Faculty Bibliography

BACKGROUND:No studies have assessed the relationship between diet quality, using the Healthy Eating Index (HEI), and adiposity, physical activity, and metabolic disease risk factors in a Hispanic college population. OBJECTIVE:To assess associations between diet quality and adiposity, metabolic health, and physical activity levels in a Hispanic college freshman population. DESIGN:This was a cross-sectional study. Measurements were obtained during a 4-hour in-person visit and included demographic information via questionnaire, height, weight, waist circumference, body mass index, body fat via BodPod, hepatic fat, visceral adipose tissue (VAT) and subcutaneous adipose tissue via magnetic resonance imaging, glucose, insulin, homeostatic model assessment of insulin resistance (HOMA-IR), and lipids via blood draw from fasting subjects, physical activity (ie, step counts per day and time spent in different intensity levels) via 7-day accelerometry, and dietary intake via three to four 24-hour dietary recalls. Dietary quality was calculated using the HEI-2015. PARTICIPANTS/SETTING:Hispanic college freshmen (n=92), 18 to 19 years, 49% male, who were enrolled at University of Texas at Austin from 2014 to 2015. MAIN OUTCOME MEASURES:Main outcome measures were diet quality and adiposity, metabolic health, and physical activity levels. STATISTICAL ANALYSES PERFORMED:Linear regressions determined if dietary quality is related to adiposity, metabolic, and physical activity outcomes. A priori covariates included sex, body fat, and body mass index percentile (for metabolic models), and moderate and vigorous physical activity (MVPA, for adiposity and metabolic models). RESULTS:The average HEI-2015 total score was 54.9±13.4. A 1-point increase in HEI score was associated with 1.5 mL lower VAT (P=0.013); 8 minutes per day higher light activity (P=0.008), and 107 more step counts per day (P=0.002); and 0.10 μg/mL lower insulin (P=0.046) and 0.5 U lower HOMA-IR (P<0.001). CONCLUSION:Results suggest that small improvements in diet quality may be positively associated with a reduction in metabolic disease risk, during a critical time period in a young person's life.

Learning Objective #1: Recognize pancreatic-enteric fistulization as a rare complication of pancreatitis Learning Objective #2: Define the mechanisms for fistula formation in hemorrhagic pseudocysts CASE: The patient is a 31-year-old female with a past medical history of systemic lupus erythematosus complicated by end stage renal disease on dialysis, and pancreatitis complicated by pseudocyst formation, presenting with acute onset abdominal pain, nausea, and vomiting. On presentation, she was afebrile and hemodynamically stable with exam notable for diffuse abdominal tenderness and voluntary guarding without rebound. CT abdomen and pelvis showed hemorrhage into the known pancreatic tail pseudocyst with interval enlargement from 8 to 12 cm. CTAngiogram obtained four days after the onset of abdominal pain showed an open fistula between the pseudocyst and transverse colon, without evidence of active arterial bleeding. The patient then had two episodes of bright red blood per rectum. She became tachycardic and hypotensive with labs notable for a one-point hemoglobin drop from 9.7 to 8.5. She was triaged to the surgical ICU and underwent urgent exploratory laparotomy with transverse colectomy, partial pancreatectomy, and splenectomy, followed by staged colostomy creation. IMPACT/DISCUSSION: Fistulization of pancreatic pseudocysts is an extremely rare complication, occurring in less than 3% of cases, and can involve a variety of abdominal organs. Connections with sources other than the colon often cause spontaneous drainage and resolution of symptoms, and thus do not require surgery. However, communication with the colon can lead to other complications such as hemorrhage and sepsis, as seen in this case, which require definitive management. A proximal diverting colostomy is standard practice in order to prevent further backup of fecal matter into the pseudocyst and prevent rupture into the abdominal cavity. Multiple mechanisms have been proposed to explain the cause of hemorrhage and rupture of pancreatic pseudocysts. These mechanisms include the presence of severe inflammation due to activated lytic enzymes of the pancreas, as well as persistent compression of blood vessels due to mass effect. Colonopancreatic fistula formation in the case of our patient with lupus is likely secondary to the pro-inflammatory environment compounded by high wall pressures and suppressed healing mechanisms due to chronic steroid use.
Conclusion(s): Given the gravity of a missed diagnosis, hospitalists must keep complications of pancreatic pseudocysts on their differential for patients with known pathology and acute abdominal pain. Management strategies differ based on the type of complication, however, urgent operative management is key in certain cases of fistula formation, especially when it involves the colon as in our patient

