Faculty Bibliography

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: Considerable resources are put into training physicians to be effective providers after residency. Practicing physicians are generally assumed to be more effective and more efficient than resident physicians who are still undergoing training. We capitalize on a unique opportunity to test that hypothesis using the controlled methodology of Unannounced Standardized Patients (USPs), Standardized Patients sent into clinical environments to systematically assess provider skills in the context of a standardized clinical scenario. Due to last minute scheduling changes, a small sample of attending physicians ended up seeing USPs we had intended to send to residents. In this study, we report on comparisons between how these attending physicians performed in terms of their patient centeredness, patient activation, assessment, and communication skills in comparison to residents.
Method(s): 6 USP visits were delivered to primary care clinics in an urban safety net hospital from 2009 to 2015. Of those 700+ visits, visits were completed inadvertently with 16 attendings. We selected the 16 attendings with at least 4 years of post-graduate experience and then matched them with 2 resident visits based on hospital, time period, and USP visit type (n=32 residents). In all visits, USPs completed a behav-iorally anchored post-visit checklist that assessed patient centeredness (4 items), patient activation (2 items), visit-specific assessment (10 items), and communication skills including information gathering (4 items), relationship development (5 items) and patient education (3 items). Items were rated as not done or partially done vs. well done and summary scores were calculated as % well done. Mean scores for attendings and matched residents were compared using t-tests.
Result(s): Resident and attending scores on patient centeredness (68% vs 73%), patient activation (44% vs 38%), assessment (53% vs 51%), patient education (49% vs 52%), information gathering (71% vs 78%) and relationship development (70% vs 73%) did not significantly differ (p>.05). Nor did we see any substantial differences in variances or find any outliers.
Conclusion(s): In our matched sample of residents and attendings, there were no significant differences by training level for any of the assessed clinical skills. While we viewed the inadvertent scheduling of USP visits with attendings as an opportunity to investigate the impact of training, our study is limited by the small sample size and whether we were able to create good matches. Findings may reflect ceiling effects (our checklists are too hard) or expertise-reversal effects (experts can skip some elements of the interaction and still arrive at the correct diagnosis and treatment plan). Further research, if our mistakenly-assessed attending sample increases, could explore the influence of PGY level and of patient load as attendings carry substantially heavier patient panels and see more (and probably more complex) patients per day then residents

Background: Diagnostic tests account directly for 5% of healthcare costs, but influence decisions constituting 70% of health spending. Only 5% of ordered labs are actually " high value," depending on clinical circumstances. Low-value tests, defined as not appropriate for a given clinical scenario, are ordered in one in five clinic visits. Up to $ 750 billion is spent on these low-value tests, contributing to the estimated one-quarter to one-third of healthcare spending is on wasteful services. We sought to quantify test-specific low-value ordering behaviors in urban outpatient clinics across three standardized patient cases.
Method(s): Unannounced standardized patients (USPs-highly trained actors portraying patients with standardized case presentations) were introduced into medicine residents' primary care clinics in a large urban, safety net hospital over the past five years. The USPs simulated three common outpatient clinical scenarios: a " Well" visit, a visit with a chief complaint of " Fatigue," and a visit with a diagnosis of " Asthma." Diagnostic orders were extracted via retrospective chart review for these standardized visits. For each scenario, appropriateness of diagnostic testing was determined by reference to United States Preventative Services Task Force (USPSTF) and relevant specialty society clinical practice guidelines (CPGs). " Wasteful" (over-ordered) tests were defined as those not explicitly indicated for the given scenario. Costs were derived from GoodRx.com according to local ZIP codes.
Result(s): The most commonly wasteful tests for the Asthma case were CBC (8% of 170 visits) and Chem-7 (6%), though the relative risk of over-ordering TSH was 3.8x that of other scenarios. The most commonly over-ordered tests for the Fatigue case were LFTs (14% of 148 visits) and HBV (5%), with LFTs ordered up to 15-fold more frequently than in other scenarios. The most commonly over-ordered tests for the Well case were BMP (35% of 124 visits), CBC (15%), LFTs (15%), and HBV (11%) ordered at rates up to 6.3x, 2.0x, 14.2x, and 7.4x higher than other scenarios. Finally, the average per patient excess costs were $ 8.27 (+/-$ 1.76), $ 6.79 (+/-$ 4.5), and $ 23.5 (+/-$ 9.34) for Asthma, Fatigue, and Well cases respectively.
Conclusion(s): Inappropriateness in test ordering patterns were observed through USP simulated cases. Certain tests (CBC, BMP, LFTs, and HBV) were more likely used wastefully across cases. Between cases, specific tests were ordered in an inappropriate manner (such as TSH for Asthma, LFTs for Fatigue, and BMP for Well visits). The per patient direct cost of low value testing rose above $ 20 per visit for the Well visit, though the Fatigue case exhibited the most variation. Notably, this excludes downstream (indirect) costs inestimatable from standardized encounters alone. Knowledge of wasteful utilization patterns associated with specific clinical scenarios can guide interventions targeting appropriate use of testing

