to effectively treat SUDs, courses such as BAMare an effective and essential part of residency. Further studies are needed to assess if the changes in residents' attitudes persist and whether we influenced practice

Learning Objective #1: Explain how the hemodynamics of pericarditis can produce the clinical manifestations (signs and symptoms) seen in pericarditis. Learning Objective #2: Categorize the progressive electrocardiogram stages consistent with pericarditis. CASE: A 70 year-old female with hypertension and diabetes presented to the hospital with a one-day history of non-positional, left-sided chest pain associated with shortness of breath and subjective fevers. Physical exam and vitals were unremarkable. Work up included three negative troponins, EKG in normal sinus rhythm (Figure 1), and D-Dimer of 1100 ng/mL. CTA chest revealed a right subsegmental middle lobe filling defect consistent with pulmonary embolism for which patient was initiated on anticoagulation with resolution of chest pain. Approximately 24 hours after initial presentation the patient reported a new chest pain described as sharp, pleuritic, worse with lying flat and improved with sitting forward. Vitals revealed fever to 100. 5 F. Repeat EKG demonstrated diffuse ST elevations (Figure 2). Labs showed a negative troponin and ESR and CRP at 63 mm/hr and > 190 mg/L, respectively. Echo showed a trace pericardial effusion, normal ejection fraction, and no evidence of right heart strain. The patient was diagnosed with acute pericarditis and initiated on colchi-cine and NSAIDs with resolution of symptoms. Common causes for pericarditis including viral URI, TB, connective tissue disorders, and malignancy were ruled out with a negative review of symptoms, subsequent laboratory analysis and additional history from the patient's primary care provider. Given the unlikeliness of other etiologies, her acute pericarditis was felt to be secondary to her pulmonary embolism. IMPACT/DISCUSSION: Between 80-90% of pericarditis cases are idiopathic or presumed to be of viral etiology. Given the relatively benign course of the majority of causes of pericarditis a definitive work up is often not performed. However, this case highlights an additional "can't miss" cause of pericarditis-pulmonary embolism. Although rare, post-pulmonary embolism pericarditis is a well-documented phenomenon associated with elevated ESR, CRP, and low-grade fevers as in this patient's presentation. Proposed mechanisms include increased friction of an enlarged pulmonary artery and right ventricle against the pericardium and an immunologic response, similar to Dressler syndrome.
Conclusion(s): Despite being a known cause of pericarditis, pulmonary embolism is frequently overlooked or completely excluded from clinicians' differentials. Although the exact cause of pericarditis is often unknown, in patients with idiopathic pericarditis with no infectious signs, pulmonary embolism should always be considered based on history and physical exam findings to avoid missing a "can't miss" diagnosis

BACKGROUND:For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors. OBJECTIVE:To explore student perceptions of challenges and opportunities when participating in implicit bias instruction. APPROACH:We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes. KEY RESULTS:Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers. CONCLUSIONS:These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management.

Learning Objective #1: Identify non-HACEK gram-negative endocarditis early in its clinical course. Learning Objective #2: Recognize the morbidity and mortality of Escherichia coli endocarditis. CASE: A 54 year-old Hispanic man with no known past medical history presented with one month of constitutional symptoms: unintentional weight loss, anorexia, fatigue, and arthralgias. On admission, he was febrile, tachycardic, and breathing comfortably on room air. The exam was otherwise significant for a thin stature with temporal wasting, thrush, a lateral tongue ulcer, a raised non-blanching erythematous macular rash on sun-exposed areas of the extremities, and erythematous papules on the hands. There were no murmurs detected on cardiac auscultation. Initial labs were significant for anemia and leukopenia. A broad differential diagnosis initially included malignancy, rheumatologic disease, and systemic infection. Work-up revealed positive anti-Smith and anti ds-DNA antibodies, C3/C4 hypocomplementemia, and a pericardial effusion on transthoracic echocardiogram (TTE). He was diagnosed with systemic lupus erythematous (SLE), and started on hydroxychloroquine and steroids with improvement. On hospital day three, blood cultures grew Escherichia coli (E. coli) in four bottles, with an unclear source with aseptic urine and no localizing symptoms. CT scans of the head, chest, abdomen, and pelvis were notable for multiple peripherally located pulmonary airspace opacities concerning for septic emboli. A TTE was negative for vegetation, but given the high clinical suspicion for endocarditis, notwithstanding the rarity of E. coli as a pathologic organism, transesophageal echocardiogram (TEE) was pursued. TEE revealed a mobile echodensity on the aortic valve consistent with vegetation. The patient completed four weeks of ceftriaxone to treat E. coli endocarditis. IMPACT/DISCUSSION: E. coli bacteremia is common; however, due to decreased adherence of the organism to the endocardium, infective endocarditis from E. coli is rare, accounting for 0.51% of cases. Risk factors include immunocompromised states. Our patient was leukopenic from SLE. Sources of infection are often gastrointestinal and urinary. However, as in our patient, initial source is unclear in approximately half of cases. Murmur is often absent, and the disease is more common in native valves than prosthetic or degenerative valves. For these reasons, diagnosis is difficult. One study reported at least one month from onset to clinical diagnosis in 90% of patients with non-HACEK gram-negative endocarditis. However, given its high surgical intervention rate (42%), high complication rate (including heart failure and abscess), and high mortality rate of 21% (drastically higher than the 4% from HACEK gram-negative endocarditis), clinicians should maintain a high degree of suspicion to make this diagnosis early.
Conclusion(s): E. coli endocarditis is rare, occurs in immunocompro-mised patients, and is difficult to diagnose. However, given its high morbidity and mortality, timely recognition is critical