Background: Newly recruited clinicians have heterogeneous Backgrounds and experiences and need a substantive introduction to their new institution's patient communication expectations and safety culture and standards for clinician performance. We describe a unique onboarding program designed to ensure that newly hired clinicians receive actionable, behaviorally specific feedback from the patients' perspective to support a satisfying transition to the new work environment, enhance patient experience and reduce the need to punitively react to complaints once they have started.
Method(s): During the 2-hour onboarding, participants complete 3, 10-minute Objective Structured Clinical Exam cases designed to assess how they address a medical error, manage the patient's discharge goals of care, and respond to an impaired learner. During each encounter, participants interact with highly trained Standardized Patients (SPs) or Standardized Learners (SLs) who use behaviorally-anchored checklists to evaluate provider performance on communication and case-specific skills. Following each encounter, participants complete a self-assessment while the SPs/SLs complete a behavior-specific checklist, after which the two discuss the encounter and the SL/SP provides confidential and actionable feedback. At the end, participants are encouraged to set individual learning goals to implement in their daily work, complete a program evaluation, and engage in a debrief with experienced facilitators. Participants also receive their SP checklists in addition to an institutional guide containing relevant resources and contacts.
Result(s): Over 2 years, 57 faculty members representing 6 clinical sites participated in the onboarding program. They are heterogeneous with respect to general and case specific performance on these SP/SL cases. For example, 86% adequately elicited the SP/SLs story during the discharge case compared to 66% in the other two cases, 77% addressed pain management (a key patient goal), while 44% did not discuss important medication side effects. Participants have universally found this onboarding to be useful and relevant; 98% agreed/strongly agreed that the program was an effective way to reinforce good habits in patient and learner communication, 96% felt it enhanced confidence about their ability to communicate effectively, and 96% felt it reinforced the institutional culture of safety. All 56 participants who completed the evaluation agreed/strongly agreed that the event was engaging and well-designed, and 93% felt it was a good use of their time and would recommend the program.
Conclusion(s): Traditional orientations are not well recalled and do not address knowledge and skills in real-time. Although it requires additional resources, participants are enthusiastic about our low-stakes introduction to the institution's expectations. This program sets high standards and introduces a new model for skills-based onboarding which may lead to measurably improved patient outcomes

Background: Electronic health record (EHR) documentation may contribute to burnout, especially for those with substantial clinical effort. We assessed whether clinical effort is associated with working in the EHR after work hours.
Method(s): We included all ambulatory physicians in a medicine specialty continuously practicing at any NYU Langone Health Faculty Group Practice site between May 1 and October 31, 2018. We quantified minutes logged into the EHR on days without scheduled appointments, and minutes logged into the EHR 30 minutes before and after appointments on days with scheduled appointments. We termed this time " work after work." We categorized physicians by their average number of days with appointments per week. Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC). We calculated least squares means of fixed effects to account for heterogeneous variances, and compared means using Tukey's multiple comparison test. This study met institutional review board criteria for quality improvement work.
Result(s): We included 300 physicians, of whom 28.6% were general internists. The average physician had 3 days/week with scheduled appointments, spent 114.9 min in the EHR on days without appointments, and spent 21.7 min in the EHR after work hours on days with appointments. Time spent in the EHR on days without appointments increased with the number of appointment days per week (14.7 min/unscheduled day for 1 day/week vs. 193.8 min/unscheduled day for > 4 days/week, p< 0.001). Time spent in the EHR after hours on days with scheduled appointments did not significantly differ (Table 1).
Conclusion(s): All ambulatory physicians spend a substantial amount of time working in the EHR after hours and on unscheduled days (including weekends), but physicians with more clinical time were disproportionately burdened. The most clinically active spent an average of 2.8 hours in the EHR each unscheduled day. These findings add to concerns about EHR usability and documentation burden, particularly for busier clinicians. Our institution is now building dashboards to track work after work, offloading tasks to ancillary team members to reduce physician work burden, and exploring whether outliers would benefit from personalized technical assistance and training. Work after work analyses could be employed elsewhere to motivate similar improvements

Background: The core Entrustable Professional Activities medical school graduates should be able to perform on day 1 of residency provides a framework for readiness for residency. Communication skills are an essential foundation for these core EPAs and yet there have been few studies that describe communication competence across the UME-GME continuum. We report on our OSCE-based assessment of communication skills from the first few weeks of medical school to the first year of medicine residency.
Method(s): Assessment of communication is consistent in our OSCE program across UME and GME. Domains include Information Gathering (5 items), Relationship Development (6 items), and Patient Education (3 items) and these are assessed via a behaviorally anchored checklist (scores=% well done) that has strong reliability and validity evidence. In this study, we report on 3 multi-station OSCEs: the Introductory Clinical Experience (ICE) OSCE that occurs within the first weeks of medical school; the high-stakes, pass/fail Comprehensive Clinical Skills Examination (CCSE) OSCE that is fielded after clerkship year; and the Medicine Residency Program's PGY 1 OSCE. Across 3 classes of medical school (2014-2016) we have complete data for the 24 students who continued on in our Medicine Residency (and who provided consent to include their educational data in an IRB-approved registry). Analyses focus on differences in communication skills over time and between cohorts and the relationship between communication skills measured in medical school and those assessed in residency.
Result(s): Communication scores show significant improvement through medical school (but not into residency) in Information gathering (ICE mean=56%; CCSE mean=76%; PGY1 mean=77%) (F=11.54, p<.001, ICE< CCSE) and in relationship development (ICE=59%; CCSE=78%; PGY1= 74% (F=10.68, p<.001, ICE < CCSE). Mean patient education skills, however, increase significantly across all 3 time points (32% to 50% to 65%; F=31.00, p<.001). Patterns are similar across cohorts except that the Class of 2016 means increase from CCSE to PGY1. Regression analyses show that CCSE information gathering scores are more strongly associated with PGY performance than ICE scores (Std Beta=.32 vs.06), while for relationship development, it is the ICE scores that are more strongly associated (Std Beta=.40 vs.24). ICE and CCSE patient education skills have associations with PGY1 skill of similar size (Std Beta=.30 and.28).
Conclusion(s): Findings, despite the small sample, suggest a clear developmental trajectory for communication skills development and that information gathering and patient education skills may be more influenced by medical school than relationship development. That communication skills seem to level out in PGY1 highlights need for re-consolidation as clinical complexity increases. Results can inform theory development on how communication skills develop and point to transitions where skills practice/feedback may be particularly important

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: 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: 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