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

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: 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

Learning Objective #1: Recognize risks of hypoglycemia associated with sulfonylureas and thiazolidinediones Learning Objective #2: Apply evidence-based guidelines for appropriate management of diabetes in elderly patients CASE: A 72 year-old Spanish-speaking man with poorly controlled type 2 diabetes, hypertension, and newly diagnosed prostate cancer was bought by ambulance with confusion and weakness. He was found to have a fingerstick glucose of 30 mg/dl. Additional workup was unremarkable and symptoms resolved with 50% dextrose. He was admitted for symptomatic hypoglycemia. The patient reported taking multiple oral hypoglycemic agents, including glipizide twice daily, pioglitazone, metformin, and sitagliptan. Four months prior, pioglitazone was tripled due to A1c 10.4%. He also revealed unintentional weight loss (possibly due to his cancer), and multiple home fingersticks in the 60s. Repeat A1c was 6.7%. The sulfo-nylurea and pioglitazone were discontinued. The patient was educated on his medications, glucose targets, and symptoms of hypoglycemia. He was discharged with advice to follow with his primary physician. IMPACT/DISCUSSION: Nearly 25% of patients over age 65 have diabetes. Elderly diabetics are uniquely vulnerable, with higher risks of symptomatic hypoglycemia, increased hospitalizations, and higher overall associated morbidity and mortality. Polypharmacy, low health literacy, and language barriers contribute to their complex medical management. Recent studies have shown that tighter A1c control (< 7.0%) is associated with additional harms in geriatric patients, including a higher mortality rate. As a result, medical organizations have revised their glycemic control guidelines towards more personalized, patient-centered management. These guidelines include differential A1c goals (from 7.0-9.0%) based on overall health, comorbidities, and life expectancy. Guidelines for geriatric diabetes care were updated in 2018 to include recommendations that overtreatment of diabetes should be avoided, medication classes at low risk of hypoglycemia are preferred, and complex medication regimens should be simplified to reduce hypoglycemia. Our patient illustrates the importance of each of these guidelines. With his age and comorbid-ities, including newly diagnosed cancer, he had indications for looser A1c goals. He was also at high-risk for medication-related adverse events, given his polypharmacy and limited health literacy. Metformin and sitagliptin would have been favored agents. Education on symptoms of hypoglycemia, as well as interpreting fingersticks, was crucial to prevent rehospitalization and improve health literacy.
Conclusion(s): Geriatric patients with diabetes represent a unique and vulnerable population. Guidelines for diabetes management in these patients are evolving, with increased emphasis on personalized, patient-centered management, including looser A1c goals for those with comorbidities or shorter life expectancy. Providers are encouraged to simplify medications and avoid polypharmacy to improve outcomes and save lives

Learning Objective #1: Recognize protein malnutrition and cirrhosis as potential complications of biliopancreatic diversion with duodenal switch (BPD-DS). CASE: A 37-year-old man with a history of severe obesity status post laparoscopic BPD-DS presented with diffuse swelling. The patient was admitted six months previously for severe protein-calorie malnutrition requiring initiation of total parental nutrition (TPN). During that admission, he was found to have elevated liver enzymes and ascites. Workup for autoimmune, infectious, and hereditary etiologies of cirrhosis was unremarkable; a liver biopsy showed steatosis without evidence of alcoholic hepatitis or cirrhosis. He now complained of abdominal distension and lower extremity edema that had progressed over several weeks, requiring multiple large-volume paracenteses. He endorsed past heavy alcohol use, but denied recent exposure. On physical examination, he was grossly anasarcic with a distended abdomen and appreciable fluid wave, 3+ pitting edema to the hips, and scrotal edema. His admission Model for End-Stage Liver Disease (MELD) score was 14. Repeat biopsy demonstrated prominent portal fibrosis and focal nodularity indicative of advanced-stage cirrhosis, with an interval decrease in steatosis from his previous biopsy. The rapidity of fibrosis and reversal of fatty change suggested the etiology was his bariatric surgery. He was treated with intravenous diuretics with improvement in his anasarca. At one-month follow-up, he had a stable MELD and diuretic-responsive ascites. He has been approved for liver transplant evaluation, with plans to reverse his bypass prior to transplant. IMPACT/DISCUSSION: BPD-DS is classically associated with improvement in hepatic function due to reversal of nonalcoholic steatohepatitis (NASH). However, case reports of hepatic failure following BPD-DS do exist. Clinicians should be alert to this complication and monitor post-surgical patients closely for signs of hepatic decompensation.
Conclusion(s): BPD-DS is the most effective bariatric surgery technique for sustained weight loss in the super-obese (BMI > 50 kg/m, ²). Nevertheless its widespread adoption has been limited by technical complexity and concerns over vitamin deficiencies and malnutrition. Loss of hepatotrophic factors due to protein malnutrition has been advanced as a mechanism to explain its contribution to the development of cirrhosis. With the increasing prevalence of obesity and the documented effectiveness of BPD-DS for sustained weight loss this surgery will likely become more commonplace. Awareness of this potential complication and vigilance to ensure adequate protein intake, with aggressive intervention-including the initiation of TPN-to preserve nutritional status is paramount to effective management of BPD-DS patients post-operatively

Background: A relative dearth of literature exists on preferences of young gay male patients have regarding the sexual orientation and gender identity (SOGI) of their healthcare providers. Further research in this area is warranted to better serve the young MSM population.
Method(s): Data collection: A sample of 800 young adult gay men completed a brief survey on healthcare preferences between 2015-2016. Participant inclusion criteria were: age 18-29, male gender, self-identified gay sexual orientation, living in US for 5+ years, and being a resident of the New York City metropolitan area. Only participants who reported having a current PCP provided information on preferred PCP characteristics (i.e. male and/or LGBT). Data analysis: Multivariable logistic regression models were built to assess factors associated with participant preference for an LGBT or male PCP. Covariates for inclusion were considered based on prior literature as well as those identified as significant in bivariate logistic regression analyses. Backward model selection with variance inflation factor (VIF) analysis was used to eliminate collinearity and arrive at the most parsimonious models.
Result(s): In this sample, n=614 men (77%) reported having a PCP. Of those 614 with a PCP, 42% indicated a preference for male PCP, 36% preferred a gay or LGBT PCP, and a total of 20% preferred a male-LGBT provider. A preference for consolidated care and distrust in the health system were associated with preference for a sexual orientation concordant PCP. Preference for sexual orientation concordance was strongly associated with preference for gender concordance, and vice versa. Minority race was also found to be associated with preference for a gender-identity concordant (male) PCP.
Conclusion(s): Gay men who wish to discuss their overall health and sexual health with their primary care provider (ie, receive consolidated care) tend to prefer a LGBT provider. This is also true of gay men who distrust the healthcare system, possibly because they anticipate these providers will provide more culturally sensitive care. A surprising association was found between minority racial Background and preference for a gender concordant provider. Further research is warranted to explore the factors giving rise to this finding